Showing papers in "American Journal of Critical Care in 2003"

The Link Between Teamwork and Patients’ Outcomes in Intensive Care Units

Abstract: • BACKGROUND Links between teamwork and outcomes have been established in a number of fields Investigations into this link in healthcare have yielded equivocal results • OBJECTIVE To examine the relationship between the level of self-identified teamwork in the intensive care unit and patients’ outcomes • METHOD A total of 394 staff members of 17 intensive care units completed the Group Development Questionnaire and a demographic survey The questionnaire is a reliable and valid measure of team development and effectiveness Each unit’s predicted and actual mortality rates for the month in which data were collected were obtained Pearson product moment correlations and analyses of variance were used to analyze the data • RESULTS Staff members of units with mortality rates that were lower than predicted perceived their teams as functioning at higher stages of group development They perceived their team members as less dependent and more trusting than did staff members of units with mortality rates that were higher than predicted Staff members of high-performing units also perceived their teams as more structured and organized than did staff members of lower-performing units • CONCLUSIONS The results of this study and others establish a link between teamwork and patients’ outcomes in intensive care units The evidence is sufficient to warrant the implementation of strategies designed to improve the level of teamwork and collaboration among staff members in intensive care units (American Journal of Critical Care 2003;12:527-534)

Oral Care Interventions in Critical Care: Frequency and Documentation

Abstract: • BACKGROUND No data have been collected to describe the products, methods, and frequency of oral care needed to reduce dental plaque, oral colonization, and ventilator-associated pneumonia in critically ill patients. • OBJECTIVES To describe the frequency of use of oral care interventions reported by nurses in several intensive care units in a large southeastern medical center. • METHODS Staff members completed a written survey describing their oral care practices, and oral care interventions were recorded from the unit’s flow sheet for the previous 24 hours for all patients at 5 randomly selected times during 1 month. • RESULTS Most respondents (75%) reported providing oral care 2 or 3 times daily for nonintubated patients, and 72% reported providing care 5 times daily or more for intubated patients. However, oral care was documented on the unit’s flow sheet a mean of 1.2 times per patient. Reported use of toothpaste and a toothbrush was significantly greater in nonintubated patients (P < .001), and use of a sponge toothette was significantly greater in intubated patients (P < .001). Nurses’ mean rating of oral care priority was 53.9 on a 100-point scale. • CONCLUSIONS Despite evidence that they are ineffective for plaque removal, sponge toothettes remain the primary tool for oral care, especially in intubated patients in intensive care units. Nurses report frequent oral care interventions, but few are documented. Education and focus on good oral care strategies are required; nursing research to delineate the best procedure for all patients in intensive care units is needed. (American Journal of Critical Care. 2003;12:113-119)

Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use.

Abstract: • BACKGROUND Inadequate communication persists between healthcare professionals and patients and patients’ families in intensive care units. Unwanted or ineffective treatments can occur when patients’ goals of care are unknown or not honored, increasing costs and care. Having the primary physician provide medical information and then having a physician and clinical nurse specialist team improve opportunities for patients and their families to process that information could improve the situation. This model has not been tested for its effect on patients’ outcomes and resource utilization. • OBJECTIVES To evaluate the effect of a communication team that included a physician and a clinical nurse specialist on length of stay and costs for patients near the end of life in the intensive care unit. • METHODS During a 1-year period, patients judged to be at high risk for death (N = 151) were divided into 2 groups: 43 patients who were cared for by the medical director teamed with a clinical nurse specialist and 108 patients who received standard care, provided by an attending physician. • RESULTS Compared with the control group, patients in the intervention group had significantly shorter stays in both the intensive care unit (6.1 vs 9.5 days) and the hospital (11.3 vs 16.4 days) and had lower fixed ($15 559 vs $24 080) and variable ($5087 vs $8035) costs. • CONCLUSIONS Use of a physician and a clinical nurse specialist focused on improving communication with patients and patients’ families reduced lengths of stay and resource utilization. (American Journal of Critical Care. 2003;12:317-324)

Family Presence During Cardiopulmonary Resuscitation and Invasive Procedures: Practices of Critical Care and Emergency Nurses

Abstract: • BACKGROUND Increasingly, patients’ families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence. • OBJECTIVE To identify the policies, preferences, and practices of critical care and emergency nurses for having patients’ families present during resuscitation and invasive procedures. • METHODS A 30-item survey was mailed to a random sample of 1500 members of the American Association of Critical-Care Nurses and 1500 members of the Emergency Nurses Association. • RESULTS Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures). Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedure) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures). • CONCLUSIONS Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended. (American Journal of Critical Care. 2003;12:246-257)

