Developing a care program to better know the chronically critically ill

Patients requiring prolonged periods of intensive care and mechanical ventilation are termed chronically critically ill. These patients present a challenge to the healthcare team. In the fast-paced environment of the intensive care unit, their slow progress can be a source of frustration. At the University Hospital Geneva, a team, led by a clinical nurse specialist, addressed this problem by implementing a new care program with a goal to better know this patient population and improve their care. Values of emancipatory practice development guided the project, which utilized an action research methodology. Key assessment tools included a nursing focused patient history at admission and weekly nursing rounds, which allowed for periodic holistic assessment and care planning. New interventions focused on communication, physical care, and providing a context of understanding for the patient beyond hospitalisation, operationalised as a patient diary. The structure of the new program allowed the nurses to develop new skills and provided an environment for dynamic reflection. The care of this demanding patient population is beginning to be perceived by nurses as challenging and interesting.     

慢性重症患者ICU过渡期家属需求的质性研究

目的 了解慢性重症(chronic critical illness,CCI)患者ICU过渡期家属的心理需求,为CCI患者ICU过渡期护理方案的制定提供依据。方法 采用目的抽样法,选取2020年7月-12月在某三甲医院综合ICU住院后安全转出的13例CCI患者家属,对其进行半结构式访谈,所有资料用Nvivo 11软件管理,采用Colaizzi七步分析法分析资料并提炼主题。结果 共提炼出以下主题:(1)CCI患者转出前家属担心患者病情,需要转出信息支持;(2)转出时家属的需求包括患者状况可视化、病情解释和安全转运;(3)转出后家属的需求包括延续性照护及缓解ICU相关并发症。结论 CCI患者ICU过渡期家属需求主要有信息支持、安全转运、延续性照护和缓解ICU相关并发症,建议制定CCI患者ICU过渡期护理方案的时候充分考虑并尽量满足家属的需求,以保证患者安全转出,促进其回归家庭。     

住院危重患者发生呼吸机相关肺炎的影响因素

目的探讨住院危重患者发生呼吸机相关肺炎(VAP)的影响因素。方法选取2013年10月到2014年12月德阳市人民医院收治的重症监护患者140例进行研究,将患者按照是否发生VAP分为VAP组与非VAP组,分析VAP发病的相关因素。结果根据数据统计,VAP组患者和非VAP组患者的年龄和性别差异均无统计学意义(P0.05)。VAP组患者和非VAP组患者的住院时间、气管留置时间、血清蛋白、吸痰次数、吸烟史、呼吸系统史和慢性健康状况(APACHEⅡ)评分,差异有统计学意义(P0.05)。经过VAP发生的多因素分析,与VAP发生的相关因素包括住院时间、气管留置时间、吸痰次数、呼吸系统史和APACHEⅡ评分,经概率型非线性(Logistic)回归分析,差异有统计学意义(P0.05)。结论住院危重患者发生VAP的影响因素很多,其中,最主要的影响因素包括住院时间、气管留置时间、血清蛋白、吸痰次数、吸烟史、呼吸系统史和APACHEⅡ评分。     

Age differences in survival outcomes and resource use for chronically critically ill patients

Purpose

Chronically critically ill (CCI) patients use a disproportionate amount of resources, yet little research has examined outcomes for older CCI patients. The purpose of this study was to compare outcomes (mortality, disposition, posthospital resource use) between older (≥65 years) and middle-aged (45-64 years) patients who require more than 96 hours of mechanical ventilation while in the intensive care unit.

Methods

Data from 2 prospective studies were combined for the present examination. In-hospital as well as posthospital discharge data were obtained via chart abstraction and interviews.

Results

One thousand one hundred twenty-one subjects were enrolled; 62.4% (n = 700) were older. Older subjects had a 1.3 greater risk for overall mortality (from admission to 4 months posthospital discharge) than middle-aged subjects. The Acute Physiology Score (odds ratio [OR], 1.009), presence of diabetes (OR, 2.37), mechanical ventilation at discharge (OR, 3.17), and being older (OR, 2.20) were statistically significant predictors of death at 4 months postdischarge. Older subjects had significantly higher charges for home care services, although they spent less time at home (mean, 22.1 days) than middle-aged subjects (mean, 31.3 days) (P = .03).

Conclusion

Older subjects were at higher risk of overall mortality and used, on average, more postdischarge services per patient when compared with middle-aged subjects.     

