Trauma is an event during which individuals are confronted with a threat to their own or to someone else’s integrity. If intense fear, horror and helplessness are experienced during the event there may be psychological traumatisation. However, individuals may experience physical trauma and require hospitalisation. The patients’ subjective experiences from the hospitalisations may precipitate further trauma. Although families of patients are not involved in the traumatic event, they may experience their own traumatisation. The individuals and their families experience the trauma on the biological, psychological and social levels. Medical literature is mostly positivistic and there is little qualitative research on the experience of hospitalisation, particularly of family experiences of the intensive care unit (ICU). There is also a paucity of research on psychological experiences in the medical world. The research that has been conducted in psychology is mostly with psychiatrists. The aim of this research is to explain the sense families make of physical trauma using narrative. Narrative is the sense individuals make of experiences across time through telling and re-telling stories. Qualitative research is most suited to explore these subjective experiences of individuals. Social constructionism is one form of qualitative research and a process exploring the world of individuals in the context of culture, history and social interaction. Individuals arrange these stories using myths, symbols and archetypes that will provide coherence to the lived experience. Languaging the experiences facilitates meaning attribution that informs behaviour. Data was collected through photographs taken by the participants and individual interviews were conducted. The co-construction of this text occurred in the context of the researcher as a counsellor, the researcher as a previous physical trauma patient and the family perspectives of the participants. The exploration of the photographs and their sequence are followed by a narrative analysis of the interview texts using storymaps. Narratives were co-created in this context. The participants selected the stories and created coherence by narrating and ordering the sequence of photographs. Since the family language this lived experience, the members explored various selves and their relationships with their worlds. The family was impacted biopsychosocially and is writing an alternate story in the discourse of the medical world that says further rehabilitation is difficult, if not impossible. They have made sense of the physical trauma by searching for unique outcomes and narrating on a temporal framework: stories of their self, relationships with others, their physical self and their physical environments. This will create space for their alternate story. / Dissertation (MA (Counselling Psychology))--University of Pretoria, 2008. / Psychology / unrestricted

Intensive care unit delirium from nurse's perspective Introduction: Delirium is a disturbance of consciousness, one of the most frequent organ dysfunctions in the ICU. Delirium occurs in 60 - 80% patients who receive mechanical ventilation and is independently associated with increased mortality and development of post-ICU neurocognitive deficit in adult ICU patients. It is recommended to monitor delirium routinely with validated screening tools (CAM-ICU or ICDSC). Experienced and well educated nurse, armed with appropriate diagnostic tools, can actively participate in prevention, diagnosis and therapy od delirium. Objective: This Master diploma thesis objective was to get to know current knowledge of nursing staff working in Czech ICUs about delirium and their clinical praxis. Method: Quantitative research was conducted with a questionnaire filled by nursing staff of ICUs for adult patients in two university and one regional hospital in Czech Republic from August to September 2017. Results: Altogether, 110 questionnaires from 130 have returned (84% return). The outcomes showed that 63% of nurses are sufficiently informed on ICU delirium, 66% would appreciate more education on the subject. All in all, 51% of nurses don't prevent delirium in their patients and 35% don't even know what are the...

Introduction: The coronary heart disease is still an actual topic. The mortality has been in recent years declining, but prevalence in the population stagnates, so involve a large group of patients. The incidence of acute myocardial infarction is still high. One of the methods of reperfusion therapy is the cardiac surgery by coronary artery bypass graft, which may be postoperatively complicated by the development of low cardiac output syndrome with the need of the extracorporeal membrane oxygenation. These patients require very specialized not only during the critical phase, but also during the long-term convalescence including rehabilitation, weaning from the artificial lung ventilation, self-sufficiency training and help with return to normal life. Literature search: The theoretical part is based on the research of National Medical Library (NLK) and Study and Scientific Library of the Pilsen Region (SVKPL). The PubMed, Scopus, Web of science and Science direct databases were used to search articles in professional publications, including the latest cohort studies. The periodicals Cor et Vasa, the European Heart Journal, Critical Care and the European Journal of Cardiovascular Nursing were used. An important source of information is the guidelines of the Czech Society of Cardiology (ČKS), European...