A Multisite Survey of Suctioning Techniques and Airway Management Practices

Abstract: • BACKGROUND Ventilator-associated pneumonia, common in critically ill patients, is associated with microaspiration of oropharyngeal secretions and may be related to suctioning and airway management practices. • OBJECTIVES To describe institutional policies and procedures related to closed-system suctioning and airway management of intubated patients, and to compare practices of registered nurses and respiratory therapists. • METHODS A descriptive, comparative, multisite study of facilities that use closed-system suctioning devices on most intubated adults was conducted. Nurses and respiratory therapists who worked at the sites completed surveys related to their practices. • RESULTS A total of 1665 nurses and respiratory therapists at 27 sites throughout the United States responded. The typical respondent had at least 6 years’ experience with patients receiving mechanical ventilation (61%) and a baccalaureate degree or higher (54%). Most sites had policies for management of endotracheal tube cuffs (93%), hyperoxygenation (89%) and use of gloves (70%) with closed-system suctioning, and instillation of isotonic sodium chloride solution for thick secretions (74%). Only 48% of policies addressed oral care and 37% addressed oral suctioning. Nurses did more oral suctioning and oral care than respiratory therapists did, and respiratory therapists instilled sodium chloride solution more and rinsed the suctioning device more often than nurses did. • CONCLUSIONS Policies vary widely and do not always reflect current research. Consistent performance of practices such as wearing gloves for airway management and maintaining endotracheal cuff pressures must be evaluated. Collaborative, research-based policies and procedures must be developed and implemented to ensure best practices for intubated patients. (American Journal of Critical Care. 2003;12:220-232)

Obesity and the metabolic syndrome.

Abstract: The prevalence of marked obesity is increasing rapidly among adults and has more than doubled in 10 years. Sixty-one percent of the adult population of the United States is overweight or obese. Americans are the fattest people on earth. Paradoxically these increases in the numbers of persons who are obese or overweight have occurred during recent years when Americans have been preoccupied with numerous dietary programs, diet products, weight control, health clubs, home exercise equipment, and physical fitness videos, each "guaranteed" to bring rapid results. Overweight and obesity are also world problems. The World Health Organization estimates that 1 billion people around the world are now overweight or obese. Westernization of diets has been part of the problem. Fruits, vegetables, and whole grains are being replaced by readily accessible foods high in saturated fat, sugar, and refined carbohydrates. Since class 3 obesity (morbid or extreme obesity) is associated with the most severe health complications, the incidence of hypertension, stroke, heart disease, diabetes, and peripheral vascular disease will increase substantially in the future. Recently, obesity alone has been implicated in the development of cardiac hypertrophy and CHF. The metabolic syndrome associated with abdominal obesity, which includes insulin resistance, dyslipidemia, and elevated CRP levels, identifies subjects who have an increase in cardiovascular morbidity and mortality. Twenty to 25% of the adult population in the United States have the metabolic syndrome, and in some older groups this prevalence approaches 50%. The prevalence of overweight children in the United States has also been increasing dramatically, especially among non-Hispanic blacks and Mexican-American adolescents. Overweight children usually become overweight adults. Atherosclerosis begins in childhood. The degree of atherosclerotic changes in children and young adults can be correlated with the presence of the same risk factors seen in adults. As health providers, our direction is obvious!

Life Support Withdrawal: Communication and Conflict

Abstract: • BACKGROUND Skillful communication between and among clinicians and patients’ families at the patients’ end of life is essential for decision making. Yet communication can be particularly difficult during stressful situations such as when a family member is critically ill. This is especially the case when families are faced with choices about forgoing life-sustaining treatment. • OBJECTIVES Data from a larger study on treatment withdrawal (n = 74) indicated that the family members (n = 20) of some patients experienced conflict with clinicians during decision making. This secondary analysis was done to examine and describe the communication difficulties from the perspectives of patients’ family members who experienced conflict with clinicians about the care and treatment of the patients during withdrawal of life support. • METHODS A qualitative descriptive analysis of family members (n = 20, representing 12 decedents) who experienced conflict. • RESULTS Families described several unmet communication needs during the often rapid shift from aggressive treatment to palliative care. These needs included the need for timely information, the need for honesty, the need for clinicians to be clear, the need for clinicians to be informed, and the need for clinicians to listen. • CONCLUSIONS Although family members who experienced conflict were in the minority of the larger study sample, their concerns and needs are important for clinicians to examine. Paying careful attention to these communication needs could reduce the occurrence of conflict between clinicians and patients’ families in caring for dying patients and reduce stress for all involved. (American Journal of Critical Care. 2003;12:548-555)

Pathophysiology and Management of Abdominal Compartment Syndrome

Abstract: Abdominal compartment syndrome is a potentially lethal condition caused by any event that produces intra-abdominal hypertension; the most common cause is blunt abdominal trauma. Increasing intra-abdominal pressure causes progressive hypoperfusion and ischemia of the intestines and other peritoneal and retroperitoneal structures. Pathophysiological effects include release of cytokines, formation of oxygen free radicals, and decreased cellular production of adenosine triphosphate. These processes may lead to translocation of bacteria from the gut and intestinal edema, predisposing patients to multiorgan dysfunction syndrome. The consequences of abdominal compartment syndrome are profound and affect many vital body systems. Hemodynamic, respiratory, renal, and neurological abnormalities are hallmarks of abdominal compartment syndrome. Medical management consists of urgent decompressive laparotomy. Nursing care involves vigilant monitoring for early detection, including serial measurements of intra-abdominal pressure.