危重病患者静注胺碘酮的疗效及安全性

目的 :评价急危重疾病合并心律失常患者静注胺碘酮的疗效及安全性。方法 :选择急诊危重症合并快速心律失常患者 6 8例 ,其中 4 9例伴不同程度的心力衰竭。患者均接受静注胺碘酮治疗 ,根据心律失常转复为窦性心律或心率减慢、期前收缩减少或心律失常未纠正、心率未减慢而分别评为显效、有效和无效。同时分析用药前后的血压、心率以及药物不良反应 ,并评价心力衰竭有无加重。结果 :6 8例患者中显效率 6 7.7% ,有效率4 5 .6 % ,无效率 7.4 % ,无心力衰竭加重 ,无严重的药物不良反应发生。结论 :危重症合并快速心律失常特别是缺血性心脏病合并心功能不全患者 ,静注胺碘酮是有效和安全的。     

高压氧舱内呼吸机在危重症救治中的应用

呼吸机进舱一直是高压氧（HBO）治疗面临的难题。由于普通电动呼吸机达不到舱内防火要求不能进舱,致使部分有适应症的危重症患者由于呼吸微弱或无自主呼吸不能进行常规高压氧治疗,     

主动输液实践模式在呼吸内科危重患者治疗中的应用

目的 探讨主动输液实践模式对呼吸内科危重患者输液安全及并发症的影响.方法 选取2010年3月至2012年10月我院呼吸内科收住的危重患者240例为研究对象,按人院时间先后分为对照组和实验组各120例,分别实施传统输液模式和主动输液实践模式,比较两组患者静脉输液方式、人均穿刺数、输液费用、静脉炎和药物外渗的发生情况及患者满意度.结果 实验组患者较对照组输液方式更多的选择了中心静脉置管,人均穿刺数和输液费用较对照组减少,静脉炎和药物外渗的发生率较对照组降低,患者满意度较对照组高,差异均具有统计学意义（P＜ 0.01或P＜0.05）.结论 实施主动输液实践模式能够保证呼吸内科危重患者用药安全,预防输液并发症、减轻患者痛苦,值得临床推广.     

The perceived needs of Jordanian families of hospitalized, critically ill patients

The purpose of this study was to identify needs of Jordanian families of hospitalized, critically ill patients. The Critical Care Family Needs Inventory was introduced to 158 family members who were visiting their hospitalized, critically ill relatives. The findings revealed that > or = 80% of the family members perceived 16 need statements as important or very important. The participants ranked order needs for assurance, information and proximity the highest and needs for support and comfort the lowest. Specifically, the most important needs of the families were to receive information about the patients, to feel that the hospital personnel care about the patients and to have the information given in understandable terms. Results of this study indicated that Jordanian families had specific and identifiable needs. Providing families of critically ill patients clear, simple and updated information about the patients, and assuring them about the quality of care the patients receive, should be essential components of the critical care nursing delivery system.     

Evaluation of a risk score for interhospital transport of critically ill patients

Background

Interhospital transfer imposes essential risk for critically ill patients. The Risk Score for Transport Patients (RSTP) scale can be used as a triage tool for patient severity.

Methods

In total, 128 transfers of critically ill patients were classified in two groups of severity according to the RSTP. Statistical analysis was performed using the receiver operating characteristic (ROC) curve and goodness of fit statistics.

Results

In total, 66 patients (51.5%) were classified as group I and 62 (48.4%) as group II. Major en route complications were more common in group II patients (19.3% v 3%, p<0.001). Haemodynamic instability was the most common complication. There were significant differences in the mean risk scores between group I and II patients (mean (SD) 4.48 (1.01) v 11.04 (3.47), p<0.001). Discrimination power of RSTP was acceptable (area under the ROC curve 0.743; cutoff value ⩾8). Goodness of fit was adequate (p = 0.390).

Conclusion

The RSTP had acceptable discrimination and adequate goodness of fit and could be considered as a triage tool. Haemodynamic instability is the most common problem encountered during transfer.     

急诊危重患者院内安全转运的护理

目的：总结急诊危重患者院内安全转运的护理。方法：对2011年10月～2012年10月应用转运制度及流程对197例危重患者的院内转运情况进行回顾性分析。结果：共发生各类不良事件82起,其中35起（42．68％）是患者本身相关的不良事件,47起（57．32％）是由于仪器设备引起的相关不良事件,经过一系列护理措施的改进,降低了患者转运途中风险的发生,确保了转运患者的安全。结论：加强护理工作者的护理安全防范意识,提高专业知识,认真执行各项制度,是确保医疗安全、提升医疗质量的关键举措。     

The nature of hope in hospitalized chronically ill patients

BACKGROUND: Hope as a universal human phenomenon has been studied from various perspectives often conceptualized as having a unified set of attributes. In this study however hope is viewed to be experienced by people in various patterns structured by different orientations and emphases depending upon their life circumstances. There is a paucity of studies in the literature examining patterns of hope experienced by people in chronic illness or in special life circumstances. OBJECTIVES: The aim of this study was to discover patterns of hope in hospitalized chronically ill patients and to identify the major threads that structure various patterns of hope experienced by them. DESIGN: Q-methodology, which is an approach designed to discover patterns in various subjective experiences, was used as the method for data collection and theory generation. Q-methodology involves five steps in its approach, the first two as the first phase and the last three as the second phase. The study was carried out at a general acute-care, tertiary hospital in a New England state in the US. The study obtained data from a convenient sample of 12 chronically ill patients and 16 oncology nurses for the first phase, and a different convenient sample of 20 chronically ill patients for the second phase. RESULTS AND CONCLUSIONS: Five patterns of subjective experiences of hope emerged as: (a) externalism orientation, (b) pragmatism orientation, (c) reality orientation, (d) future orientation, and (e) internalism orientation. This means that chronically ill patients experience hope in various ways by focusing on different dimensions of meaning, suggesting the conceptualization of hope as a unitary construct may not reflect people's experiences of hope accurately. The major implication of the study is to rethink ways to assess patients' hope in terms of pattern differences rather than in terms of quantity.     

