Evaluating the implementation of confusion assessment method‐intensive care unit using a quality improvement approach

Quality improvement (QI) is a way through which health care delivery can be made safer and more effective. Various models of quality improvement methods exist in health care today. These models can help guide and manage the process of introducing changes into clinical practice. The aim of this project was to implement the use of a delirium assessment tool into three adult critical care units within the same hospital using a QI approach. The objective was to improve the identification and management of delirium. Using the Model for Improvement framework, a multidisciplinary working group was established. A delirium assessment tool was introduced via a series of educational initiatives. New local guidelines regarding the use of delirium assessment and management for the multidisciplinary team were also produced. Audit data were collected at 6 weeks and 5 months post‐implementation to evaluate compliance with the use of the tool across three critical care units within a single hospital in London. At 6 weeks, in 134 assessment points out of a possible 202, the tool was deemed to be used appropriately, meaning that 60% of patients received timely assessment; 18% of patients were identified as delirious in audit one. Five months later, only 95 assessment points out of a possible 199 were being appropriately assessed (47%); however, a greater number (32%) were identified as delirious. This project emphasizes the complexity of changing practice in a large busy critical care centre. Despite an initial increase in delirium assessment, this was not sustained over time. The use of a QI model highlights the continuous process of embedding changes into clinical practice and the need to use a QI method that can address the challenging nature of modern health care. QI models guide changes in practice. Consideration should be given to the type of QI model used.     

Oral intake evaluation in patients following critical illness: an ICU cohort study

Timely and adequate nutrition improves health outcomes for the critically ill patient. Despite clinical guidelines recommending early oral nutrition, survivors of critical illness experience significant nutritional deficits. This cohort study evaluates the oral nutrition intake in intensive care unit (ICU) patients who have experienced recent critical illness. The oral nutrition intake of a convenience sample of ICU patients post‐critical illness was observed during a 1‐month period. Data pertaining to both the amount of oral nutrition intake and factors impacting optimal oral nutrition intake were collected and analysed. Inadequate oral intake was identified in 62% of the 79 patients assessed (n = 49). This was noted early in the ICU stay, around day 1–2, for most of the patients. A significant proportion (25%) of patients remained in the hospital with poor oral intake that persisted beyond ICU day 5. Unsurprisingly, these were the patients who had longer ICU stays. Critical illness weakness was a factor in the assessment of poor oral intake. To conclude, patients who have experienced critical illness also experience suboptimal oral nutrition. The three key factors that were identified as impacting optimal oral nutrition were early removal of nasogastric tubes, critical illness weakness and poor appetite post‐critical illness. Seven key recommendations are made based on this cohort study. These recommendations are related to patient assessment, monitoring, documentation and future guidelines. Future research opportunities are highlighted, including the investigation of strategies to improve the transition of patients' post‐critical illness to oral nutrition.     

Effects of nonpharmacological interventions on sleep improvement and delirium prevention in critically ill patients: A systematic review and meta-analysis

ObjectiveSleep disturbance and delirium are common problems experienced by critically ill patients in the intensive care unit (ICU). These interrelated issues increase the length of stay in the ICU but might also negatively affect long-term health outcomes. The objective of this study was to identify the nonpharmacological interventions provided to improve sleep or prevent delirium in ICU patients or both and integrate their effect sizes.Review methodsThis study was a registered systematic review and meta-analysis. We searched MEDLINE, CINAHL, EMBASE, Web of Science, and Cochrane Library from their inception until December 2021. We included randomised controlled trials and nonrandomised controlled trials-(RCT) that provided nonpharmacological interventions and reported sleep or delirium as outcome variables. Studies not published in English or whose full text was not available were excluded. The quality of the evidence was assessed with version 2 of the Cochrane risk-of-bias tool for RCTs and the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I).ResultsThe systematic review included 118 studies, and the meta-analysis included 100 studies. Overall nonpharmacological interventions had significant effects on subjective sleep quality (standardised mean difference = 0.30, 95% confidence interval [CI] = 0.05 to 0.56), delirium incidence (odds ratio = 0.62, 95% CI = 0.53 to 0.73), and delirium duration (standardised mean difference = −0.68, 95% CI = −0.93 to −0.43). In individual interventions, aromatherapy, music, and massage effectively improved sleep. Exercise, family participation, information giving, cognitive stimulation, bright light therapy, architectural intervention, and bundles/protocols effectively reduced delirium. Light/noise blocking was the only intervention that ensured both sleep improvement and delirium prevention.ConclusionsOur results suggest nonpharmacological interventions improve sleep and prevent delirium in ICU patients. We recommend that ICU nurses use nonpharmacological interventions that promote person–environment compatibility in their clinical practice. The results of our review can guide nurses in adopting interventions related to sleep and delirium.Prospero reference numberCRD42021230815     