Incidence, Timing, Symptoms, and Risk Factors for Atrial Fibrillation After Cardiac Surgery

Abstract: • BACKGROUND Atrial fibrillation is the most common complication after cardiac surgery and a major cause of morbidity and increased cost of care. • OBJECTIVES To examine the incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery. • METHODS A total of 302 patients were continuously monitored for atrial fibrillation with standard hardwire and telemetry devices during hospitalization after coronary artery bypass graft and/or valve surgery and with wearable cardiac event recorders for 2 weeks after discharge from the hospital. After discharge, patients recorded and transmitted their rhythm by telephone daily and whenever they had symptoms suggestive of atrial fibrillation. • RESULTS Of the 302 patients, 127 (42%) had atrial fibrillation; 41 had it after discharge, and for 10 it was their first episode. The first episode occurred at a mean of 2.9 days after surgery (SD, 3.1; range, day of surgery to 21 days after surgery). Although palpitations was the most common symptom (17%), most episodes of atrial fibrillation (69%) were not associated with symptoms. Independent predictors of atrial fibrillation were age 65 years or greater, history of intermittent atrial fibrillation, atrial pacing, male sex, white race, and not having hyperlipidemia. Independent predictors of atrial fibrillation after discharge from the hospital were having atrial fibrillation while hospitalized, valve surgery, and pulmonary hypertension. • CONCLUSIONS Atrial fibrillation is common after cardiac surgery and often occurs after discharge from the hospital and without accompanying symptoms. Outpatient monitoring may be warranted in patients with characteristics that place them at increased risk for atrial fibrillation. (American Journal of Critical Care. 2003;12:424-435)

Collaborative Practice: Development, Implementation, and Evaluation of a Weaning Protocol for Patients Receiving Mechanical Ventilation

Abstract: • BACKGROUND Use of protocols to reduce weaning time for patients receiving mechanical ventilation helps reduce cost and length of stay. However, implementation of this type of protocol is not easy and requires a consistent collaborative effort. • OBJECTIVE To provide a systematic approach to the weaning process by developing, implementing, and evaluating a protocol for weaning patients from mechanical ventilation in a medical respiratory intensive care unit. • METHODS The weaning protocol used was a modification of a protocol developed by Ely et al. Modifications included a more aggressive approach in proceeding to the spontaneous breathing trial, inclusion of the Richmond Agitation-Sedation Scale, and documentation of the production of secretions. • RESULTS Implementation of the protocol significantly reduced the duration of mechanical ventilation as measured by 8-hour shifts and ventilator days. Although length of stay in the intensive care unit was not significantly reduced (P = .29), a continuing downward trend occurred, from a mean of 8.6 days before the protocol was implemented to 7.9 days during the last 6 months of data collection (P = .07). • CONCLUSIONS The need to provide efficient care requires the collaboration of all disciplines involved in providing patients’ care. The weaning protocol introduced in this study demonstrates the benefits of using a collaborative team to identify best practices and implement them in a practice setting. (American Journal of Critical Care. 2003;12:454-460).

Skin Care Intervention for Patients Having Cardiac Surgery

Abstract: • BACKGROUND Pressure ulcers are a major problem after cardiovascular surgery, occurring in 9.2% to 38% of patients. • OBJECTIVES To determine the effectiveness of a skin care intervention program in preventing development of ulcers or progression from one stage to another and to determine the extent to which selected risk factors were associated with development and progression of pressure ulcers. • METHODS A simple interrupted time series design was used. The protocol involved interrelated assessment, staging, and type of intervention provided. The Braden Scale was used to determine risk for skin breakdown. • RESULTS Of the 351 patients in the study, 327 (93%) maintained skin integrity and 24 (7%) had skin breakdown. Breakdown by stages was as follows: stage 1, 62% (n = 15); stage 2, 29% (n = 7); stage 3, 4% (n = 1); and stage 4, 4% (n = 1). Age, sex (female), and heart failure were statistically significant risk factors for breakdown (P = <.001, .02, and .02, respectively). The mean scores on the Braden Scale of the breakdown group differed significantly from those of the skin integrity group from days 2 through 5 after surgery (P = .01). Seventeen (71%) of the breakdowns occurred during the first 4 days after surgery.