[pt] As UTIs se tornaram o lugar frequente de morte para grande parte das pessoas no mundo. A morte ou a ameaça da perda de um ente querido promovem desequilíbrio no sistema familiar, fazendo emergir sensações de impotência, de fragilidade e de vulnerabilidade. Para a equipe médica, a morte do paciente traz a possibilidade de entrar em contato com os próprios processos de morte e finitude, suscitando angústia e desconforto. O processo de medicalização da morte traz em seu bojo questões éticas e bioéticas ligadas à prática médica, principalmente relacionadas aos limites de ação terapêutica. Nesse cenário, os conflitos entre família e equipe de saúde podem surgir com força e de forma descontrolada. O objetivo deste estudo foi compreender as repercussões da terminalidade em terapia intensiva para a família e para a equipe médica. Para tal, desenvolveu-se uma discussão interdisciplinar abordando as seguintes temáticas: o setting da UTI e a integração dos cuidados paliativos aos cuidados finais de vida nessa unidade; o impacto da terminalidade na dinâmica e no funcionamento familiar, compreendido pelo prisma da terapia familiar sistêmica e das teorias sobre o processo de luto na família e os aspectos concernentes à formação médica, ao estresse advindo do exercício da medicina e ao processo de comunicação com as famílias. O cenário deste estudo é uma UTI de um hospital privado, de médio porte, localizado na cidade do Rio de Janeiro. Utilizou-se a metodologia clínicoqualitativa de pesquisa. Foram entrevistados seis familiares de pacientes em situação de terminalidade e seis membros da equipe médica, totalizando 12 participantes. A partir da análise do material discursivo das entrevistas dos participantes, emergiram 11 categorias, 6 das falas dos médicos e 5 das falas dos familiares. Constatou-se que a terminalidade do paciente em UTI é atravessada por questões clínicas, familiares, sociais, culturais, religiosas, econômicas e éticas, abarcando aspectos multidimensionais. A morte iminente do paciente promove grande angústia e sofrimento para os familiares, ocasionando intensas vivências de desamparo. Para o médico intensivista, a morte e o morrer são fenômenos que causam estranheza, apesar de naturalizá-los, pois este espera conseguir salvar a vida do paciente, já que conta com equipamentos de suporte avançado de vida. Foram ressaltados como elementos essenciais para uma boa qualidade de morte, a comunicação empática, afetiva e efetiva entre todos os atores envolvidos e a participação do paciente e da família no processo de tomada de decisões. / [en] ICUs have become a frequent place of death for most people in the world. The death or the threat of loss of a loved one creates imbalance in the family system, giving rise to feelings of impotence, fragility and vulnerability. For the medical staff, the patient s death brings the possibility of contact with their own death and finitude processes, bringing up anguish and discomfort. The process of medicalization of death brings with it ethical and bioethical issues in the medical practice, mainly related to the limits of therapeutic action. In this scenario, conflicts between the family and the health care team may come up with some strength and without control. The objective of this study is to understand the impact of terminal illness in intensive care for the family and the medical staff. This study required an interdisciplinary discussion, in which we developed the following themes: the setting of the ICU and the integration of palliative care for end of life care in that unit; the impact of terminal illness in the family dynamics and functionality under the light of systemic family therapy and the theories about the grieving process in the family. We also discussed the aspects regarding the medical training, the stress arising from this type of work and the process of communication with families. The setting for this study was an ICU of a private hospital, midsize, located in the city of Rio de Janeiro. We used the clinicalqualitative research methodology. There were six interviewed relatives of patients terminally ill and six members of the medical staff, totaling twelve participants. From the analysis of the discursive material, 11 categories emerged, 6 from the doctors speeches and 5 from the families speeches. It was found that the patient s terminal illness in the ICU is crossed by clinical, family, social, cultural, religious, economical and ethical issues, covering multiple dimensions. The imminent death of the patient promotes great anguish and suffering for the family, causing intense experiences of helplessness. Although death and dying are natural processes, they are phenomena that cause strangeness for intensive care physicians, who hope to save the patient s life as they have advanced life support equipment. We have highlighted some elements that are considered essential to a good quality of death, which are empathic, affective and effective communication among all people involved and the participation of the patient and family in the decision-making process.

Today’s intensive care units monitor patients through the use of various medical devices, which generate a high ratio of false positive alarms due to a low alarm specificity. The false alarms have resulted in a stressful working environment for healthcare professionals that are getting more desensitized to triggered alarms and causing alarm fatigue. The patient safety is also compromised by having high noise levels in the patient room, which disturbs their sleep. This thesis has developed an intelligent alarm system with an improved alarm management and the use of 23 intelligent algorithms to minimize the number of false positive alarms. The suggested system is capable of improving the alarm situation and increasing the patient safety in critical care. The algorithms were modeled with fuzzy logics consisting of delays and multi parameter validation. The results were iteratively developed by having focus groups with various experts.