Skin lesions in the ICU

Objective: The objective of this study is to identify the dermatological disorders (DDs) responsible for the most common skin lesions in the ICU, their incidence and their impact on mortality, degree of severity and length of stay in the ICU.¶Design and setting: We performed a 2-year prospective study in a general medical and surgical ICU including, exceptionally, paediatric cases.¶Patients: We included all patients who presented skin lesions upon admission or developed them during their ICU stay.¶Results: Forty-six patients (10 % of all admissions) were enrolled, with 51 DDs. SAPS II score (43) and mean length of stay (19 days) were significantly higher than in the general group of ICU admissions. Differences in mortality rates (26 % versus 29 %) were not statistically significant.¶Conclusions: DDs are entities that should be borne in mind in the critically ill patient; their incidence is by no means negligible and makes careful examination of the skin mandatory both on admission and during a patient's ICU stay.     

Sleep during and following critical illness: A narrative review

Sleep is a complex process influenced by biological and environmental factors. Disturbances of sleep quantity and quality occur frequently in the critically ill and remain prevalent in survivors for at least 12 mo. Sleep disturbances are associated with adverse outcomes across multiple organ systems but are most strongly linked to delirium and cognitive impairment. This review will outline the predisposing and precipitating factors for sleep disturbance, categorised into patient, environmental and treatment-related factors. The objective and subjective methodologies used to quantify sleep during critical illness will be reviewed. While polysomnography remains the gold-standard, its use in the critical care setting still presents many barriers. Other methodologies are needed to better understand the pathophysiology, epidemiology and treatment of sleep disturbance in this population. Subjective outcome measures, including the Richards-Campbell Sleep Questionnaire, are still required for trials involving a greater number of patients and provide valuable insight into patients’ experiences of disturbed sleep. Finally, sleep optimisation strategies are reviewed, including intervention bundles, ambient noise and light reduction, quiet time, and the use of ear plugs and eye masks. While drugs to improve sleep are frequently prescribed to patients in the ICU, evidence supporting their effectiveness is lacking.     

Patient,family-centred care interventions within the adult ICU setting: An integrative review

ObjectivesPatient, Family-Centred Care (PFCC) is internationally advocated as a way to improve patient care. The aim of this integrative review was to extend the knowledge and understanding by synthesising empirical evidence of PFCC interventions within the adult intensive care unit (ICU) setting.Review method usedAn integrative review methodological framework was employed, permitting the inclusion of all research designs. A comprehensive and systematic search, selection, quality appraisal, and data extraction of research were conducted to synthesise knowledge and identify research gaps.Data sourcesA systematic search of the following databases was conducted: MEDLINE; CINHAL; PsycINFO; Cochrane Library; Web of Science—Current Contents Connect; Web of Science—Core Collection; The Joanna Briggs Institute EBP Database; ProQuest Sociological Abstracts; and ProQuest Dissertation and Theses Global. Primary research in adult ICUs was included.Review methodsData extracted from the studies included authors, year, country of origin, design, setting, sample, intervention, data collection strategies, main findings and limitations. Study quality was assessed using the Mixed Methods Appraisal Tool.ResultsForty-two articles met the inclusion criteria and were included in the review. Only a third of the papers stated the theory underpinning their study. Three themes emerged with interventions predominantly around Interacting with the target sample; Culture and Connection and Service Delivery interventions were also identified. Few studies integrated more than one dimension of PFCC.ConclusionsResearch into PFCC interventions is diverse; however, few researchers present a multi-dimensional approach incorporating a culture shift to enact PFCC throughout the ICU trajectory. There is an opportunity for future research to describe, develop, and test instruments that measure PFCC based on its multiple dimensions and not on one component in isolation. Importantly, for PFCC to successfully individualise quality patient care, a commitment and enactment of partnerships between health care professionals, patients, and family members is imperative.     