Critical Care Nurses' Beliefs About and Reported Management of Anxiety

Abstract: • BACKGROUND Anxiety is associated with increased morbidity and mortality. Critical care nurses are uniquely positioned to reduce anxiety in their patients. Critical care nurses’ beliefs about and frequency of use of strategies to reduce anxiety have not been studied. • OBJECTIVES To explore critical care nurses’ beliefs about the importance of anxiety management and to describe nurses’ reported use of strategies to manage anxiety in their patients. • METHODS A random sample (N = 2500) of members of the American Association of Critical-Care Nurses was asked to complete the Critical Care Nurse Anxiety Identification and Management Survey. • RESULTS Respondents (n = 783) were primarily female (92%), white (88.5%) staff nurses (74.1%) who thought that anxiety is potentially harmful (mean, 4.1; SD, 0.8; range, 1 = no harm to 5 = lifethreatening harm), that anxiety management is important (mean, 4.8; SD, 0.6; range, 1 = not important to 5 = very important), and that effective anxiety management is beneficial (mean, 4.6; SD, 0.6; range, 1 = no benefit to 5 = profound benefit). A majority commonly used pharmacological management; most also used information and communication interventions. Fewer subjects used the presence of patients’ family members to alleviate patients’ anxiety; few reported using stress-reduction techniques. • CONCLUSION Most respondents thought that treating anxiety is important and beneficial. Commonly used strategies included pharmacological relief of anxiety and pain and information and communication interventions. Although these strategies are useful, they may not effectively reduce anxiety in all patients. (American Journal of Critical Care. 2003;12:19-27)

Endotracheal suctioning with or without instillation of isotonic sodium chloride solution in critically ill children.

Abstract: • BACKGROUND Instillation of isotonic sodium chloride solution for endotracheal tube suctioning is controversial. Research has focused on the effect of such instillation in adults; no studies in children have been published. • OBJECTIVES (1) To describe differences in oxygen saturation depending on whether or not isotonic sodium chloride solution is instilled during suctioning and (2) to describe the rates of occlusion of endotracheal tubes and nosocomial pneumonia. • METHODS A convenience sample of 24 critically ill patients were enrolled before having suctioning and after informed consent had been given. Ages ranged from 10 weeks to 14 years. Patients were randomized to 1 of 2 groups. In group 1, subjects received between 0.5 and 2.0 mL of isotonic sodium chloride solution, depending on their age, once per suctioning episode. In group 2, subjects received no such solution. A total of 104 suctioning episodes were analyzed. Oxygen saturation was recorded at predetermined intervals before and for 10 minutes after suctioning. Occlusion of endotracheal tubes and rates of nosocomial pneumonia also were compared. • RESULTS Patients who had isotonic sodium chloride solution instilled experienced significantly greater oxygen desaturation 1 and 2 minutes after suctioning than did patients who did not. No occlusions of endotracheal tubes and no cases of nosocomial pneumonia occurred in either group.

Management of Patients in the Intensive Care Unit: Comparison Via Work Sampling Analysis of an Acute Care Nurse Practitioner and Physicians in Training

Abstract: • BACKGROUND Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients’ outcomes. • OBJECTIVE To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients’ care in a step-down medical intensive care unit. • METHODS Work sampling techniques were used to collect data when the nurse practitioner had 6 months’ or less experience in the role (T 1 ), after the nurse practitioner had 12 months’ experience in the role (T 2 ), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T 3 ). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities. • RESULTS Results for T 1 and T 2 were similar. When T 2 and T 3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001). • CONCLUSION The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients’ families and collaborating with health team members. (American Journal of Critical Care. 2003;12:436-443)

Readiness for Behavioral Changes in Patients With Heart Failure

Abstract: • BACKGROUND Successful self-care in heart failure often requires lifestyle changes such as avoiding sodium, excess fluid intake, alcohol, and tobacco; exercising regularly; and losing weight. The Transtheoretical Model, a framework for making behavioral changes, proposes that change requires a series of stages. • OBJECTIVES To identify the stage of readiness for change in 6 lifestyle behaviors important in heart failure and to determine differences in signs and symptoms of heart failure, self-reported knowledge of the disease, and self-reported behavior between patients who have taken action and patients who have not. • METHOD A mail survey of 250 patients with heart failure. • RESULTS Most respondents reported consistent avoidance of tobacco (90.6%), alcohol (87.9%), sodium (81%), and excess fluid (72.6%) and regular participation in exercise (67.1%) and trying to lose weight (64.7%). Yet only 38.7% had a regular exercise program, and 94.2% had eaten high-sodium foods in the preceding 24 hours. Knowledge of heart failure was low (mean score, 67.4%) and did not differ by stage of change. Only 30.4% of the respondents were at their desired weight, and most overweight subjects had been trying to lose weight for more than 6 months. • CONCLUSIONS Although respondents thought they were consistently adhering to recommended guidelines for changes in lifestyle, actual reported behaviors did not always support this evaluation. Use of the stage of change tool to assess stage of readiness to make lifestyle changes may not work well in patients with heart failure, perhaps because of the number and complexity of the changes needed. (American Journal of Critical Care. 2003;12:444-453)

