Australian Critical Care RSS feed: Articles in Press. Australian Critical Care is a peer-reviewed journal, providing clinically relevant research, reviews and articles of interest to our members. Australian Critical Care is published quarterly. Original contributions relevant to critical care nursing are invited. The editor welcomes manuscripts reporting original research or innovative practices and technologies, continuing education articles, descriptions of instructive case studies and editorials and book reviews sought by the editor. Authors may also contribute unsolicited editorials and book reviews by arrangement with the editor. Nursing Consult Visit our new nursing resource, Nursing Consult To purchase books on Critical Care Nursing or to browse our comprehensive range of nursing titles, please visit us at shop.elsevier.com.au. For a limited time we are offering 10% discount and free freight to all ANZ orders. Shop.elsevier.com.au/CriticalCare http://www.australiancriticalcare.com//inpress?rss=yesElsevier Inc.en © 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Inc. All rights reserved. Australian Critical Care1036-73142012-02-06 © 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.australiancriticalcare.com/article/PIIS1036731411002335/abstract?rss=yesSummary: The aim of this paper is to review the differences and similarities in critical care nursing staffing, education and practice standards in the US, Canada, UK, New Zealand and Australia.Search methods: A university library discovery catalogue, Science Direct, Scopus databases and professional websites were searched. Key terms used included, critical care, specialist, standards, competency, practice, scope, workforce, staffing, ratios, qualifications, adverse events, and patient outcomes. The search was limited to articles that referred to critical care environments including paediatric and neonatal settings.Results: The database and hand search identified 40 relevant articles. Website searching resulted in a further 36 documents. A diversity of critical care nursing contexts and a lack of comparable workforce data made it difficult to quantify differences and similarities between countries. There is a general consensus about the importance of optimum staffing by registered nurses with a proportion of those holding relevant post-registration qualifications although there is no consistency in defining the educational preparation for a ‘qualified’ critical care nurse. Critical care nursing standards for the US, Canada, UK and New Zealand were predominantly developed by expert panels while the Australian standards were developed with a multi-methods study including observations of practice. All five standards documents were built upon national entry-to-practice nurse standards and contained similar constructs, although there was no construct common to all of the standards.Conclusion: There is a lack of evidence to support nursing staffing with post registration specialty qualifications. Existing standards are predominantly opinion based rather than supported by research. The expected standards for nursing practice are fundamentally similar.A review of critical care nursing staffing, education and practice standards - Corrected ProofFenella J. Gill, Gavin D. Leslie, Carol Grech, Jos M. Latour10.1016/j.aucc.2011.12.056Australian Critical Care (2012)2012-02-06Australian Critical Care2012-02-06RESEARCH PAPERhttp://www.australiancriticalcare.com/article/PIIS1036731411002323/abstract?rss=yesSummary: Background: The increasing and widespread use of complementary and alternative medicine in the general population requires health-care professionals to have a knowledge and appreciation of their use to ensure that decisions about care are appropriate, safe and meet patients’ needs. This is also the case for critical care nurses. Presently, healthcare professionals including nurses have limited formal education on complementary and alternative medicine. Critical care nurses’ role in relation to complementary and alternative medicine is important for two patient care reasons: some can adversely interact with conventional medicines and others can potentially improve patient's well-being. Australian critical care nurses’ knowledge of complementary and alternative medicine is unknown.Purpose: To identify Australian critical care nurses’ assessment practices, attitudes, knowledge, and use of complementary and alternative medicine in practice.Methods: A descriptive, exploratory online survey of Australian critical care nurses through a national critical care nursing database was undertaken during early 2011.Findings: Five of twenty-eight therapies were endorsed by the respondents (n=379) most positively regarding legitmacy, knowledge, benefit and use in practice: exercise; diet; counselling/psychology; relaxation techniques; and massage. The findings also suggest that a specific area within patient files promotes the practice of identifying and recording current complementary and alternative medicine use and that the majority of respondents supported further education.Conclusion: Critical care nurses although supporting a number of therapies also identified a need for increased knowledge