Nasal high-flow oxygen therapy in ICU: A before-and-after study

BackgroundNon-intubated intensive care patients commonly receive supplemental oxygen by high-flow face mask (HFFM), simple face mask (FM) and nasal prongs (NP) during their ICU admission. However, high-flow nasal prongs (HFNP) offer considerable performance capabilities that may sufficiently meet all their oxygen therapy requirements.Study aimsTo assess the feasibility, safety and cost-effectiveness of introducing a protocol in which HFNP was the primary oxygen delivery device for non-intubated intensive care patients.MethodProspective 4-week before-and-after study (6 months apart) for all adult patients admitted to a 22-bed tertiary ICU in Melbourne, Australia.Results117 patients (57 before, 60 after) were included: 86 (73.5%) received mechanical ventilation. Feasibility revealed a significant reduction in HFFM (52.6–0%, p < .001), FM (35.1–8.3%, p = .002) and NP (75.4–36.7%, p < .001) use and an increase in HFNP use (31.6–81.7%, p < .05) during the after period. Following extubation, there was a significant reduction in HFFM use (65.7% vs. 0%, p < .05) and an increase HFNP use (8.6% vs. 87.5%, p < .05). Costing was in favour of the after period with a consumable cost saving per patient (AUD $32.56 vs. $17.62, p < .05). During the after period, more patients were discharged from ICU with HFNP than during the before period (5 vs. 33 patients, p < .05) and fewer patients (5 vs. 14 patients) used three or more oxygen delivery devices. Safety outcomes demonstrated no significant difference in the number of intubations, re-intubations, readmissions or non-invasive ventilation use between the two time periods.ConclusionsUsing HFNP as the primary oxygen delivery method for non-intubated intensive care patients was feasible, appeared safe, and the oxygen device costs were reduced. The findings of our single-centre study support further multi-centre evaluations of HFNP therapy protocols in non-ventilated intensive care patients.     

非药物干预比较改善ICU患者睡眠质量效果的网状Meta分析

目的采用网状Meta分析方法评价非药物干预改善ICU患者睡眠质量的效果。方法计算机检索The Cochrane Library、PubMed、EMbase、Web of Science、CNKI、WanFang Data、VIP和CBM数据库,搜集非药物干预改善ICU患者睡眠质量效果的随机对照试验(RCT),检索时限均为建库至2018年12月。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Stata 13.0软件进行网状Meta分析。结果共纳入12个RCT,包括1223例患者,涉及9种非药物干预方法(音乐疗法、综合护理干预、中医情志、音乐疗法+中医情志、中药枕疗法、耳穴压豆、眼罩+耳塞+音乐、眼罩+耳塞、常规护理)。针对匹兹堡睡眠质量指数(PSQI)的网状Meta分析结果显示:在改善ICU患者睡眠质量方面,眼罩+耳塞、眼罩、综合护理干预优于常规护理,其差异有统计学意义。结果排序图显示:眼罩+耳塞>眼罩>综合护理干预、音乐疗法+中医情志>中医情志>音乐疗法>常规护理。针对Richards-Campbell睡眠量表(RCSQ)的网状Meta分析结果显示:眼罩+耳塞+音乐、中药枕疗法、耳穴压豆优于常规护理,其差异有统计学意义。结果排序图显示:眼罩+耳塞+音乐>中药枕疗法>音乐疗法>耳穴压豆>常规护理。结论当前证据显示,在改善ICU患者睡眠质量方面,眼罩+耳塞、眼罩、综合护理干预、音乐疗法+中医情志都可能是有效的干预方式,建议未来开展更多非药物干预改善ICU患者睡眠质量效果的RCT。     