Early Predictors of Long-Term Disability After Injury

Abstract: • BACKGROUND Improving outcomes after serious injury is important to patients, patients’ families, and healthcare providers. Identifying early risk factors for long-term disability after injury will help critical care providers recognize patients at risk. • OBJECTIVES To identify early predictors of long-term disability after injury and to ascertain if age, level of disability before injury, posttraumatic psychological distress, and social network factors during hospitalization and recovery significantly contribute to long-term disability after injury. • METHODS A prospective, correlational design was used. Injury-specific information on 63 patients with serious, non‐central nervous system injury was obtained from medical records; all other data were obtained from interviews (3 per patient) during a 2 1 ⁄2-year period. A model was developed to test the theoretical propositions of the disabling process. Predictors of long-term disability were evaluated using path analysis in the context of structural equation modeling. • RESULTS Injuries were predominately due to motor vehicle crashes (37%) or violent assaults (21%). Mean Injury Severity Score was 13.46, and mean length of stay was 12 days. With structural equation modeling, 36% of the variance in long-term disability was explained by predictors present at the time of injury (age, disability before injury), during hospitalization (psychological distress), or soon after discharge (psychological distress, short-term disability after injury). • CONCLUSIONS Disability after injury is due partly to an interplay between physical and psychological factors that can be identified soon after injury. By identifying these early predictors, patients at risk for suboptimal outcomes can be detected. (American Journal of Critical Care. 2003;12:197-205)

Administration of Sedatives and Level of Sedation: Comparative Evaluation via the Sedation-Agitation Scale and the Bispectral Index

Abstract: • OBJECTIVES To compare levels of sedation in patients receiving continuous intravenous infusions of sedative/hypnotic or narcotic agents with levels in patients not receiving infusions and to compare subjective (Sedation-Agitation Scale) and objective (Bispectral Index) evaluations of sedation. • METHODS Patients receiving mechanical ventilation in a medical intensive care unit were evaluated prospectively. Level of sedation was assessed with the Sedation-Agitation Scale (range 1-7, unarousable to dangerous agitation) and the Bispectral Index (range 0-100, flat line to awake waveform) recorded before and after stimulation. Patients were classified as receiving continuous infusions if an infusion had been administered within 24 hours preceding assessment. • RESULTS Nineteen patients were evaluated on 80 occasions. Scores on the Sedation-Agitation Scale ranged from 1 to 5 (mean 2.6 and median 2) and correlated highly with values for the Bispectral Index (R 2 = 0.48 before and 0.44 after stimulation, P < .001). Patients receiving continuous infusions were more deeply sedated than were patients receiving boluses or no medication (mean [SD] scores, Sedation-Agitation Scale: 2.1 [1.2] vs 3.3 [1.0], P < .001; Bispectral Index before stimulation: 63 [24] vs 86 [13], P < .001). Patients receiving continuous infusions were more likely to have a score of 2 or less on the Sedation-Agitation Scale (32/44 vs 8/35, P < .001). • CONCLUSION Objective and subjective assessments of sedation are highly correlated. Use of continuous infusions is associated with deeper levels of sedation, and patients receiving continuous infusions are more likely to be oversedated. Sedation therapy should be guided by subjective or objective assessment. (American Journal of Critical Care. 2003;12:343-348)

Gastric Feeding in Critically Ill Children: A Randomized Controlled Trial

Abstract: • BACKGROUND Provision of enteral nutrition via the gastric route is a common nursing procedure in pediatric intensive care units. Little research, however, has focused on children’s tolerance of different types of gastric feeding regimens. • OBJECTIVES To examine the relationship between 2 gastric feeding regimens, continuous and intermittent, and children’s tolerance as measured by the number of stools and prevalences of diarrhea and vomiting. • METHODS A randomized controlled trial was conducted in an Australian pediatric intensive care unit; 45 children were randomly assigned to either the continuous or the intermittent gastric feeding groups. Participants remained in the assigned feeding group for the duration of the study, and values of variables used to monitor patients’ tolerance were recorded. • RESULTS Both feeding groups were similar with respect to Pediatric Index Mortality score, age, weight, sex, diagnosis, and use of pharmacological agents known to affect the gastrointestinal tract. Additionally, the 2 groups did not differ in study duration or the daily volume of administered enteral formula per kilogram of body weight. The number of stools per day and the prevalences of diarrhea and vomiting did not differ significantly between the 2 groups. • DISCUSSION Continuous and intermittent gastric feeding regimens have similar outcomes with respect to the number of stools per day and the prevalence of diarrhea and vomiting in pediatric intensive care patients. Further gastric feeding studies and the development of enteral feeding guidelines for critically ill children are needed. (American Journal of Critical Care. 2003;12:461-468)

Risk of Colonization of Central Venous Catheters: Catheters for Total Parenteral Nutrition Vs Other Catheters

