Nurses' and physicians' approaches to delirium management in the intensive care unit: A focus group investigation

BackgroundDelirium in the intensive care unit (ICU) is common, but reliable evidence-based recommendations are still limited.ObjectivesThe aim of our study was to explore nurses' and physicians' experiences and approaches to ICU delirium management.MethodOur study had a qualitative multicentre design using interdisciplinary focus groups and framework analysis. Participants were strategically selected to include nurses and physicians with experience in delirium management at five ICUs in four out of five regions in Denmark.ResultsWe conducted eight focus group interviews with 24 nurses and 15 physicians; median ICU experience was 9 years (range 1–35). The main issues identified were (1) the decision to treat or not to treat ICU delirium based on delirium phenotype, (2) the decision to act based on experience or evidence, and (3) the decision to intervene using nursing care or medications. ICU delirium was treated with pharmacological interventions in patients with signs of agitation, hallucinations, and sleep deprivation. The first choice of agent was haloperidol or olanzapine. Agitated and combative patients received benzodiazepines, propofol, or dexmedetomidine. Calm delirious patients were managed with non-pharmacological solutions. Physicians recommended pro re nata (PRN) orders to prevent over medication, whereas nurses opposed PRN orders with the fear that it would increase their responsibilities.ConclusionOur study described an algorithm of contemporary delirium management in Danish ICUs based on qualitative inquiry. When evidence-based solutions are unclear, nurses and physicians rely on personal experience, collective experience, and best available evidence to determine which patients to treat and what methods to use to treat ICU delirium. Delirium management still needs clear objectives and guidelines with evidence-based recommendations for first-line treatment and subsequent treatment options.     

监护病房中高血钠发生的危险因素及护理对策

目的 分析监护病房中高血钠发生的危险因素及护理对策。方法 用急性生理功能与慢性健康状况评分Ⅱ评分系统评估疾病严重程度，采用单因素x^2检验和多因素Logistic回归分析判定发生高血钠的危险因素。结果 监护病房中高血钠患者的发生率为16．55％，高血钠发生与患者不同程度的意识水平，尿量，高热，基础疾病较严重，经口饮水受限及使用脱水剂不当等因素显著相关。结论 高血钠是监护病房中常见并发症，应重视其危险因素，加强护理，减少发生率。     

Complications of care in a pediatric intensive care unit: A prospective study

Objectives (a) To examine the frequency, type, and severity of complications occurring in a pediatric intensive care unit; (b) to identify populations at risk; and (c) to study the impact of complications on morbidity and mortality.Design Prospective survey.Setting Pediatric intensive care unit (PICU) of a university-affiliated hospital.Patients 1035consecutive admissions over an 18-month period.Results 115 complications occurred during 83 (8.0%) admissions, for 2.7 complications per 100 PICU-days; 48 (42%) complications were major, 45 (39%) moderate, and 22 (19%) minor. Sixty complications (52%) were ventilator-related, 14 were drug-related, 13 procedure-related, 24 infectious, and 22 involved invasive devices (18 vascular catheters). Human error was involved in 41 (36%) cases, 21 of which were major (18%). Treatments included reintubation <24 h (28), intravenous antimicrobials (24), and invasive bedside procedures (14). Cardiopulmonary resuscitation was required in 6 patients. Thirteen patients with complications died (15.7%); 2 deaths were directly due to complications.Patients with complications were younger, had longer lengths of stay, and had a higher mortality. Length of stay was a positive risk factor for complication risk (odds ratio=1.09, 95% confidence interval: 1.05 to 1.13;p=0.0001); other patient characteristics had no predictive effect. Kaplan-Meier estimates showed that the most severe complications occurred early in the PICU stay. The best indicators of patient mortality were number of complications (odds ratio=2.96, 95% confidence interval 1.72 to 5.08;p=0.0001), and mortality risk derived from the Pediatric Risk of Mortality Score (odds ratio=1.08, 95% confidence interval 1.06 to 1.10;p=0.0001). Mortality was correlated with increasing severity of complications.Conclusion Complications have a significant impact on patient care. Patients may be at increased risk earlier in their PICU course, when the number of interventions may be greatest. Complications may increase patient mortality and predict patient death better than other patient variables.     