Team collaboration is a fundamental part of Quality Management (QM), and working together successfully is an important part of improving an organization. Team collaboration is also essential for achieving quality of care, patient safety and care continuity, especially when handling critically ill patients. Transferring a patient from an intensive care unit (ICU) to a general ward demands planning, communication, competence, a system view, and a quality culture. This patient transfer process, called ICU transitional care, extends across hospital boundaries, which have different organizational cultures, technologies, and knowledge. It is a challenge to manage these differences in order for team collaboration to meet the needs of patients, relatives and co-workers. To achieve this, further research is required to understand how care teams, both within hospital units and between organizational boundaries, can collaborate more successfully and efficiently to achieve quality of care in the ICU transitional care process. The overall purpose of this thesis is to contribute to a deeper understanding of how to improve team collaboration within ICU transitional care aiming to increase quality of care. To achieve this, four research questions were formulated and three case studies conducted. In the first case, a systematic literature review was performed to explore the extent to which Quality Management and Nursing Science can offer complementary perspectives to provide better quality of care by looking at Quality Management core concepts and tools. Findings from this study revealed, among other things, a need for further research on team collaboration in ICU transitional care. The purpose of the second study was to develop and test a questionnaire aiming to measure the perception of team collaboration in the patient transfer process from the ICU to the general ward. This study also aimed to analyze the results to see how the questionnaire could help improve team collaboration within ICU transitional care. Empirical data were collected from two ICUs at two hospitals. Participants at the ICUs answered the developed questionnaire, and the results showed that it could be used for measuring perceived team collaboration in this patient transfer process. The results from the questionnaire also gave insights that might be useful for improving team collaboration in this ICU transitional care process. The purposes of the third study were, first, to describe how co-workers’, within a team, perceived team collaboration in patient transfers from ICU to general wards and, second, to describe co-workers’ suggestions for an improved future state of team collaboration. Focus group discussions (FGDs) were conducted at two hospitals to answer the two questions. There were several findings from the study, and the results indicated that team collaboration has an important role when creating prerequisites for a holistic view of the process, and that there was a perceived need among the co-workers to improve team collaboration over organizational boundaries. Co-workers also expressed a need for more involving patients and relatives when improving team collaboration.   Four overarching conclusions can be drawn from this research. Firstly, Quality Management is used in ICU transitional care to improve the quality of care. Secondly, multi-professional team collaboration is perceived to be easier and better developed within hospital units than between them. Collaborating in teams between hospital units is challenging for several reasons. Some reasons are unclarity in routines for communication and decision-making, for example who decides what.  A third conclusion is the importance of how teams and team collaboration are defined and structured in ICU transitional care. This involves roles and responsibilities of teams. Teams have specific characteristics that are important for their performance. A fourth conclusion is an expressed need to involve patients and relatives more when it comes to improve team collaboration in ICU transitional care. The main findings from the three studies presented in this thesis have given insight and deeper understanding of how co-workers perceive team collaboration within ICU transitional care at two hospitals located in Sweden, and co-workers’ suggestions for how team collaboration can be improved aiming to increase quality of care. / <p>Vid tidpunkten för framläggningen av avhandlingen var följande delarbete opublicerat: delarbete 3 (inskickat).</p><p>At the time of the defence the following paper was unpublished: paper 3 (submitted).</p>

Bakgrund: I slutet av år 2019 upptäcktes ett nytt coronavirus, SARS-CoV-2 och sedan dess har det spridit sig över världen och lett till COVID-19 pandemin. Detta har ställt höga krav på intensivvården och dess organisation, oerfaren personal har fått arbeta inom intensivvården för att möta upp det ökade patientflödet. Tidigare studier visar hur teamarbetet skall fungera och vad som krävs för att det ska fungera optimalt för att uppnå god patientsäkerhet. Syfte: Syftet med denna studie var att beskriva intensivvårdssjuksköterskors upplevelse av teamarbete under COVID-19 pandemi. Metod: Designen som valdes var en kvalitativ intervjustudie, Urvalet som användes var ett ändamålsenligt urval och åtta intensivvårdssjuksköterskor intervjuades med hjälp av semistrukturerade intervjuer. Data analyserades med en kvalitativ innehållsanalys. Resultat: Fyra kategorier framkom; En extraordinär och svår utmaning, Genom utmaningar utvecklas man som team och individ, Alla bidrar med sin kompetens för patientens bästa samt Nya relationer, funktioner och personer i teamet. I resultatet framkom det att intensivvårdssjuksköterskorna upplevt utmaningar och utvecklingar inom teamarbetet,o erfarna har fått en mer etablerad plats och nya rutiner har förbättrat teamarbetet. Första tiden var mycket påfrestande men utveckling har skett. Diskussion: Tidigare forskning visar på att teamarbetet har mycket utmaningar att övervinna för att fungera optimalt, men det finns tillvägagångssätt för att underlätta när läget väl är skarpt. Slutsats: Det finns möjligheter för att öka beredskapen genom utbildning, men ytterligare forskning om pandemins effekter på teamarbete är något som författarna anser vara av stor vikt.