Abstract: • BACKGROUND Infected central venous catheters cause morbidity and mortality. • OBJECTIVE To compare the risk for colonization of central venous catheters used for total parenteral nutrition with that of catheters used for other purposes. • METHODS Retrospective review of prospectively acquired data on 260 patients with a stay in a surgical intensive care unit longer than 3 days. Single-lumen catheters used solely for total parenteral nutrition were inserted into the subclavian vein and cared for by a dedicated team. Catheters for other purposes were placed and cared for by other staff. Catheters were cultured if clinical findings suggested infection. • RESULTS Of 854 central venous catheters, 61 (7%) were used for total parenteral nutrition. During 4712 catheter days of observation, 89 catheters of all types were colonized. Risk factors for colonization included duration of catheterization (P < .001), having 3 or more lumens (hazard ratio, 1.7; 95% CI, 1.1-2.6), pulmonary artery catheterization (hazard ratio, 1.7; 95% CI, 1.1-2.7), and placement in the internal jugular vein (hazard ratio, 1.6; 95% CI, 1.1-2.5). Catheters used for total parenteral nutrition (hazard ratio, 0.14; 95% CI, 0.04-0.57) and those in the subclavian vein (hazard ratio, 0.51; 95% CI, 0.3-0.8) were at lower risk of colonization. In a multivariate Cox model, the only significant factor was a 5-fold lower risk of infection for catheters used for total parenteral nutrition (hazard ratio, 0.19; 95% CI, 0.04-0.83). • CONCLUSION Rates of colonization were lowest for catheters used solely for total parenteral nutrition, suggesting that a team approach improves patients’ care. (American Journal of Critical Care. 2003;12:328-335)

From Theory to Practice: Preventing Pain After Cardiac Surgery

Abstract: A pain management guideline was developed at the Royal Columbian Hospital, New Westminster, British Columbia, to prevent pain after cardiac surgery. The guideline was based on a wellness model and was predicated on the World Health Organization’s analgesic ladder. Patients are given nonopioids around the clock and throughout the postoperative stay and are given an opioid to prevent procedural pain and treat breakthrough pain. In an evaluation of the guideline, records from 133 cardiac surgery patients were retrospectively reviewed. The type and dose of analgesics administered for the first 6 days after surgery, the effectiveness of the pain management plan, the occurrence of adverse effects, time to extubation, and postoperative lengths of stay were determined. Ninety-five percent of patients had effective pain relief. Almost all patients received acetaminophen around the clock. A total of 89% received indomethacin. All patients received opioids intermittently. Doses of opioids were converted to morphine oral equivalents, which peaked on day 1 after surgery (38 equivalents) and decreased sharply by day 2 (<10 equivalents). Median postoperative length of stay was 5 days for patients who had bypass surgery and 6 days for patients who had valve surgery. This proactive, low-tech, low-risk, well-tolerated pain management approach is cost-effective, simple, and feasible to use. The findings support use of this approach in managing pain after cardiac surgery. (American Journal of Critical Care. 2003;12:136-143)

Physicians' estimates of cardiac index and intravascular volume based on clinical assessment versus transesophageal Doppler measurements obtained by critical care nurses.

Abstract: • OBJECTIVES To compare physicians’ estimates of cardiac index and intravascular volume with transesophageal Doppler measurements obtained by critical care nurses, to assess the overall safety of transesophageal Doppler imaging by critical care nurses, and to compare hemodynamic measurements obtained via transesophageal Doppler imaging with those obtained via pulmonary artery catheterization. • METHODS Data were collected prospectively on 106 patients receiving mechanical ventilation. Physicians estimated cardiac index and intravascular volume status by using bedside clinical assessment; critical care nurses, by using transesophageal Doppler imaging. In 24 patients, Doppler measurements were obtained within 6 hours of placement of a pulmonary artery catheter and recording of cardiac output and pulmonary artery occlusion pressure. • RESULTS With Doppler measurements as the reference, physicians correctly estimated cardiac index in 46 (43.8%) of 105 patients, underestimated it in 24 (22.9%), and overestimated it in 35 (33.3%). They correctly estimated volume status in 31 patients (29.5%), underestimated it in 16 (15.2%), and overestimated it in 58 (55.2%). Doppler measurements of cardiac output correlated with those obtained via pulmonary artery catheterization (r = 0.778; P < .001). Two patients had minor complications: dislodgement of a nasogastric tube and inability to obtain a Doppler signal. • CONCLUSION Physicians’ assessment of cardiac index and intravascular volume in patients receiving mechanical ventilation is correct less than half of the time. Transesophageal Doppler imaging by critical care nurses appears to be a safe method for measuring cardiac index and estimating intravascular volume. Measurements obtained via Doppler imaging correlate well with those obtained via pulmonary artery catheterization. (American Journal of Critical Care. 2003;12:336-342)

Paramedic and Emergency Department Care of Stroke: Baseline Data From a Citywide Performance Improvement Study

Abstract: BACKGROUND Rapid diagnosis and transport by paramedics and efficient, effective emergency management are essential to improving care of acute stroke patients. OBJECTIVES To measure the performance of paramedics and emergency departments providing care for patients with suspected acute stroke. METHODS Two stroke centers and 4 other hospitals where most patients with acute stroke in Houston, Tex, are admitted participated. Hospital and paramedic performance data were collected prospectively on 446 patients with suspected acute stroke transported by paramedics between September 1999 and February 2000. RESULTS Paramedics had a sensitivity of 66%, specificity of 98%, and overall accuracy of 72% in diagnosing stroke. For patients with suspected stroke, 58.5% arrived in the emergency department within 120 minutes of symptom onset; in confirmed cases, that percentage was 67%. Mean total transport time was 42.2 minutes and was significantly longer (P < .001) to inner-city hospitals (44 minutes) than to suburban, community-based centers (39 minutes). Door to computed tomography times were significantly (P < .001) shorter for the 2 stroke centers than the other hospitals. Overall thrombolysis treatment rate among patients with confirmed ischemic stroke was 7.4% (range, 0-19.4%); treatment rates at the 2 stroke centers were 5.9% and 19.4%. CONCLUSIONS More than half of patients with suspected stroke arrive at hospitals while thrombolytic treatment is still feasible. Although the current rate for thrombolytic treatment in Houston exceeds the national rate, performance of paramedics and hospitals in treating acute stroke can be improved by increasing efficiency and standardizing medical practices.