Nursing team leader handover in the intensive care unit contains diverse and inconsistent content: An observational study

BackgroundDespite a proliferation of evidence and the development of standardised tools to improve communication at handover, evidence to guide the handover of critical patient information between nursing team leaders in the intensive care unit is limited.ObjectiveThe study aim was to determine the content of information handed over during intensive care nursing team leader shift-to-shift handover.DesignA prospective observational study.SettingA 21-bed medical/surgical adult intensive care unit specialising in cardiothoracic surgery at a tertiary referral hospital in Queensland, Australia.ParticipantsSenior nurses (Grade 5 and 6 Registered nurses) working in team leader roles, employed in the intensive care unit were sampled.MethodAfter obtaining consent from nursing staff, team leader handovers were audiotaped over 20 days. Audio recordings were transcribed and analysed using deductive and inductive content analysis. The frequency of content discussed at handover that fell within the a priori categories of the ISBAR schema (Identify-Situation-Background-Assessment-Recommendation) was calculated.ResultsForty nursing team leader handovers were recorded resulting in 277 patient handovers and a median of 7 (IQR 2) patients discussed at each handover. The majority of nurses discussed the Identity (99%), Situation (96%) and Background (88%) of the patient, however Assessment (69%) content was varied and patient Recommendations (60%) were discussed less frequently. A diverse range of additional information was discussed that did not fit into the ISBAR schema.ConclusionsDespite universal acknowledgement of the importance of nursing team leader handover, there are no previous studies assessing its content. Study findings indicate that nursing team leader handovers contain diverse and inconsistent content, which could lead to inadequate handovers that compromise patient safety. Further work is required to develop structured handover processes for nursing team leader handovers.     

人性化综合护理措施对重症监护室患者恢复的影响

目的:探讨人性化综合护理措施对普外科重症监护室患者恢复的影响.方法:将2011年1月～2012年1月我院普外科重症监护室收治的100例患者作为对照组,给予常规护理;将2012年2～10月我院普外科重症监护室收治的77例患者作为研究组,在常规护理的基础上给予人性化综合护理措施.对比分析两组患者的住院时间、抢救成功率、焦虑情绪及对护理工作的满意度.结果:研究组患者的住院时间短于对照组(P＜0.05),抢救成功率高于对照组(P＜0.05),人住重症监护室第15 d焦虑得分低于对照组(P＜0.05),对护理工作的满意度高于对照组(P＜0.05).结论:人性化综合护理能有效提高普外科重症监护患者的抢救成功率,促进患者恢复,缩短患者住院时间,降低患者焦虑情绪,最终提高其对护理工作的满意率,值得临床推广应用.     

A nurse-led critical care outreach program to reduce readmission to the intensive care unit: A quasi-experimental study with a historical control group

IntroductionVarious critical care outreach services have been developed and evaluated worldwide; however, the conflicting findings indicate the need to strengthen the outreach service research. This study aimed to evaluate the effects of a nurse-led critical care follow-up program on intensive care unit (ICU) readmission and hospital mortality in patients with respiratory problems discharged from the ICU in Hong Kong.MethodsA quasi-experimental study design, with a historical control and a prospective intervention for 13 months, was used. The intervention group received a nurse-led, multidisciplinary ICU follow-up program in addition to the usual care. The outcome measures included ICU readmission within 72 h after ICU discharge, all ICU readmission (ICU readmission irrespective of the time frame after ICU discharge), hospital mortality, and 90-day mortality rate. Logistic regression analysis was used to determine the predictors for ICU readmission within 72 h.ResultsA total of 369 participants (the intervention group: 185; the control group: 184) were recruited. A significant reduction in ICU readmission within 72 h was observed in the intervention group compared to the control group (p = 0.001), even after controlling for confounders (odds ratio: 0.158, p = 0.007). The intervention group also demonstrated a significant reduction in all ICU readmission (p < 0.001) and hospital mortality (p = 0.042), but not on 90-day mortality (p = 0.081), when compared with the control group. This nurse-led ICU follow-up program was shown to be cost-effective, saving an estimated US$ 145,614 for a period of 13 months.ConclusionThe findings demonstrated that a nurse-led multidisciplinary ICU follow-up program was a beneficial and cost-saving strategy to avert ICU readmission in patients with respiratory problems after ICU discharge. It also highlighted the competent role of ICU nurses in planning and leading the implementation of a multidisciplinary program. The results contributed to the database of an innovative follow-up program to inform the practice worldwide.     

