Australian Critical Care - Articles in Press

A national survey of Australian Intensive Care Unit (ICU) Liaison Nurse (LN) services - Corrected Proof

Suzanne Eliott, Wendy Chaboyer, David Ernest, Andrea Doric, Ruth Endacott — 2012-05-07

Summary: Background: The Intensive Care Unit (ICU) Liaison Nurses (LNs) emerged as a member of the multidisciplinary team to: assist in the transition of patients from ICU to the ward, respond to the deteriorating patient in an appropriate and timely manner, and in some instances act as an integral member of Rapid Response Teams (RRT).Purpose: To identify the common core aspects and diversity within the ICU LN role across Australia and to determine whether the ICU LN hours of operation and the participation in MET teams has any impact on the activities undertaken by the ICU LN.Method: This descriptive survey of 152 Australian ICUs was conducted in April 2010. The Advanced Practice Nurse (APN) framework was used to develop the survey instrument, which comprised of four scales, education (5 items), collaboration (6 items), practice (8 items) research and quality (6 items) and a number of demographic questions. Descriptive statistics (mean, standard deviation (SD), median, interquartile ranges (IQR) and frequency) were used to summarise the data. Student's t-tests and Pearson's correlations were used to test the hypotheses.Results: Surveys were received from 113 hospitals (55 metropolitan, 58 regional): a 74% response rate. ICU LN services operated in 31 (27%) of these hospitals. LN services tended to operate in larger hospitals with higher ICU admission rates.The median weekly hours of operation was 56 (IQR 30; range 7–157), delivered by a median of 1.4 (IQR 0.9; range 0.0–4.2) Full Time Equivalent (FTE) staff. The median weekly patient visits made by the LN was 25 (IQR 44; range 2–145). The LN was reported to be a member of the Medical Emergency Team (MET) in 17 (68%) of the 25 hospitals that provided both MET and ICU LN services. The ICU LN activities were grouped under four key Advanced Practice Nurse (APN) domains: education, collaboration, practice and research/quality. Mean scale scores were calculated for each APN domain. The ICU LN reported being involved in activities associated with all four APN domains, and more frequently they were involved in education and expert practice during their daily work. Neither the presence of a MET nor the weekly operational hours of the LN service significantly affected the key activities undertaken by ICU LNs (education, collaboration, practice, research and quality).Conclusion: Whilst many hospitals across Australia have introduced an ICU LN service, the staffing, hours of service, job classifications, reporting lines, referral processes and APN activities undertaken by the ICU LN, vary between hospitals, highlighting the diverse nature of ICU LN services across Australia.

Measuring paediatric intensive care nursing knowledge in Australia and New Zealand: How the Basic Knowledge Assessment Tool for pediatric critical care nurses (PEDS-BKAT4) performs - Corrected Proof

Debbie Long, Jeanine Young, Claire M. Rickard, Marion L. Mitchell — 2012-04-20

Summary: Validated professional knowledge measures are limited in paediatric intensive care unit (PICU) nursing. The Basic Knowledge Assessment Tool for Pediatric Critical Care Nurses (PEDS-BKAT4) measures knowledge, however content and practice differences exist between various PICUs. The study aim was to evaluate the PEDS-BKAT4 in the Australian and New Zealand setting. A panel of 10 experts examined item and scale content validity. Items were evaluated for 31 evidence-based item writing flaws and for cognitive level, by a 4-person expert panel. Thirty-six PICU nurses completed the PEDS-BKAT4, with reliability and item analysis conducted. Mean item content validity was 0.70, and 43% of items had content validity less than 0.8. Overall (Scale) content validity was 0.71. Thirty-five percent of items were classified as flawed. Thirty-five percent of items were written at the ‘knowledge’ level, and 58% at ‘understanding’. The mean PEDS-BKAT4 score was 60.8 (SD=9.6), KR-20 reliability 0.81. The mean item difficulty was 0.62, and the mean discrimination index was 0.23. The PEDS-BKAT4 was not a reliable and valid measure of basic PICU nursing knowledge in Australian and New Zealand. Further research into the types of knowledge and skills required of PICU nurses in this setting are needed to inform the development of a future tool.

Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: A literature review - Corrected Proof

Matthew McGahan, Geraldine Kucharski, Fiona Coyer — 2012-04-20

Summary: Background: Studies have shown that nurse staffing levels, among many other factors in the hospital setting, contribute to adverse patient outcomes. Concerns about patient safety and quality of care have resulted in numerous studies being conducted to examine the relationship between nurse staffing levels and the incidence of adverse patient events in both general wards and intensive care units.Aim: The aim of this paper is to review literature published in the previous 10 years which examines the relationship between nurse staffing levels and the incidence of mortality and morbidity in adult intensive care unit patients.Methods: A literature search from 2002 to 2011 using the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Australian digital thesis databases was undertaken. The keywords used were: intensive care; critical care; staffing; nurse staffing; understaffing; nurse–patient ratios; adverse outcomes; mortality; ventilator-associated pneumonia; ventilator-acquired pneumonia; infection; length of stay; pressure ulcer/injury; unplanned extubation; medication error; readmission; myocardial infarction; and renal failure. A total of 19 articles were included in the review. Outcomes of interest are patient mortality and morbidity, particularly infection and pressure ulcers.Results: Most of the studies were observational in nature with variables obtained retrospectively from large hospital databases. Nurse staffing measures and patient outcomes varied widely across the studies. While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies concluded that a trend exists between increased nurse staffing levels and decreased adverse events.Conclusion: While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies demonstrated a trend between increased nurse staffing levels and decreased adverse patient outcomes in the intensive care unit which is consistent with previous literature. While further more robust research methodologies need to be tested in order to more confidently demonstrate this association and decrease the influence of the many other confounders to patient outcomes; this would be difficult to achieve in this field of research.

Is the evidence for the use of subglottic drainage to prevent ventilated-associated pneumonia sufficient to change practice? - Corrected Proof

Teresa A. Williams — 2012-04-09

Summary: This paper critiques the systematic review and meta-analysis of the effect of subglottic drainage among patients who received mechanical ventilation. Subglottic secretion drainage can reduce bacterial pathogens from entering the lower respiratory tract and potentially reduce the occurrence of ventilator-associated pneumonia. A summary of the systematic review and meta-analysis is provided. The critique examines the study's strengths and weaknesses and implications for practice are discussed. It is a well-conducted systematic review and meta-analysis with few suggestions for improvement. Subglottic secretion drainage reduced the incidence of ventilator-associated pneumonia. Several studies have shown positive effects of using subglottic drainage but despite the evidence, the practice in ICUs is not widespread.

Why don’t intensive care nurses perform routine delirium assessment? A discussion of the literature - Corrected Proof

Louise.G. Wells — 2012-04-06

Summary: Delirium is a well recognised and serious problem in adult intensive care patients. With a reported incidence as high as 87%, it has been associated with increased length of stay, higher costs of care, ongoing cognitive impairment and increased mortality rates. The problem is so significant that routine, formal delirium assessment is recommended for all intensive care patients. However, there is evidence to suggest that few intensive care nurses are incorporating this screening into their daily practice. The aim of this paper is to discuss what is currently known about intensive care nurses’ attitudes and beliefs in relation to caring for adults who are experiencing delirium, with a focus on identifying possible barriers to formal delirium assessment. It will be argued that intensive care nurses are well placed to perform regular delirium assessment and therefore have a responsibility to promote an improvement in delirium assessment practices.

A case of pressure ulceration and associated haemorrhage in a patient using a faecal management system - Corrected Proof

Mark G. Reynolds, Frank van Haren — 2012-04-05

Summary: Diarrhoea is a difficult patient problem to manage in the intensive care setting, causing odour, discomfort and embarrassment for the patient and potential for loss of skin integrity and cross contamination. Caring for these patients is resource-intensive. A recently developed product for the management of faecal incontinence is the Flexi-Seal Faecal Management System (FMS©).Whilst this product is usually effective for managing diarrhoea, there are uncommon but serious complications associated with its use. Rectal bleeding attributed to pressure ulceration of the rectal mucosa can be severe, especially in conjunction with the use of anticoagulation.We report a case of severe rectal bleeding requiring surgical intervention and administration of large amounts of blood products, caused by pressure ulceration as a result of the use of a Flexi-Seal FMS©. The case report is followed by a review of the literature. Similar complications have been described by others. Although, based on the number of reported complications, the incidence of serious complications appears to be low, a publication bias cannot be ruled out.Knowledge of the complications associated with the device is important for evaluating the appropriateness of insertion and for ensuring the safe and effective on going care of patients using Flexi-Seal FMS©.

Correlational analysis - Corrected Proof

Roshani K. Prematunga — 2012-04-05

Summary: A common question of interest in nursing research is the relationships between variables. Correlational analysis is a statistical technique employed to investigate the magnitude and significance of such relationships. This paper presents commonly used techniques to examine bivariate relationships of interval/ratio, ordinal and nominal variables.