Sleep monitoring in the intensive care unit: comparison of nurse assessment, actigraphy and polysomnography

Objective  Sleep loss and sleep disruption are common in critically ill patients and may adversely affect clinical outcomes. Although polysomnography remains the most accurate and reliable way to measure sleep, it is costly and impractical for regular use in the intensive care unit. This study evaluates the accuracy of two other methods currently used for measuring sleep, actigraphy (monitoring of gross motor activity) and behavioural assessment by the bedside nurse, by comparing them to overnight polysomnography in critically ill patients. Design  Observational study with simultaneous polysomnography, actigraphy and behavioural assessment of sleep. Setting  Medical-surgical intensive care unit. Patients and participants  Twelve stable, critically ill, mechanically ventilated patients [68 (13) years, Glasgow coma scale 11 (0)]. Interventions  None. Measurements and results  Sleep was severely disrupted, reflected by decreased total sleep time and sleep efficiency, high frequency of arousals and awakenings and abnormal sleep architecture. Actigraphy overestimated total sleep time and sleep efficiency. The overall agreement between actigraphy and polysomnography was <65%. Nurse assessment underestimated the number of awakenings from sleep. Estimated total sleep time, sleep efficiency and number of awakenings by nurse assessment did not correlate with polysomnographic findings. Conclusions  Actigraphy and behavioural assessment by the bedside nurse are inaccurate and unreliable methods to monitor sleep in critically ill patients.     

Factors promoting intensive care patients’ perception of feeling safe: A systematic review

Background

Feeling safe in the intensive care unit is of great importance while recovering from critical illness. Moreover, feeling unsafe can result in distress. In order to meet the safety needs of intensive care patients as well as to stimulate their recovery and prevent distress, nurses must be aware of factors promoting patients’ perception of feeling safe during an intensive care admission. To our knowledge, there is no synthesis of these factors available as yet.

Objective

To systematically describe the factors that promote patients’ perception of feeling safe in an intensive care unit.

Design

A systematic review of qualitative and quantitative studies.

Data sources

PubMed, Embase, CINAHL, and PsycINFO were searched up to March 2012.

Review methods

Methodological quality was assessed by two authors using the QualSyst tool. Data from the included studies were extracted into a customised data extraction form.

Results

The initial search resulted in 1326 records. Ultimately, eleven studies were relevant to the research question and included in the review. No studies needed to be excluded because of low quality scores. Analysis of the factors in these studies resulted in four overarching themes that promote intensive care patients’ perception of feeling safe. These themes were: nursing care, patients’ issues, relatives, and technological support. Nursing care was described most frequently as an important factor promoting patients’ feeling of safety in an intensive care unit. Relatives were the link between intensive care patients and staff.

Conclusions

Nurses can increase the perception of feeling safe in critically ill patients by taking into account the promoting factors described in this review. By being aware of these factors nurses can improve quality of care in their intensive care unit.     

夜间降低噪音对ICU患者谵妄及睡眠质量的影响

目的：较高的噪音水平被认为可能诱导ICU患者睡眠障碍的发生。而睡眠障碍是增加重症患者谵妄发生的重要风险因素。危重病人的谵妄发生往往与各种临床不良预后相关呢。本研究假设通过降低夜间整体环境噪音水平,可以改善ICU患者的睡眠质量和谵妄发生率。方法：在成人外科重症监护病房进行序列研究。将干预前53例患者与干预后61例施夜间降音方案的患者进行比较。主要的观察指标是不同噪音环境下ICU患者睡眠质量与谵妄发生率的变化。分别采用谵妄筛查量表(ICDSC)和睡眠质量量表(RSCQ)测量。次要的观察指标是睡眠诱导或镇静药物的使用。结果：干预前后谵妄发生率有显著差异（分别为11.3% 和27.9%, p=0.03）。睡眠质量评分改善（分别为64.3±13.0和57.6±11.26,p<0.01）。干预后使用睡眠诱导药物的患者比例减少（分别为15.1%和32.8%, p=0.03）。结论：采用夜间降音方案后,ICU患者的谵妄发生率降低,且睡眠质量得到改善。