急诊科危重患者院内安全转运的护理

目的:了解急诊科危重患者院内安全转运的影响因素和防范对策。方法:对该院急诊科2005年1～8月126例危重症患者转运时意外情况进行统计。结果:126例转运途中发生意外42例。讨论:要做好转运前的评估、准备工作,以及急救药品和器材的准备,加强相关科室的协调,提高护送人员的责任心,以确保危重患者院内转运的安全。     

转运流程在重症病人院内转运中的应用

目的探讨转运流程在重症病人院内转运中的应用效果。方法采用传统转运方法对315例重症病人(对照组)进行院内转运,采用转运流程对309例重症病人(实验组)进行院内转运,观察两组病人意外事件发生情况,了解接收重症病人科室护士的满意率。结果实验组病人意外事件总发生率低于对照组,护士对转运流程的评价优于对传统方法的评价,差异均有统计学意义(P0.01)。结论实施转运流程可有效降低重症病人院内转运的风险,提高接收重症病人科室护士的满意率,值得推广应用。     

ICU信息管理系统在危重症病人救护中的应用成效

目的提高ICU病人监护信息采集的准确性、病人服务满意度及护理工作效率。方法应用ICU信息管理系统进行病人信息、床位管理、医嘱处理、整体护理、电子病历、护理文书、科研统计、系统设置及效果评价。结果应用ICU管理信息系统后缩短了24 h护士书写文书时间,24 h护士床边护理时间明显延长,提高了护士护理文书书写合格率、观察病情及时率和病人对护理工作满意度(P0.01或P0.05)。结论 ICU信息管理系统的应用改进了ICU综合管理模式,提升了护士救护能力和病人满意度。     

纤维支气管镜灌洗治疗危重症合并肺部感染患者34例疗效评价

目的探讨纤维支气管镜灌洗治疗危重症合并肺部感染患者的疗效。方法选取严重肺部感染合并Ⅰ型或Ⅱ型呼吸衰竭的危重症患者34例,均因病情危重而行有创机械通气和气管切开治疗,在静脉抗生素给药、化痰平喘和全身营养支持等治疗的基础上,采用床边纤维支气管镜灌洗治疗,并比较治疗前后患者体温、痰量及性质、肺部湿口罗音、肺不张者肺段呼吸音情况、血气分析、C反应蛋白(CRP)的变化及胸部X线表现。结果机械通气时间为1~62 d,灌洗时间为机械通气后1~19d,纤维支气管镜灌洗治疗后较治疗前SaO2、Pa(O2)明显提高,Pa(CO2)明显下降,差异均有统计学意义(P<0.05);28例经纤维支气管镜灌洗治疗后肺内感染得到控制,CRP水平明显下降,其中9例肺不张者经纤维支气管镜灌洗治疗后肺完全复张,6例因机械通气时间相对过长(>1周)并发混合感染后治疗失败。结论纤维支气管镜灌洗治疗危重症合并肺部感染患者,可有效切断痰阻塞—炎症加重—痰液雍滞的恶性循环,改善患者肺通气和换气功能,促进肺部炎症的吸收和消退。     

追踪方法学在危重病人护理质量检查中的应用

近年来国际医院评审中出现的追踪方法学是一种以病人为中心的评价方法及过程管理方法,更加注重病人的感受和细节管理。本研究将追踪方法学应用于危重病人护理质量检查中,寻找护理工作中的问题,不断完善危重病人管理体系,提高了危重病人的护理质量和护士的综合能力。     

漂浮导管技术在危重症患者围术期的临床应用

目的探讨漂浮导管在危重症患者围术期的临床应用效果以及并发症的防治。方法分析6例ASA(美国麻醉医师协会)分级在3级以上的危重症患者围术期,使用漂浮导管指导救治的效果。结果根据漂浮导管血流动力学监测指标指导救治6例患者,有5例危重症患者平稳度过围术期,1例于术后1 h死亡。结论在围术期中,危重症患者使用漂浮导管进行血流动力学监测是安全、可靠的,且并发症少,能够降低麻醉风险,对指导危重症患者围术期的抢救有重要意义,但所检测的数据要根据不同病人的病理、生理特点具体分析。     

术中血气分析在危重患者中的应用

目的探讨术中血气分析在危重患者中的应用。方法对2011年10月至2012年10月82例患者采用外周动脉穿刺,留置动脉留置针进行血气分析的患者进行回顾性分析。结果本组病例在观察期间对血气分析各项目进行了及时监控,动脉穿刺成功率在90％以上。结论血气分析监测对指导术中危重患者的临床治疗、判断疗效具有重要意义。