Pain Assessment and Management in the Critically Ill: Wizardry or Science?

Abstract: Assessment and management of patients’ pain across practice settings have recently received the increased attention of providers, patients, patients’ families, and regulatory agencies. Scientific advances in understanding pain mechanisms, multidimensional methods of pain assessment, and analgesic pharmacology have aided in the improvement of pain management practices. However, pain assessment and management for critical care patients, especially those with communication barriers, continue to present challenges to clinicians and researchers. The state of nursing science of pain in critically ill patients, including development and testing of pain assessment methods and clinical trials of pharmacological interventions, is described. Special emphasis is placed on results from the Thunder Project II, a major multisite investigation of procedural pain. (American Journal of Critical Care. 2003;12:310-316)

Subjective perceptions and physiological variables during weaning from mechanical ventilation.

Abstract: Background As costs related to mechanical ventilation increase, clear indicators of patients' readiness to be weaned are needed. Research has not yet yielded a consensus on physiological variables that are consistent correlates of weaning outcomes. Subjective perceptions rarely have been examined for their contribution to successful weaning. Objective To explore the subjective perceptions of dyspnea, fatigue, and self-efficacy and selected physiological variables in patients being weaned from mechanical ventilation. Methods Data were collected prospectively on 68 patients being weaned from mechanical ventilation. Subjective perceptions were measured by using 3 visual analog scales; physiological variables were measured by using the Burns Weaning Assessment Program and a patient profile. Weaning outcomes were recorded 24 hours after data collection. Results Participants were primarily white women and required mechanical ventilation for a mean of less than 4 days. Participants reported mild dyspnea, moderate fatigue, and high weaning self-efficacy. High PaO2, low PaCO2, stable hemodynamic status, adequate cough and swallow reflexes, no metabolic changes, and no abdominal problems were associated with complete weaning (P = .05). Subjective perceptions were associated with physiological variables but not with weaning outcomes. Conclusions Multidimensional assessment of both primary and secondary indicators of readiness to be weaned is necessary for timely, efficient weaning from mechanical ventilation. Primary assessments include physiological variables related to gas exchange, hemodynamic status, diaphragmatic expansion, and airway clearance. Secondary assessments include perceptions related to key physiological variables. Additional research is needed to determine the predictive value of physiological variables and perceptions of dyspnea, fatigue, and self-efficacy.

Naturalistic Decision Making: A Model to Overcome Methodological Challenges in the Study of Critical Care Nurses’ Decision Making About Patients’ Hemodynamic Status

Abstract: The quality of critical care nurses' decision making about patients' hemodynamic status in the immediate period after cardiac surgery is important for the patients' well-being and, at times, survival. The way nurses respond to hemodynamic cues varies according to the nurses' skills, experiences, and knowledge. Variability in decisions is also associated with the inherent complexity of hemodynamic monitoring. Previous methodological approaches to the study of hemodynamic assessment and treatment decisions have ignored the important interplay between nurses, the task, and the environment in which these decisions are made. The advantages of naturalistic decision making as a framework for studying the manner in which nurses make decisions are presented.

Pattern and Predictors of Early Rejection After Lung Transplantation

Abstract: • BACKGROUND Most lung transplant recipients experience improvement in their underlying pulmonary condition but are faced with the threat of allograft rejection, the primary determinant of long-term survival. Several studies examined predictors of rejection, but few focused on the early period after transplantation. • OBJECTIVES To describe the pattern and predictors of early rejection during the first year after transplantation to guide the development of interventions to facilitate earlier detection and treatment of rejection. • METHODS Data for donor, recipient, and posttransplant variables were retrieved retrospectively for 250 recipients of single or double lung transplants. • RESULTS Most recipients (85%) had at least 1 episode of acute rejection; 33% had a single episode; 23% had recurrent rejection; 3% had persistent rejection; 13% had refractory rejection; and 14% had clinicopathological evidence of chronic rejection. Serious rejection (refractory acute rejection or chronic rejection) developed in 27% of recipients. Compared with other recipients, recipients who had serious rejection had more episodes of acute rejection (P = .004), and the first acute episodes occurred sooner after transplantation (P = .01) and were of a higher grade (P = .002). • CONCLUSIONS Recipients who experienced higher grades for their first episode of acute rejection (P = .03) and higher cumulative rejection scores (P = .004) were significantly more likely than other recipients to have serious rejection during the first year after transplantation. (American Journal of Critical Care.