and understanding. As the findings also suggest that patients and families are requesting a range of therapies there is a need to investigate the provision of appropriate educational resources for critical care nurses to ensure safe and evidence-based care.Complementary and alternative medicine and critical care nurses: A survey of knowledge and practices in Australia - Corrected ProofMarie Cooke, Marion Mitchell, Evelin Tiralongo, Jenny Murfield10.1016/j.aucc.2011.12.055Australian Critical Care (2012)2012-01-30Australian Critical Care2012-01-30http://www.australiancriticalcare.com/article/PIIS1036731411001676/abstract?rss=yesSummary: Background: Less invasive methods of determining cardiac output are now readily available. Using indicator dilution technique, for example has made it easier to continuously measure cardiac output because it uses the existing intra-arterial line. Therefore gone is the need for a pulmonary artery floatation catheter and with it the ability to measure left atrial and left ventricular work indices as well the ability to monitor and measure a mixed venous saturation (SvO2).Purpose: The aim of this paper is to put forward the notion that SvO2 provides valuable information about oxygen consumption and venous reserve; important measures in the critically ill to ensure oxygen supply meets cellular demand. In an attempt to portray this, a simplified example of the septic patient is offered to highlight the changing pathophysiological sequelae of the inflammatory process and its importance for monitoring SvO2.Relevance to clinical practice: SvO2 monitoring, it could be argued, provides the gold standard for assessing arterial and venous oxygen indices in the critically ill. For the bedside ICU nurse the plethora of information inherent in SvO2 monitoring could provide them with important data that will assist in averting potential problems with oxygen delivery and consumption. However, it has been suggested that central venous saturation (ScvO2) might be an attractive alternative to SvO2 because of its less invasiveness and ease of obtaining a sample for analysis. There are problems with this approach and these are to do with where the catheter tip is sited and the nature of the venous admixture at this site. Studies have shown that ScvO2 is less accurate than SvO2 and should not be used as a sole guiding variable for decision-making. These studies have demonstrated that there is an unacceptably wide range in variance between ScvO2 and SvO2 and this is dependent on the presenting disease, in some cases SvO2 will be significantly lower than ScvO2.Conclusion: Whilst newer technologies have been developed to continuously measure cardiac output, SvO2 monitoring is still an important adjunct to clinical decision-making in the ICU. Given the information that it provides, seeking alternatives such as ScvO2 or blood samples obtained from femorally placed central venous lines, can unnecessarily lead to inappropriate treatment being given or withheld. Instead when using ScvO2, trending of this variable should provide clinical determinates that are useable for the bedside ICU nurse, remembering that in most conditions SvO2 will be approximately 16% lower.Mixed venous oxygen saturation monitoring revisited: Thoughts for critical care nursing practice - Corrected ProofMartin Christensen10.1016/j.aucc.2011.10.001Australian Critical Care (2011)2011-11-23Australian Critical Care2011-11-23REVIEW PAPERhttp://www.australiancriticalcare.com/article/PIIS1036731411001688/abstract?rss=yesSummary: Introduction: Health professionals are confronted with the difficulty of adequately evaluating pain in critically ill, brain-injured patients, as these patients are often unable to self-report. In addition, their confused and stereotyped behaviours may change their responses to pain; the indicators and descriptors generally used to evaluate pain in the critically ill may therefore not be appropriate for brain-injured patients.Aim: The aim of this integrative review was to identify clinically measurable and observable pain indicators and descriptors for brain-injured, critically ill adults.Method: A search of electronic databases (Medline, CINAHL, Embase) combined with cross-referencing was performed. Articles were included if they described pain indicators in critically ill adults and included brain-injured patients in their population.Results: Seven articles met the inclusion criteria. They were critically appraised for their quality and their relevance for the population of brain-injured patients. Behavioural pain indicators such as facial expressions, body movements and muscle tension were found in all of the articles. However, the descriptions of the indicators differ from one article to another. The intensity and nature of behavioural pain responses vary according to the level of consciousness. Changes in physiological parameters have also been reported, but these results are inconclusive.Conclusion: Additional research is needed to identify and better describe pain indicators that are specific to brain-injured patients in the ICU. Studies with large samples, different brain injury diagnoses and various levels of consciousness are warranted.Pain