Implementation and evaluation of a network-based pilot program to improve palliative care in the intensive care unit

Background

Intensive care unit (ICU) care could be improved by implementation of time-triggered evidence-based interventions including identification of a patient/family medical decision maker, the patient’s advance directive status, and cardiopulmonary resuscitation preferences by Day 1; offer of social work and spiritual support by Day 3; and a family meeting establishing goals of care by Day 5. We implemented a program to improve care for ICU patients in five Department of Veterans Affairs’ ICUs.

Measures

We measured the percent of ICU patients with lengths of stay of five or more days that received the care processes by the appropriate day.

Intervention

Critical care and palliative care providers trained ICU nurse teams to improve care through auditing, performance feedback, improvement tools, education, and monthly team meetings.

Outcomes

Pre- and postintervention care were compared. Offering social work and spiritual support, identification of the medical decision maker, and documentation of family meetings significantly improved.

Conclusions/Lessons Learned

ICU nurse teams can be engaged to improve care under the aegis of a collaborative quality improvement project.     

临床医护工作站在急诊重症监护病房的应用与效果

目的研究临床医护工作站在急诊重症监护室环境下的应用方法与效果。方法首先对病室空间及环境进行改造,在急诊重症监护室患者床旁设立临床医护工作站实施管理。结果设立临床医护工作站后,临时医嘱处理时间缩短,不良事件的发生率下降,患者满意度提升。结论临床医护工作站的设立,能够帮助护理人员快速发现急危重症患者病情变化,及时处理医嘱,发现和防范医护工作隐患,减少护理不良事件的发生。     

手卫生干预措施提高新生儿重症监护室手消毒依从性的观察与效果

目的研究提高新生儿重症监护室的手消毒依从性。方法建立手卫生干预措施,并用视频监测手段观察干预前后共13个月的各类接触。结果实施手卫生干预措施后手消毒依从性从25．15％上升为88．20％;培训后护理员的手消毒依从性较医生和护士低,夜间护士和护理员的手消毒依从性低于白班（P〈0．01）。结论手卫生干预措施能有效提高手消毒的依从性。     

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.     

月市部超声在ICU的应用

对于危重症患者来说,呼吸功能的评价至关重要。一般临床医生通过体格检查配合x线胸片及CT等放射学检查即可对患者肺部情况得出大致印象。通常X线胸片敏感性较低,往往需进一步CT检查,而CT又因为其辐照度高使得检查重复性较差。降低辐照度是现代影像医学的发展方向之一。     

重症监护临床信息系统在急诊重症监护室中的应用

目的探讨重症监护临床信息系统(ICIS)在急诊重症监护室(EICU)中的应用效果。方法将本院急诊医学部重症监护室2014年8月—2015年1月收治的重症患者366例设为对照组,2015年2月—2015年7月收治的重症患者353例设为观察组。对照组患者应用"军卫一号",观察组应用重症监护临床信息系统,观察比较2组病情记录时间、观察项维护时间、出入量维护时间、核对确认医嘱时间及病情记录差错率、观察项维护差错率、出入量维护差错率和核对确认医嘱差错率。结果观察组护理记录时间、核对确认医嘱时间、护理工作记录差错率及核对确认医嘱差错率均显著低于对照组(P0.05)。结论 ICIS的应用提高了临床工作效率,节省了护理记录时间,降低了护理差错率,明显提高了临床护理质量和患者满意度。     

提高综合性ICU护理实习生带教质量方法探讨

目的:探讨提高综合性ICU护理实习生临床带教质量的方法。方法:对研究组的62名护理实习生按"一人总负责,一师一生"新的带教管理模式实施临床带教实习,出科前进行带教质量的理论与临床技能考核评价,并与对照组61名(一人专职带教)带教的质量考评结果相比较。结果:通过在综合性ICU为期6周的临床实习,新方法带教的护理实习生对实习大纲要求的各项综合性ICU理论知识与临床技能考评得分分别为(91.5±4.4)分和(88.2±4.1)分,均明显高于对照组(均P<0.01)。结论:在综合性ICU实施"一人总负责,一师一生"新的带教模式可以明显提高护理实习生的带教质量。     