Frequency and Outcomes of Transient Myocardial Ischemia in Critically Ill Adults Admitted for Noncardiac Conditions

Abstract: • BACKGROUND Critically ill adults admitted for noncardiac conditions are at risk for acute myocardial ischemia. • OBJECTIVES To detect myocardial ischemia and injury in patients admitted for noncardiac conditions and to examine the relationship of myocardial ischemia, injury, and acuity to cardiac events. • METHODS Transient myocardial ischemia, acuity, elevations in serum troponin I, and in-hospital cardiac events were examined in 76 consecutive patients. Transient myocardial ischemia, determined by using continuous electrocardiography, was defined as a 1-mm (0.1-mV) change in ST level from baseline to event in 1 or more leads lasting 1 or more minutes. Acuity was determined by scores on Acute Physiology and Chronic Health Evaluation II. • RESULTS A total of 37 ischemic events were detected in 8 patients (10.5%); 32 (86%) were ST-segment depressions, and 35 (96%) were silent. Twelve patients (15.8%) had elevated levels of troponin I. Transient myocardial ischemia, elevated troponin I levels, and advanced age were significant predictors of cardiac complications (R 2 = 0.387, F = 15.2, P < .001). Acuity correlated only modestly with increased length of stay in the intensive care unit (r = 0.26, P = .02) and elevated troponin I levels (r = 0.25, P = .03). Patients with transient myocardial ischemia had significantly higher rates of elevations in troponin I (P < .001) and cardiac events (P < .001) than did patients without. • CONCLUSIONS Transient myocardial ischemia and advanced age are predictors of cardiac events and may indicate patients at risk for cardiac events. (American Journal of Critical Care. 2003;12:508-517)

Heart period variability of intubated very-low-birth-weight infants during incubator care and maternal holding.

Abstract: • BACKGROUND Heart rate has been used to measure infants’ physiological stability during skin-to-skin holding. Variability in heart period (interbeat interval), a more sensitive measure of autonomic nervous system tone, has not. • OBJECTIVE To describe heart period variability in intubated very-low-birth-weight infants during incubator care and during maternal skin-to-skin holding. • DESIGN/METHODS An experimental, interrupted time series, crossover design was used; infants served as their own controls. Infants were randomly assigned to treatment order: 2 hours of intermittent skin-toskin holding for 2 consecutive days followed by 2 days of incubator care or vice versa. The analog signal representing heart period was sampled and quantized at 5 Hz via a dedicated computer system in multiple 300-second epochs each day. • RESULTS Fourteen infants with similar characteristics completed the protocol. The mean interbeat interval was 332 ms during skin-to-skin care and 368 ms during incubator care. Power within the lowand high-frequency regions of heart period was not significantly different between skin-to-skin holding and incubator care. Mean low-frequency power was 124.6 ms 2 during skin-to-skin holding and ranged from 51.9 ms 2 to 71.4 ms 2 during all periods of incubator care. Mean high-frequency power was similar during skin-to-skin holding and incubator care (8.8 ms 2 and 6.1 ms 2 ). Infants of 32 to 34 weeks’ corrected gestational age had increased power in the low- and high-frequency regions. • CONCLUSIONS Heart period variability did not improve during skin-to-skin holding. Gestationally older infants had increased power in the low- and high-frequency regions, suggesting a maturing autonomic nervous system. (American Journal of Critical Care. 2003;12:54-64)

Perceived self-efficacy in performing and willingness to learn cardiopulmonary resuscitation in an elderly population in a suburban community.

Abstract: • BACKGROUND Older persons are the group most likely to respond to cardiac arrests in private residences. • OBJECTIVE To characterize the knowledge about, attitudes toward, and perceived self-efficacy of older persons in learning and providing cardiopulmonary resuscitation. • METHODS A total of 2743 surveys were mailed to adults 55 years and older who resided in a single Michigan suburb. Data were collected on demographics, medical history, training in and willingness to provide cardiopulmonary resuscitation, and concerns about providing this intervention. • RESULTS The 631 persons (24.6%) who responded were elderly (mean age, 73.5 years) and had a mean of 1.7 occupants per household. More than one third lived alone. Of all respondents, 275 (43.6%) had received training in cardiopulmonary resuscitation, 370 (58.6%) indicated a willingness to learn cardiopulmonary resuscitation, and 412 (65.3%) thought that they had the ability to perform this intervention. Respondents 80 years or younger were significantly more likely than respondents more than 80 years old to be willing to learn cardiopulmonary resuscitation (65.7% vs 19.0%, P < .001) and perceived themselves as able to perform it (73.0% vs 34.0%, P < .001). The absence of mouth-to-mouth ventilation as part of training had minimal impact on the willingness of either age group to receive training (61.2% vs 58.6%, P = .19). Perceived ability to learn and perform cardiopulmonary resuscitation did not vary with the medical history of the respondent or the respondent’s spouse. • CONCLUSION Adults 56 to 80 years old perceive themselves as able to perform cardiopulmonary resuscitation and are interested in receiving training. (American Journal of Critical Care. 2003;12:65-70)