Chronic obstructive pulmonary disease (COPD) requiring long-term oxygen therapy (LTOT) is an incurable lung disease often complicated by other comorbidities. Research is limited for hospitalized COPD exacerbations with LTOT and palliative care services. The purpose of this quantitative research study was to determine the correlation between palliative care interventions and COPD patient outcomes specific to an intensive care unit (ICU) stay, invasive mechanical ventilator support, physician orders for cardiopulmonary resuscitation (CPR) code status, and hospital discharge to hospice care. The theoretical base for this study was Donabedian's quality improvement theory. The quasi-experimental, nonequivalent groups design divided COPD hospitalized patient sample into 2 groups, those with and those without palliative care, for comparison. An independent-samples t test, one-way MANOVA, and follow-up univariate ANOVAS was done to compare the means of ICU days and ventilator days; a cross tabulation, chi-square test of independence, and Fisher exact test was done to compare code status and place of hospital discharge. The mean number of the ICU days and ventilator days for palliative care patients was significantly higher than patients who did not receive palliative care. A significant interaction was found for palliative care and code status change from CPR to no CPR; however, data relating to palliative care and hospital discharge to hospice was insignificant. In conclusion, palliative care does not reduce costs by limiting the number of days spent in an ICU or the number of days on invasive mechanical ventilation; although, it may have an important role in the code status order change from CPR to no CPR to align with the patient's end of life care preference.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18885号 / 医博第3996号 / 新制||医||1009(附属図書館) / 31836 / 京都大学大学院医学研究科医学専攻 / (主査)教授 中山 健夫, 教授 福原 俊一, 教授 小池 薫 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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This is a quality improvement project that focuses on implementing screening for acute stress disorder using the Acute Stress Disorder Structured Interview–DSM-IV tool in a Trauma Intensive Care Unit (ICU) at a Level 2 Trauma Center in Nashville, TN. Currently, at this hospital there is not a screening process implemented for these patients. Every trauma patient meets the criteria for acute stress disorder. Starting the process early aims for patients to be properly educated about their trauma and gets them the resources they need to heal mentally from the trauma. During the 6-week implementation period of this project, the trauma performance investigator (TPI) team screens patients for acute stress disorder. The team records how many patients screened, how many patients were available to screen, if they screened positive with a 9 or greater score, if they received a “telepysch” visit, and if a referral card for mental health visit after discharge was given. From this information, it will be determined how to continue to improve the implementation process. Information gathered data by the TPI will be recorded in Excel spreadsheets. The ASD screening tool scores will be used to compare the mechanism of injury to the score to determine if a correlation exists. Some patients that do not screen positive still want a referral card due to the education provided during the screening process. This shows the continued need for patient screening and education about acute stress disorder for this patient population.

BACKGROUND: People survive repeated health crises that used to be fatal and, at times, treatment intended to prolong life, prolongs death instead. Many people die in hospitals although they say they prefer to die at home. At the same time, research identifies multiple ways the American healthcare system is ill equipped to serve patients at the end of life. Presently, 20% of Americans die in Intensive Care Units (ICU), thus ICUs represent an important setting for learning about end-of-life care and death in America today. PURPOSE: To explore the nature of ICU care as perceived by family members, this qualitative study analyzed 693 reports from surveys mailed to family members of patients who died in the ICU of a major Boston hospital between 2009 and 2015. The study focused on experiences of received services as reported in responses to the survey’s three open-ended questions regarding helpful and unhelpful aspects of care surrounding the patient’s death. Family member experiences with social work services were also explored. METHODS: Data were assessed using the Family-centered Care (FCC) model, an emerging framework for provision of best practices in hospital settings. This framework emphasizes that patients, families, and health care providers work in partnership to set treatment goals. Since FCC has been correlated with better outcomes, one research objective here was to explore the extent to which family members’ experiences reflected the presence of FCC. The study also assessed family members’ experiences that fell outside the realm of FCC. Using NVivo software, analysis was guided by Braun and Clarke’s (2012) six-phase thematic analysis approach. FINDINGS AND IMPLICATIONS: Family members described numerous positive experiences. Deaths were humane and the delivery of FCC was evident. An in-depth data analysis provided illuminating details of FCC and explicated over 47 themes important to families’ ICU experiences. Families reported that they received emotional support, were well-informed, and were treated with respect. Findings suggest that FCC is possible in an ICU setting, supporting the use of FCC in ICU care and suggesting that it could profoundly improve the quality of end-of-life care. Responses concerning the role of social work were limited.