indicators in brain-injured critical care adults: An integrative review - Corrected ProofMarie-José Roulin, Anne-Sylvie Ramelet10.1016/j.aucc.2011.10.002Australian Critical Care (2011)2011-11-21Australian Critical Care2011-11-21REVIEW PAPERhttp://www.australiancriticalcare.com/article/PIIS103673141100169X/abstract?rss=yesSummary: The aim of an Intensive Care Nurse Consultant (ICNC) service is to optimise care of complex ward patients and reduce adverse events. Despite their widespread implementation, specific assessment of ward nurses’ attitudes towards such is lacking. Accordingly, we surveyed ward nurses’ attitudes towards our ICNC service in five domains: (a) accessibility and approachability; (b) perceived ICNC skill and knowledge; (c) perceived influence on patient management; (d) usefulness as a resource of clinical information; (e) impact upon adverse outcomes. To achieve this, an anonymous Liker-type questionnaire was distributed to 208 ward nurses in our hospital. We also included space for free text. Completed questionnaires were entered manually into a SURVEYMONKEY™ pro-forma to permit automatic report generation and results summary.The major findings were that ICNC staff were perceived as being approachable and good communicators, were skilled at early detection of deteriorating patients, and that they reduce serious adverse events. In addition, nurses believe the ICNC service provides continuity of care post discharge from the intensive care unit (ICU), as well as assisting staff to prioritise clinical issues following medical emergency team (MET) review or ICU discharge. The ward nurses did not believe that the ICNC service reduced their skills in managing ward patients. In contrast, respondents stated that the ICNC service needed to improve the processes of referral to allied health and education of ward staff regarding deteriorating patients. Finally, ward nurses suggest they would call the MET service rather than the ICNC service for patients who had already deteriorated.This survey suggests that the ICNC service is valued, and is perceived to prevent the development of adverse events, rather than playing a major role in the management of the deteriorating patient. There is a need to improve referrals to allied health and further educate ward nurses.A survey of ward nurses attitudes to the Intensive Care Nurse Consultant service in a teaching hospital - Corrected ProofTammie McIntyre, Carmel Taylor, Glenn M. Eastwood, Daryl Jones, Ian Baldwin, Rinaldo Bellomo10.1016/j.aucc.2011.10.003Australian Critical Care (2011)2011-11-17Australian Critical Care2011-11-17http://www.australiancriticalcare.com/article/PIIS1036731411001391/abstract?rss=yesSummary: In November 1999, the Queensland Health (QH) Transition to Practice Nurse Education Program – Intensive Care (TPNEP-IC) was initiated in QH Intensive Care Units (ICUs) across Queensland. This 12-month, state-wide, workplace based education program has set minimum standards for intensive care nursing education and therefore minimum standards for intensive care nursing practice in QH. In the 12 years of operation, 824 nurses have completed TPNEP-IC, 761 achieving academic credit status and 453 utilising this academic credit status to undertake postgraduate study in critical/intensive care nursing at three Queensland universities. These outcomes were achieved through the appointment of nurse educators within ICUs who, through a united and strong commitment to this state-wide approach formed collaborative professional networks, which resulted in the development, implementation and maintenance of the program. Furthermore, these networks enabled a framework of support for discussion and dissemination of evidence based practice, to endorse quality processes for TPNEP-IC and to nurture leadership potential among educators. Challenges to overcome included obtaining adequate resources to support all aspects of the program, gaining local management and administrative support, and embedding TPNEP-IC within ICU culture. The 12 years of operation of the program have demonstrated its long term sustainability. The program is being launched through a new blended learning approach utilising e-learning strategies. To capitalise on the current success, a strong commitment by all stakeholders will be required to ensure the ongoing sustainability of the program.Transition to intensive care nursing: A state-wide, workplace centred program—12 years on - Corrected ProofAlison Juers, Margaret Wheeler, Helen Pascoe, Nicola Gregory, Cheryl Steers10.1016/j.aucc.2011.09.001Australian Critical Care (2011)2011-09-30Australian Critical Care2011-09-30http://www.australiancriticalcare.com/article/PIIS103673141100138X/abstract?rss=yesSummary: Background: There is a lack of evidence to direct and support nursing practice in the specialty of paediatric intensive care (PIC). The development of national PIC nursing research priorities may facilitate the process of undertaking clinical research and translating evidence into practice.Purpose: To (a) identify research priorities for the care of patients and their family as well as for the professional needs of PIC nurses, (b) foster nursing research