重症监护室护理记录单的优化设计与应用

目的 设计ICU护理记录单,并研究其在提高护士工作效率中的作用。 方法 根据科室实际情况优化设计了文字、表格书写相结合的记录单,并与原ICU记录单比较。 结果 优化前、后的护理记录单记录字数和记录用时均少于优化前的护理记录单。 结论 优化后的护理记录单显著提高了书写质量和护理工作效率。     

护理专业校内重症监护实验室(ICL)建设标准探讨

目的探索构建护理学专业校内重症监护实验室(ICL)的建设标准,为我校及国内其它高等护理专业院校建立科学、规范、实用的ICL提供依据。方法问卷调查了杭州市6所三级医院中心重症监护室(ICL)布局、设施、监护仪器配置、护理人员的基本信息及技能掌握等情况,并收集了15位相关专家关于ICL建设标准的咨询意见。结果6所三级医院中心ICU设施齐全,仪器设备基本能满足临床重症监护病人的护理需求,护理人员的数量严重不足,心脏电复律、胃肠内营养护理、颅内压监测等护理技能相对欠缺。结论尽快探索ICL建设标准,建立和不断完善ICL建设,强化学生重症监护技能的校内培养,满足临床ICU对护理人才的需求具有现实意义。     

Patient severity as an indicator of nursing workload in the intensive care unit

The importance of measuring nursing workload in the intensive care unit (ICU) has been supported by both an increasing demand for nursing personnel and the relationship of nursing workload with patient safety. According to previous studies, the correlation between clinical severity of ICU patients and nursing workload measured by Therapeutic Intervention Scoring System has been estimated to be particularly high. The aim of this study was to investigate whether clinical severity of ICU patients can be used for the prediction of nursing workload on a daily basis. All patients admitted in the ICU of the General University Hospital of Patras for a 5-month period were enrolled in the study. Projet de Recherche en Nursing (PRN) Réa and Acute Physiology and Chronic Health Evaluation (APACHE) II scores of patients were calculated, the first on a daily basis and the second on the day of admission. Simple linear regression was used for statistical analysis of data. One hundred thirty-eight patients were studied. A progressive increase in mean daily PRN Réa of patients all along the amplitude of APACHE II values was shown. APACHE II could predict 25.6% (p < 0.01) of the daily variability of PRN Réa of patients. Regarding categories of PRN Réa, respiration, communication, diagnostic methods and treatments were significantly predicted by APACHE II. APACHE II explained higher proportions of PRN Réa in medical male patients aged >60 years. Clinical severity of the ICU patients measured by APACHE II is an important early indicator of daily nursing workload, especially of care demands associated with respiration, diagnostic methods and treatments.     

卒中单元重症监护对急性重症脑卒中的护理效果观察

目的探讨卒中单元建立重症监护病房对急性重症脑卒中的护理效果。方法将符合监护标准的61例急性重症脑卒中患者置卒中单元重症监护病房实施重症监护作为观察组（A组）,将2006年1月之前在本院神经内科及神经外科住院的急性重症脑卒中患者60例的常规护理作为对照组（B组）。对比两组患者的意识障碍程度评分、神经功能缺损程度评分、病残程度评分和并发症的发生率、病死率等指标,分析卒中单元对急性重症脑卒中患者实施重症监护的优越性。结果A组在改善神经功能缺损程度评分、意识障碍程度评分方面,均明显优于B组（P〈0.01）,并发症的发生率亦显著低于对照组（P〈0.01）。结论卒中单元建立重症监护病房对急性重症脑卒中患者实施重症监护,能有效提高急性重症脑卒中的疗效,显著提高护理质量,改善护患关系。     

Music during after‐death care: a focus group study

Background: The intensive care unit (ICU) is not only a place to recover from injuries incurred during accidents and from serious illness. For many patients, it is also a place where they might die. Nursing care does not stop when a patient dies; rather, it continues with the care of the deceased and with family support. The aims of this study were (1) to explore the experiences and attitudes of nurses towards the use of ambient music in the ICU during after‐death care and (2) to describe the feedback nurses received from relatives when music was used during the viewing. Method: A qualitative design employing focus group interviews was used. Three focus group interviews with 15 nurses were conducted. All the interviews were audiotaped, transcribed verbatim and analysed using qualitative content analysis. Findings: Six main categories of attitudes emerged from the analysis: (1) different attitudes among nurses towards the use of music; (2) music affects the atmosphere; (3) music affects emotions; (4) use of music was situational; (5) special choice of music and (6) positive feedback from the bereaved. Conclusion: This study demonstrates that music might be helpful for nurses during after‐death care as well as for the care of the relatives. Relevance to clinical practice: Including ambient music in an after‐death care programme can help nurses show respect for the deceased as the body is being prepared. Music played during the viewing may be a way of helping relatives in their time of grieving. It may ease the situation by making that event special and memorable. However, standardizing this intervention does not seem appropriate. Rather, the individual nurse and the family must decide whether music is to be used in a particular situation.     