Long term outcome after delirium in the intensive care unit

Aims and objectives. This research studied the long term outcome of intensive care delirium defined as mortality and quality of life at three and six months after discharge of the intensive care unit. Background. Delirium in the intensive care unit is known to result in worse outcomes. Cognitive impairment, a longer stay in the hospital or in the intensive care unit and a raised mortality have been reported. Design. A prospective cohort study. Methods. A population of 105 consecutive patients was included during the stay at the intensive care unit in July–August 2006. The population was assessed once a day for delirium using the NEECHAM Confusion Scale and the CAM‐ICU. Patients were visited at home by a nurse researcher to assess the quality of life using the Medical Outcomes Study Short‐Form General Health Survey at three and six months after discharge of the intensive care unit. Delirious and non delirious patients were compared for mortality and quality of life. Results. Compared to the non delirious patients, more delirious patients died. The total study population discharged from the intensive care unit, scored lower for quality of life in all domains compared to the reference population. The domains showed lower results for the delirious patients compared to the non delirious patients. Conclusions. Mortality was higher in delirious patients. All patients showed lower values for the quality of life at three months. The delirious patients showed lower results than the non delirious patients. Relevance to clinical practice. Nurses are the first caregivers to observe patients. The fluctuating delirious process is often not noticed. Long term effects are not visible to the interdisciplinary team in the hospital. This paper would like to raise the awareness of professionals for long term outcomes for patients having experienced delirium in the intensive care unit.     

全国30个省市三级医院重症监护病房医护人员呼吸治疗工作现状的问卷调查

目的 调查我国三级医院重症监护病房(ICU)呼吸治疗的仪器装备、工作内容和完成人等,为规范和发展呼吸治疗工作提供依据.方法 在2006年8月国内召开的三次大规模会议上发放问卷,调查30个省264家三级医院320个ICU的491名医护人员.结果 有创、无创呼吸机数与床位数之比分别为0.52: 1(2 189/4 185)和0.16:1(672/4 185).320个ICU中,超声、喷射式以及定量雾化吸入器的配用率分别为55.9%(179/320)、33.8%(108/320)和12.1%(39/320);机械通气中呼吸机设置、撤机、拔管主要由医师完成的ICU占92.1%、93.1%、83.5%,更换管路、吸痰、雾化、湿化主要由护士完成的ICU占83.7%、93.9%、91.6%、90.2%.491名回答者中撤机前行自主呼吸试验者占40.9%,不知道或从来不做者占26.2%;有创通气时未监测气道开口端温度者占27.1%;对撤机未拔管患者应用气管内持续滴入/泵入盐水湿化者占34.4%;55.6%的人员使用前检测呼吸机;管路更换频率依次为每周1次占48.1%,1～3 d和3～5 d更换1次者为25.0%、14.7%.结论 目前国内三级医院ICU的呼吸机数量较前已大幅增加,但对其他实用装置的应用尚不足;呼吸治疗工作主要由医生和护理人员共同承担,尚缺少专业的呼吸治疗师;机械通气、气道管理和呼吸机管理等呼吸治疗工作差异较大,缺乏统一的规范.     