Adherence to therapeutic hypothermia guidelines for out-of-hospital cardiac arrest - Corrected Proof

Regina Boyce, Kelly Bures, Jan Czamanski, Marion Mitchell — 2012-03-29

Summary: Background: Out of hospital cardiac arrest is associated with a high rate of mortality, and poor neurological outcomes. Favourable neuro-protective effects are associated with induced hypothermia and international recommendations exist for therapeutic hypothermia.Objective: This study reviews practice for therapeutic hypothermia for out of hospital cardiac arrest patients within one ICU. It aims to describe the level of adherence to the guideline, identify barriers to implementation and to improve adherence.Setting: This project was conducted in an adult ICU which admits 2000 patients yearly.Methods: A retrospective chart audit was used to document practice for a 12month period.Results: 33 patients were admitted to the ICU with a diagnosis of out of hospital cardiac arrest and met study inclusion criteria. From this sample of 33 patients, four patients (12%) were at the goal temperature of 32.5–33.5°C, in the target time of 2h. Nearly half (n=17) were not cooled at all. The length of time the patient was in the ICU prior to active cooling commencing varied from <1h (n=15, 45%) to >3h (n=5, 15%). Twenty-four percent (n=9) were cooled for the recommended length of time. There were medical orders stating a target temperature in nearly half of the cases (n=18), however, only 27% (n=9) were consistent with the ICU guidelines. A number of strategies have been initiated. They aim to improve communication and ready access to the required materials.Conclusions: The audit indicated that less than a third of the patients experienced therapeutic induced hypothermia and only 12% were at goal temperature within the required 2h. Strategies initiated to improve guideline implementation included; regular education sessions with ICU staff; placing a cooling blanket on the bed prior to admitting a patient post OOHCA; improving ready access to cooling agents and the addition of a care path for the induction and maintenance of therapeutic hypothermia to support and prompt clinicians when using the computerised patient record system.

Design and implementation of a virtual world training simulation of ICU first hour handover processes - Corrected Proof

Ross Brown, Rune Rasmussen, Ian Baldwin, Peta Wyeth — 2012-03-21

Summary: Nursing training for an Intensive Care Unit (ICU) is a resource intensive process. High demands are made on staff, students and physical resources. Interactive, 3D computer simulations, known as virtual worlds, are increasingly being used to supplement training regimes in the health sciences; especially in areas such as complex hospital ward processes. Such worlds have been found to be very useful in maximising the utilisation of training resources. Our aim is to design and develop a novel virtual world application for teaching and training Intensive Care nurses in the approach and method for shift handover, to provide an independent, but rigorous approach to teaching these important skills. In this paper we present a virtual world simulator for students to practice key steps in handing over the 24/7 care requirements of intensive care patients during the commencing first hour of a shift. We describe the modelling process to provide a convincing interactive simulation of the handover steps involved. The virtual world provides a practice tool for students to test their analytical skills with scenarios previously provided by simple physical simulations, and live on the job training. Additional educational benefits include facilitation of remote learning, high flexibility in study hours and the automatic recording of a reviewable log from the session. To the best of our knowledge, we believe this is a novel and original application of virtual worlds to an ICU handover process. The major outcome of the work was a virtual world environment for training nurses in the shift handover process, designed and developed for use by postgraduate nurses in training.

Mechanism of paracetamol-induced hypotension in critically ill patients: A prospective observational cross-over study - Corrected Proof

Adéla Krajčová, Vojtěch Matoušek, František Duška — 2012-03-16

Summary: Objective: To elucidate the mechanism of hypotension following intravenous administration of paracetamol (acetaminophen) to patients on the Intensive Care Unit.Design: Prospective observational cross-over study.Setting: Intensive Care Unit, University Hospital Královské Vinohrady, Prague, Czech Republic.Methods: Ventilated critically ill patients monitored by PiCCO and administered intravenous paracetamol at the same time were eligible for the study. We recorded haemodynamic indices, as well as core and peripheral temperatures, continuously for 3h after the dose of paracetamol. Ranitidine was then used as a control drug known not to influence haemodynamics.Results: We included 6 subjects, and recorded 48 cycles of observations after administration of paracetamol, and 35 cycles after administration of the control drug. Haemodynamic parameters were not different at the baseline and administration of control drug did not result in any change in haemodynamics. After intravenous paracetamol, mean arterial pressure (MAP) dropped by 7% (p<0.001) with a nadir at the 19th minute. In 22 measurement cycles (45%) we noted >15% reduction in MAP with paracetamol. Analysis of these cycles suggests that hypotension with paracetamol can be caused by reduction of both cardiac index and systemic vascular resistance. In febrile cycles paracetamol caused narrowing of the gradient between central and peripheral temperatures suggesting skin vasodilation. These changes were not correlated to a change of systemic vascular resistance at any time point.Conclusion: Hypotension with intravenous paracetamol in critically ill patients is caused by a reduction of both cardiac output and systemic vascular resistance. We did not demonstrate any relation between haemodynamic changes and antipyretic action of paracetamol. A possibility that cardiac output is reduced with paracetamol might be clinically important.