Background: Critical care nurses (CCNs) provide end-of-life (EOL) care for critically ill patients. CCNs face many obstacles while trying to provide quality EOL care. Some research has been published focusing on obstacles CCNs face while trying to provide quality EOL care; however, research focusing on family behavior obstacles is limited.Objective: To determine if magnitude scores (obstacle item size x obstacle item frequency of occurrence) have changed since previous magnitude score data were first gathered in 1999.Methods: A random geographically dispersed sample of 2,000 members of the American Association of Critical-Care Nurses (AACN) was surveyed. Responses from quantitative Likert- type items were statistically analyzed for mean and standard deviation for size of obstacle and how frequently each item occurred. Current data were then compared to similar data gathered in 1999.Results: Six items’ magnitude scores significantly increased over time. Four of the six items related to issues with families including families not accepting poor prognosis, interfamily fighting about continuing or stopping life-support, families requesting life-sustaining measures contrary to the patients’ wishes and, families not understanding the term “life-saving” measures. Two other items included nurses knowing patients’ poor prognosis before families knows and unit visiting hours that were too liberal.Seven items significantly decreased in magnitude score over time, including two items specifically related to physician behavior such as physicians who would not let patients die from the disease process or physicians who avoid talking to family members. Other items which significantly decreased were poor design of units, visiting hours that were too restrictive, no available support personnel, and when the nurse’s opinion regarding direction of care was not valued or considered.Conclusions: EOL care obstacles emphasized in 1999 are still valid and pertinent. Based on magnitude scores, some EOL obstacles related to families increased significantly, whereas, obstacles related to ICU environment and physicians have significantly decreased. Based on this information, recommendations for areas of improvement include improved EOL education for families and nurses.

Objective: The diagnosis of delirium in intensive care unit patients is frequently missed. Key symptoms to identify delirium are motoric alterations, changes in activity level, and delirium-specific movements. This study aimed to explore features collected by a single wrist-worn accelerometer as indicators of delirium. Methods: The study included twenty-two patients in the intensive care unit. The data was collected with the GENEActiv accelerometer device and the activity level was calculated. Differences between the delirious and nondelirious patients were tested. Results: Differences in activity level and rest-activity patterns were noticed between the delirious and non-delirious patients. However, the differences were not found to be significant. Conclusion: Activity patterns revealed differences between delirious and non‐delirious patients. Further study is required to confirm the potential of actigraphy in the early detection of delirium in the intensive care unit. / Mål: Diagnosen delirium hos intensivvårdspatienter missas ofta. Nyckelsymptom för att identifiera delirium är motoriska förändringar, förändringar i aktivitetsnivå och deliriumspecifika rörelser. Denna studie syftade till att utforska funktioner som samlats in av en enskild handledsburen accelerometer som indikatorer på delirium. Metod: Studien omfattade tjugotvå patienter på intensivvårdsavdelningen. Data samlades in med GENEActiv accelerometerenheten och aktivitetsnivån beräknades. Skillnader mellan de delirious och icke-delirious patienterna testades. Resultat: Skillnader i aktivitetsnivå och viloaktivitetsmönster noterades mellan de deliriösa och icke-deliriösa patienterna. Skillnaderna visade sig dock inte vara signifikanta. Slutsats: Aktivitetsmönster avslöjade skillnader mellan deliriösa och ickedelirösa patienter. Ytterligare studier krävs för att bekräfta potentialen för aktigrafi vid tidig upptäckt av delirium på intensivvårdsavdelningen.

Introduction: Oral hygiene is a significant aspect of nursing care. Endocarditis, stroke, lung cancer, and hypertension have been associated with poor oral hygiene. Research exploring oral care practices for mechanically ventilated patients is well documented. In contrast, oral hygiene for the non-mechanically ventilated acute care population remains underestimated. The purpose of this study was to establish a baseline of the type, frequency, and consistency of oral hygiene being performed on non-mechanically ventilated ICU patients and explore how the oral care provided was documented. Methodology: A literature search was conducted and reported as a literature review. The databases CINAHL Plus with Full Text, MEDLINE, PsychINFO, Academic Search Premier, and Cochrane Database of Systematic Reviews were searched. Key terms used were "oral hygiene," "oral care," "oral intensity," "mouth rinse," "mouth care," chlorhexidine rinse and ICU, "intensive care unit," "critical care" and infection*, pneumonia*, NV, non-ventilat*, and nonventilat*. The articles' selection addressed type, frequency, consistency, and/or documentation of oral hygiene in ICU patients, particularly non-mechanically ventilated patients, if available. Inclusion criteria consisted of English language, and academic journal articles. No specified publication date was placed as a restriction. The results were limited to English language, academic journal articles, peer reviewed research articles, evidence-based articles or practices, and articles published within the last ten years (2006 to 2016). All articles on oral hygiene practices in the ICU or critical care population were included. Articles that did not relate to oral hygiene practices in acute care, ICU patients, or critically ill hospitalized patients were excluded. Articles focused solely on the mechanically ventilated or intubated population were also excluded. Results: The review yielded very few articles focusing solely on non-mechanically ventilated ICU patients. Nevertheless, resulting data showed four areas common to oral hygiene practices in non-mechanically ventilated patients in the ICU: type of documentation, type of products, frequency of care, and personnel providing care. Documentation was found to be lacking compared to personnel's self-reported frequency of oral care. Oral hygiene products were found to be consistent in non-mechanically ventilated patients, while there was no consistency of products used in the general acute care population. Oral hygiene was self-reported by staff members to have been performed an average of two to three times per day for non-mechanically ventilated patients. Oral hygiene self-reported frequency was found to be inconsistent among the general acute care population. Lastly, registered nurses (RNs) were the primary providers of oral hygiene to patients. Conclusions: Findings support the existing gap in the literature on oral hygiene practices in non-mechanically ventilated patients in the ICU. Despite evidence documenting the impact of oral hygiene on health, further research is guaranteed.

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