collaboration, (c) develop a research agenda for PIC nurses.Methods: Over 13 months in 2007–2008, a three-round questionnaire, using the Delphi technique, was sent to all specialist level registered nurses working in Australian and New Zealand PICUs. This method was used to identify and prioritise nursing research topics. Content analysis was used to analyse Round I data and descriptive statistics for Round II and III data.Results: In Round I, 132 research topics were identified, with 77 research priorities (mdn>6, mean MADmedian 0.68±0.01) identified in subsequent rounds. The top nine priorities (mean>6 and median>6) included patient issues related to neurological care (n=2), pain/sedation/comfort (n=3), best practice at the end of life (n=1), and ventilation strategies (n=1), as well as two priorities related to professional issues about nurses’ stress/burnout and professional development needs.Conclusion: The research priorities identified reflect important issues related to critically ill patients and their family as well as to the nurses caring for them. These priorities can be used for the development of a research agenda for PIC nursing in Australia and New Zealand.A Delphi study on National PICU nursing research priorities in Australia and New Zealand - Corrected ProofAnne S. Ramelet, Fenella Gill, The ACCCN Paediatric Intensive Care Special Interest Group10.1016/j.aucc.2011.08.003Australian Critical Care (2011)2011-09-26Australian Critical Care2011-09-26http://www.australiancriticalcare.com/article/PIIS1036731411001378/abstract?rss=yesSummary: Introduction: The work activities of an Intensive Care Unit (ICU) nurse is frequently dynamic and variable. The activities are not necessarily linear actions that occur in a structured manner but are more complex and not well documented. A greater understanding of the type and level of activity assists in informing workload models.Objective: The aim of this study was to describe and analyse the work activities of bedside Intensive Care Unit (ICU) nurses during the day shift.Methods: Time and motion observational methodology was used to observe 10 bedside ICU nurses during the day shift, Monday to Friday. All activities undertaken by the nurses during their shift were timed and recorded and then were coded according to whether they involved direct or indirect patient activities, or were unit or personally related.Results: Just over 76h of observations occurred over 10 days and 3081 activities documented during this time. The major work activity groups for the ICU nurses were; ‘direct care’ 1857 activities and 40.5% of their time, ‘indirect care’ 986 activities and 32.4% of their time, ‘personal’ activities 140 activities and 21.9% of their time and ‘unit-related’ 98 activities and 5.0% of their time. The ICU nurses undertook two activities simultaneously for 43% of the study timeframe.Conclusion: This study provides baseline evidence on the activities nurses undertake on a daily basis, with only about a quarter of their time not being spent on patient care activities, either directly or indirectly.Understanding the work of intensive care nurses: A time and motion study - Corrected ProofM. Abbey, W. Chaboyer, M. Mitchell10.1016/j.aucc.2011.08.002Australian Critical Care (2011)2011-09-22Australian Critical Care2011-09-22http://www.australiancriticalcare.com/article/PIIS1036731411001366/abstract?rss=yesAccording to Meleis and colleagues, the core of nursing practice is to coach patients through transition(s). Transitions are passages from one life phase, physical condition, or social role to another, resulting in a temporarily disconnectedness of the normal way of living, which demands an adjustment of the patient and the environment. As the primary caregivers for patients and their families, nurses need to support, educate and counsel patients, resulting in a successful transition experience for the patient. Furthermore, nurses have to facilitate the development of new skills, knowledge and behaviours in patients to achieve favourable transition outcomes.Coaching through transition: A challenge for critical care nurses - Corrected ProofEva Goossens, Deborah Hilderson, Philip Moons10.1016/j.aucc.2011.08.001Australian Critical Care (2011)2011-09-12Australian Critical Care2011-09-12GUEST EDITORIALhttp://www.australiancriticalcare.com/article/PIIS1036731411001330/abstract?rss=yesSummary: Background: Risk prediction models can assist in identifying individuals at risk of adverse events and also the judicious allocation of scare resources. Our objective was to describe risk prediction models for the rehospitalisation of individuals with chronic heart failure (CHF) and identify the elements contributing to these models.Methods: The electronic data bases MEDLINE, PsychINFO, Ovid Evidence-Based Medicine Reviews and Scopus (1950–2010), were searched for studies that describe models to predict all-cause hospital readmission for individuals with CHF. Search terms included: patient readmission; risk; chronic heart failure, congestive heart failure and heart failure. We excluded non-English studies, pediatric studies, and publications without original data.Results: Only 1 additional model was identified since the