Implementing clinical supervision for ICU Outreach Nurses: A case study of their journey - Corrected Proof

Wendy M. Cross, Alan G. Moore, Tania Sampson, Clare Kitch, Cherene Ockerby — 2012-03-05

Summary: Introduction: Many health services with Intensive Care Units have developed ward liaison programs, managed by Outreach Nurses, to facilitate the transition for patients between the intensive care and general wards. This paper reports a case study of clinical supervision for two Outreach Nurses as they adapted to their new, largely autonomous role in an Australian tertiary hospital.Method: Individual clinical supervision was provided fortnightly to two Outreach Nurses over 12months by an experienced facilitator, and evaluated using a case study methodology. The Outreach Nurses completed a journal that captured their personal and professional growth and the supervisor also provided a reflective account. An interview was conducted with both Outreach Nurses to evaluate their experiences of clinical supervision.Findings: Key themes emerging from all the data sources included: respect for clinical supervision and the supervisor; role clarification; understanding and dealing with interpersonal issues; dedicated time for reflection; facing up to issues and letting them go.Conclusion: The Outreach Nurses described the personal and professional benefits of clinical supervision and highlighted how it was successfully implemented for them in a busy clinical environment with limited available resources.

Designing observation charts to optimize the detection of patient deterioriation: Reliance on the subjective preferences of healthcare professionals is not enough - Corrected Proof

2012-03-01

Summary: Aim: Observation charts are critical to detecting patient deterioration. Research suggests their design has a dramatic impact on user performance in terms of failure rates for detecting abnormal vital signs and how quickly users can interpret recorded observations. In this study, we examined the design preferences of professional chart users to assess their alignment with objective performance data. In addition, we tested the assumptions of prior knowledge that chart designers appear to have made about chart users.Methods: We conducted an online survey of health professionals (n=347). Participants answered questions about their observation chart design preferences in general, and were randomly assigned to evaluate one of nine specific charts.Results: Chart users’ preferences for design features were not always consistent with objective performance data. While some views concurred with empirical findings (e.g., participants preferred to plot observations on a graph with graded colouring, where the colours corresponded with degrees of abnormality), others did not (e.g., participants preferred plotting blood pressure and pulse together on the same chart area, which the objective data suggest is problematic). Additionally, a substantial proportion of respondents were unfamiliar with some of the assumed knowledge required to interpret many charts (e.g., particular abbreviations).Conclusions: It is dangerous to rely solely on subjective opinions – even those of experienced health professionals – when developing patient observation charts, as optimal design may be counterintuitive and some preferences may merely reflect familiarity. Objective performance data is also required. In addition, the level of assumed knowledge required to use a chart should be minimized.

Coronary care units continue to be effective at improving patient outcomes - Corrected Proof

Andrea Driscoll — 2012-02-27

Coronary care units (CCUs) were developed in the 1960s to prevent death post acute myocardial infarction (AMI) resulting in a 15–20% reduction in mortality. However since that time the patient population in CCU has dramatically changed. Over the past half a century CCUs have been transformed from emergency management of arrhythmias post AMI to managing a patient with an intra-aortic balloon pump and/or temporary pacing, management of chronic cardiac disease and post percutaneous coronary intervention (PCI) including arterial sheath removal.

A pre-test post-test study of a brief educational intervention demonstrates improved knowledge of potential acute myocardial infarction symptoms and appropriate responses in cardiac rehabilitation patients - Corrected Proof

2012-02-27

Summary: Background: Patient delay in recognizing and responding to potential acute myocardial infarction (AMI) symptoms is an international issue. Cardiac rehabilitation provides an ideal opportunity to deliver an intervention.Aims: This study examines an individual educational intervention on knowledge of heart attack warning signs and specific chest pain action plans for people with coronary heart disease.Methods: Cardiac rehabilitation participants at five hospitals were assessed at program entry and tailored education was provided using the Heart Foundation of Australia's Heart Attack Warning Signs campaign educational tool. Participants (n=137) were reassessed at program conclusion (six to eight weeks).Results: Study participants had a mean age of 64.48 years (SD 12.22), were predominantly male (78%) and most commonly presented with a current referral diagnosis of a percutaneous coronary intervention (PCI) (80%) and/or AMI (60%). There were statistically significant improvements in the reporting of 11 of the 14 warning signs of heart attack, with patients reporting 2.56 more warning signs on average at outcome (p<.0001). Patients reported more heart attack warning signs if they had completed high school education (β=1.14) or had better knowledge before the intervention (β=.57). There were statistically significant improvements in reporting of all appropriate actions in response to potential AMI symptoms, with patients reporting an average of 1.3 more actions at outcome (p<.001), with no change in the median time they would tolerate symptoms (p=.16).Conclusions: A brief education session using a single standardised tool and adapted to a patient assessment is effective in improving knowledge of potential AMI symptoms and appropriate responses in cardiac rehabilitation up to two months following.