A critical review of daily sedation interruption in the intensive care unit

Background. Daily sedation interruption (DSI) has been proposed as a method of improving sedation management of critically ill patients by reducing the adverse effects of continuous sedation infusions. Aim. To critique the research regarding daily sedation interruption, to inform education, research and practice in this area of intensive care practice. Design. Literature review. Method. Medline, CINAHL and Web of Science were searched for relevant key terms. Eight research‐based studies, published in the English language between 1995–December 2006 and three conference abstracts were retrieved. Results. Of the eight articles and three conference abstracts reviewed, five originated from one intensive care unit (ICU) in the USA. The research indicates that DSI reduces ventilation time, length of stay in ICU, complications of critical illness, incidence of post‐traumatic stress disorder and is reportedly used by 15–62% of ICU clinicians in Australia, Europe, USA and Canada. Conclusions. DSI improves patients’ physiological and psychological outcomes when compared with routine sedation management. However, research relating to these findings has methodological limitations, such as the use of homogenous samples, single‐centre trials and retrospective design, thus limiting their generalisability. Relevance to clinical practice. DSI may provide clinicians with a simple, cost‐effective method of reducing some adverse effects of sedation on ICU patients. However, the evidence supporting DSI is limited and cannot be generalised to heterogeneous ICU populations internationally. More robust research is required to assess the potential impact of DSI on the physical and mental health of ICU survivors.     

Reconsidering the transfer of patients from the intensive care unit to the ward: a case study approach

Evidence indicates that the poorly managed transfer of a patient from the intensive care unit (ICU) to the ward can lead to physical and psychological complications for the patient, and often require ICU readmission and rehospitalization. Reviewing this patient transfer process to improve the quality of care would be a positive step towards enhancing patients' recovery and providing skills to staff. The aim of this paper is to review case studies of transferring ICU patients to general wards in order to identify the shortcomings of this process. A literature review was conducted to evaluate current practices in the ICU transfer process. The results of this paper have clinical implications, suggest approaches to improve support for patients and their carers, and provide strategies to improve the transfer procedure.     

Possibilities for cost containment in intensive care

An intensive care unit (ICU) is valuable but consumes a disproportionately high amount of health-care resources. Accordingly, cost containment has been deemed a mandatory task. A review of the literature from many countries was completed to determine the strategies for reducing the cost of care in the ICU. The results of this review show that cost reduction can be achieved by using a variety of the following strategies: (i) instituting a closed ICU, where all the patient care is directed by intensivists or full-time critical care trained physicians; (ii) the utilization of interdisciplinary approaches to the care of patients in the ICU; (iii) developing and implementing a program of television-guided remote intensivists; (iv) the use of an alerting and reminding system; and (v) increasing the number of intermediate care beds for patients who require only monitoring and intensive nursing. The conclusion reached is that many of these strategies provide evidence for hospital manager decisions regarding cost containment strategies for the delivery of health care in the ICU.     

Clinical review: impact of emergency department care on intensive care unit costs

Critical care is both expensive and increasing. Emergency department (ED) management of critically ill patients before intensive care unit (ICU) admission is an under-explored area of potential cost saving in the ICU. Although limited, current data suggest that ED care has a significant impact on ICU costs both positive and negative. ICU practices can also affect the ED, with a lack of ICU beds being the primary reason for ED overcrowding and ambulance diversion in the USA. Earlier application in the ED of intensive therapies such as goal-directed therapy and noninvasive ventilation may reduce ICU costs by decreasing length of stay and need for admission. Future critical care policies and health services research should include both the ED and ICU in their analyses.     

经皮扩张气管切开术在ICU的应用和护理

目的探讨运用经皮气管扩张切开术（PDT）在重症监护病房（ICU）中的应用效果和护理。方法以气管切开术患者40例为研究对象,随机分为标准的开放性气管切开术（OT）组和经皮扩张气管切开术（PDT）组,每组20例,比较两组的手术时间、术中出血量及术后出血量,并总结分析行PDT患者的护理过程。结果 PDT组手术时间为（10.82±1.47）min、术中出血量及术后出血量分别为（5.86±0.18）mL、（3.21±0.13）mL,与OT组比较,P〈0.01。结论与标准的外科气管切开术组比,PDT手术时间短,出血量少,更加易于护理。     

Research in intensive care nursing

• • The results of a questionnaire study about intensive care nursing in Finland indicate that the chief problems in intensive care nursing are concerned with staff coping resources, quality development and patient experiences.
• • Questions on staff stress and coping have been researched quite extensively. Earlier studies have described intensive care nursing as highly stressful and pointed to numerous problems related to coping.
• • It is clear that intensive care nursing warrants closer attention in research.