Ventricular assist devices are used in patients with heart failure refractory to standard management. Though left ventricular assist devices are more often used, patients with severe right ventricular dysfunction may also be treated with mechanical support. This case presents a patient with mixed cardiogenic and septic shock requiring placement of a percutaneous right ventricular assist device. A 38-year-old obese male with a medical history of alcoholism presented to the hospital with a complaint of dyspnea. He was found to have volume overload and was given intravenous diuretics. However, he had progressive renal insufficiency, hypotension requiring vasopressor support, and worsening respiratory status requiring mechanical ventilation. An echocardiogram showed a severely enlarged right ventricle, reduced RV function, normal RV wall thickness, moderate to severe tricuspid regurgitation, a severely dilated right atrium, ventricular septal flattening, and mild pulmonary hypertension. Left ventricular ejection fraction was 65-70%, LV diastolic function was normal, and there were no other significant valvular abnormalities. Troponin levels, ECG, and CT pulmonary angiography were unrevealing. Right heart catheterization showed a right atrial pressure of 29 mmHg (2 – 6 mmHg), right ventricular pressures of 50/24 mmHg (15-25/0-8 mmHg), pulmonary artery pressures of 56/35/43 mmHg (15-25/8-15/10-20 mmHg), a pulmonary capillary wedge pressure of 22 mmHg (6-12 mmHg), and a Prognostic Impact of Pulmonary Artery Pulsatility Index (PAPi) score of 0.3 to 0.6 (>1). Cardiac chamber oxygen saturations did not demonstrate intracardiac shunting. A right-sided mechanical circulatory support device was placed. The hospital course was complicated by sepsis due to pneumonia and presumed central line-associated bloodstream infection requiring antibiotic therapy, anemia secondary to device-related hemolysis requiring blood transfusions, renal failure requiring renal replacement therapy, and candidemia requiring antifungal therapy. Due to concern for device-associated infection, his central lines were replaced. The mechanical circulatory support device was able to be removed after ten days. Subsequent cardiac imaging did not reveal any other structural abnormalities, and a definitive cause for the right heart failure was not determined. Etiologies of right-sided heart failure include left-sided heart failure, pulmonary hypertension, chronic pulmonary disease, myocardial infarction, pulmonary embolism, myocarditis, valvular dysfunction, and congenital anomalies. Mechanical circulatory support may be used to support cardiac function, to allow the ventricular function to improve. Potential complications of mechanical circulatory support include infection, hemolysis, bleeding, device migration, and malfunction. RVAD therapy should be considered for patients with isolated right ventricular failure refractory to less invasive therapy.

Computerized physician order entry (CPOE) is used in healthcare organizations to improve workflow processes and transcription, as well as to prevent prescribing errors. Previous research has indicated challenges associated with CPOE for end-users that predispose patients to unsafe practices. Unsafe CPOE practices can be detrimental within the intensive care unit (ICU) setting due to the complexity of nursing care. Consequently, end-user satisfaction and understanding of CPOE and electronic health record (EHR) functionality are vital to avoid error omissions. CPOE initiatives should be refined post system implementation to improve clinical workflow, medication processes, and end-user satisfaction. The purpose of this quality improvement project was to refine CPOE system initiatives and develop an e-learning educational module to facilitate end-user understanding of and satisfaction with CPOE. The Iowa model of evidence-based practice, Lean methodology, and Provider Order Entry User Satisfaction and Usage Survey (POESUS) were used to guide the study. An e-learning module was implemented to increase staff understanding of the newly implemented CPOE system, and a plan was provided for ongoing data collection and investigation of end-user satisfaction and medication inadequacies with the CPOE system. A mixed-method design was recommended to key stakeholders to identify the impact of the e-learning course and refined CPOE initiatives on both end-user satisfaction and patient outcomes in the medical-surgical ICU. Findings from the study informed the impact of e-learning educational modules with CPOE system implementation. Those in organizations implementing advanced technology such as CPOE and EHR systems in critical care settings will find this paper of interest.

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