review undertaken by Ross and colleagues in 2008. All models were derived from data sets collected in the United States and patients were followed from 60 days to 18 months. The only common predictors of re-hospitalisation in the models identified by Ross and colleagues were a history of diabetes mellitus and a history of prior hospitalisation. The additional model extends its scope to include the non clinical factors of social instability and socioeconomic status as predictors of rehospitalisation.Conclusions: In spite of the burden of hospitalisation in CHF, there are limited tools to assist clinicians in assessing risk. Developing risk prediction models, based on patient, provider and system characteristics may assist in identifying individuals in the community at greatest risk and in need of targeted interventions to improve outcomes.What are the factors in risk prediction models for rehospitalisation for adults with chronic heart failure? - Corrected ProofVasiliki Betihavas, Patricia M. Davidson, Phillip J. Newton, Steven A. Frost, Peter S. Macdonald, Simon Stewart10.1016/j.aucc.2011.07.004Australian Critical Care (2011)2011-09-05Australian Critical Care2011-09-05http://www.australiancriticalcare.com/article/PIIS1036731411000968/abstract?rss=yesSummary: Background: Critical care nurses frequently and independently manage oxygen therapy. Despite the importance of oxygen therapy, there is limited evidence to inform or support critical care nurses’ oxygen therapy practices.Aim: To establish if there is variability in oxygen therapy practices of critical care nurses and examine the degree of variability.Method: On-line questionnaire of ACCCN members between April and June 2010.Results: The response rate was 36% (542/1523 critical care nurses). Overall, 378 (70%) respondents practiced in metropolitan critical care units; 278 (51%) had ≥14 years of specialty practice. In response to falling SpO2, 8.9% of nurses would never escalate oxygen therapy without a doctor's request, and 51% of nurses would not routinely escalate oxygen therapy in the absence of medical orders. Only 56% of nurses reported always increasing FiO2 prior to endotracheal suctioning. In mechanically ventilated patients, 33% of nurses believed oxygen toxicity was a greater threat to lung injury than barotrauma. More than >60% of respondents reported a tolerance for a stable SpO2 of 90%. Nurses in rural critical care units were less likely to independently titrate oxygen to their own target SpO2, but more likely to independently treat a falling SpO2 with higher FiO2.Conclusion: Critical care nurses varied in their self-reported oxygen therapy practices justifying observational and interventional studies aimed at improving oxygen therapy for critically ill patients.Critical care nurses’ opinion and self-reported practice of oxygen therapy: A survey - Corrected ProofGlenn M. Eastwood, Michael C. Reade, Leah Peck, Ian Baldwin, Julie Considine, Rinaldo Bellomo10.1016/j.aucc.2011.05.001Australian Critical Care (2011)2011-06-30Australian Critical Care2011-06-30http://www.australiancriticalcare.com/article/PIIS1036731411000555/abstract?rss=yesSummary: Background: End-of-life care is a significant component of work in intensive care. Limited research has been undertaken on the provision of end-of-life care by nurses in the intensive care setting. The purpose of this study was to explore the end-of-life care beliefs and practices of intensive care nurses.Methods: A descriptive exploratory qualitative research approach was used to invite a convenience sample of five intensive care nurses from one hospital to participate in a semi-structured interview. Interview transcripts were analysed using an inductive coding approach.Findings: Three major categories emerged from analysis of the interviews: beliefs about end-of-life care, end-of-life care in the intensive care context and facilitating end-of-life care. The first two categories incorporated factors contributing to the end-of-life care experiences and practices of intensive care nurses. The third category captured the nurses’ end-of-life care practices.Conclusions: Despite the uncertainty and ambiguity surrounding end-of-life care in this practice context, the intensive care setting presents unique opportunities for nurses to facilitate positive end-of-life experiences and nurses valued their participation in the provision of end-of-life care. Care of the family was at the core of nurses’ end-of-life care work and nurses play a pivotal role in supporting the patient and their family to have positive and meaningful experiences at the end-of-life. Variation in personal beliefs and organisational support may influence nurses’ experiences and the care provided to patients and their families. Strategies to promote an organisational culture supportive of quality end-of-life care practices, and to mentor and support nurses in the provision of this care are needed.End-of-life care in the intensive care setting: A descriptive exploratory qualitative study of nurses’ beliefs and practices - Corrected ProofKristen Ranse, Patsy Yates, Fiona Coyer10.1016/j.aucc.2011.04.004Australian Critical Care (2011)2011-05-12Australian Critical Care2011-05-12