A questionnaire survey of critical care nurses’ attitudes to delirium assessment before and after introduction of the CAM-ICU - Corrected Proof

Glenn M. Eastwood, Leah Peck, Rinaldo Bellomo, Ian Baldwin, Michael C. Reade — 2012-02-27

Summary: Background: Nurses are usually the first to identify delirium in ICU patients. We aimed to assess the attitudes of Australian critical care nurses when we introduced the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).Methods: We surveyed all 174 nurses in our ICU using two questionnaires: first after a one-month period of mandated but unstructured delirium assessments, and then following one month of CAM-ICU assessments. We also quantified antipsychotic medication usage by inspecting pharmacy records.Findings: The first survey response rate was 65/174 (37%). Most nurses (73%) thought active delirium assessment was important, and 93% thought their assessments were worth the time required. These assessments were largely unstructured, as only 20% knew a formal delirium test, and only 7% sometimes used one. The second survey response rate was 45/174 (26%). Most (89%) still thought delirium assessment was important, but only 75% thought the CAM-ICU worth the time required (p=0.01 compared to unstructured assessments). Similar proportions (75% and 73%) were confident in the accuracy of their assessments. Many (33%) found the CAM-ICU ‘quite’ or ‘very’ hard to perform, but despite this, 82% wanted to continue to use it. Free-text answers suggested this was because medical staff paid more attention to the CAM-ICU. Supporting this, prescriptions of antipsychotic medications increased significantly in the CAM-ICU period.Conclusion: Critical care nurses in our Australian ICU who responded to our survey think delirium assessment is important. Although they find unstructured assessments easier to perform, they wanted to persist with the CAM-ICU, in part because it facilitated more appropriate pharmacological treatment of delirium for their patients. We recommend the CAM-ICU as a tool to improve communication between nurses and physicians in the management of delirium.

Nursing care of the family before and after a death in the ICU—An exploratory pilot study - Corrected Proof

Melissa J. Bloomer, Julia Morphet, Margaret O’Connor, Susan Lee, Debra Griffiths — 2012-02-10

Summary: This qualitative descriptive study was undertaken in two metropolitan ICUs utilising focus groups to describe the ways in which ICU nurses care for the families of dying patients during and after the death. Participants shared their perspectives on how they care for families, their concerns about care, and detailed the strategies they use to provide timely and person-centred family care. Participants identified that their ICU training was inadequate in equipping them to address the complex care needs of families leading up to and following patient deaths, and they relied on peer mentoring and role-modelling to improve their care. Organisational constraints, practices and pressures impacting on the nurse made ‘ideal’ family care difficult. They also identified that a lack of access to pastoral care and social work after hours contributed to their concerns about family care. Participants reported that they valued the time nurses spent with families, and the importance of ensuring families spent time with the patient, before and after death.

A review of critical care nursing staffing, education and practice standards - Corrected Proof

Fenella J. Gill, Gavin D. Leslie, Carol Grech, Jos M. Latour — 2012-02-06

Summary: 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.

Complementary and alternative medicine and critical care nurses: A survey of knowledge and practices in Australia - Corrected Proof

Marie Cooke, Marion Mitchell, Evelin Tiralongo, Jenny Murfield — 2012-01-30

Summary: 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.

Mixed venous oxygen saturation monitoring revisited: Thoughts for critical care nursing practice - Corrected Proof

Martin Christensen — 2011-11-23

Summary: 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.

Pain indicators in brain-injured critical care adults: An integrative review - Corrected Proof

Marie-José Roulin, Anne-Sylvie Ramelet — 2011-11-21

Summary: 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.

A survey of ward nurses attitudes to the Intensive Care Nurse Consultant service in a teaching hospital - Corrected Proof

2011-11-17

Summary: 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.

Transition to intensive care nursing: A state-wide, workplace centred program—12 years on - Corrected Proof

Alison Juers, Margaret Wheeler, Helen Pascoe, Nicola Gregory, Cheryl Steers — 2011-09-30

Summary: 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.