A 6-y retrospective cohort study of family satisfaction with critical care and decision-making in an Australian intensive care unit

BackgroundPartnering with patients and families to make decisions about care needs is a safety and quality standard in Australian health services that is often not assessed systematically.ObjectiveThe objective of this study was to retrospectively evaluate satisfaction with care and involvement in decision-making among family members of patients admitted to the intensive care unit (ICU).MethodsA retrospective cohort analysis of a satisfaction survey administered to family members of patients admitted to an ICU in an Australian metropolitan tertiary care hospital from 2014 to 2019 was conducted. The Family Satisfaction in the Intensive Care Unit questionnaire (FSICU) questionnaire was used to assess overall satisfaction, satisfaction with care, and satisfaction with decision-making on a scale from “poor” (0) to “excellent” (100).ResultsIn total, 1322 family members fully completed the survey. Respondents were typically direct relatives of ICU patients (94.2%) with an average age of 52.6 years. Most patients had an ICU length of stay <7 d (56.8%), with most patients being discharged to the ward (96.8%). The overall mean satisfaction score was high among respondents (90.26%). Similarly, mean satisfaction with care (93.06%) and decision-making (89.71%) scores were high. Satisfaction with decision-making scores remained lower than satisfaction with care scores. Multivariable modeling indicated that those younger than 50 years reported higher satisfaction scores (p = 0.006) and those with prolonged lengths of stay in the ICU were associated with lower overall satisfaction scores (p = 0.039). Despite some criticism of waiting times and noise levels, responses showed sincere gratitude for patients’ treatment in the ICU and appreciation for the care, skill, and professionalism of the staff.ConclusionVery high satisfaction levels were reported by family members during this study. Routine, prospective evaluations of family member satisfaction with ICU experiences are feasible and can be leveraged to provide insight for clinicians and administrators seeking to improve family satisfaction with decision-making and care in ICU settings and meet national standards.     

以授课为基础的学习法和以问题为基础教学法双轨教学法在ICU临床教学中的应用

目的探讨以授课为基础的学习法（LBL）和以问题为基础的教学法（PBL）双轨教学法在实践中的互补性,以及在重症监护室临床教学中应用的效果。方法将2007-2010年在监护室轮转的学习生70人随机分成对照组和实验组,每组35人,对照组采用传统的LBL教学模式;实验组采用LBL结合PBL教学模式。并用闭卷考试和问卷调查评价教学效果。结果实验组考试总成绩、理论成绩、综合分析题成绩、护理病历书写成绩均明显高于对照组,差异有统计学意义（P〈0．01）,且实验组学生在激发学习兴趣、提高团队合作精神等方面有明显提高,差异有统计学意义（P〈0．05或P〈0．01）。结论LBL和PBL双轨教学模式对提高重症监护室临床教学具有积极的意义。     

Developing a framework for implementing intensive care unit diaries: a focused review of the literature

ObjectiveIntensive care unit diaries have been shown to improve post-critical illness recovery, however, prior reports of diary implementation are heterogeneous. We sought to construct a common framework for designing and implementing Intensive Care Unit diaries based on prior studies.Review method used/data sourcesWe conducted a focused review of the literature regarding intensive care diaries based on a systematic search of several databases. Two reviewers assessed 56 studies and data were abstracted from a total of 25 eligible studies conducted between 1990 and 2014. We identified key information regarding the development, design, and implementation of the journals. We then grouped elements that appeared consistently across these studies within three main categories: (1) diary target populations; (2) diary format and content; and (3) the manner of diary return and follow-up.ResultsMost studies were conducted in European countries in adult intensive care units and targeted patients in both medical and surgical units. The timing of diary initiation was based on the elapsed length of stay or duration of mechanical ventilation. We categorised diary format and content as: entry content, authors, use of standardised headings, type of language, initiation, frequency of entries, and physical location of diaries. Diaries were hand written and many studies found that photographs were an essential element in ICU diaries. We categorised the manner of diary return and follow-up. The context in which intensive care unit diaries were returned were felt to be important factors in improving the use of diaries in recovery.ConclusionsIn conclusion, we describe a common framework for the future development of intensive care unit diaries that revolves around the target population for the diaries, their format and content, and the timing of their use. Future studies should address how these elements impact the mechanisms by which intensive are diaries exert beneficial effects.