Background: Traumatic injury remains a major cause of mortality in the US. Older Americans experience lower rates of injury and higher rates of death at lower injury severity than their younger counterparts. The objectives of this study were to explore pre-injury factors and injury patterns that are associated with post-discharge mortality among injured elderly surviving index hospitalization. Methods: We queried a 5% random sample of Medicare beneficiaries (n=2,002,420) for any hospitalization with a primary ICD-9 diagnosis code for injury. Patients admitted without urgent/emergent admission were excluded, as well as patients presenting from inpatient hospitalization or rehabilitation. The primary endpoint was all-cause mortality. Patients were categorized into three mortality groups: death within 0-30 days, 31-90 days, or 91- 365 days post-discharge from the index hospitalization. These groups were compared with those who survived greater than one year post-discharge. Univariate tests of association and multivariable logistic regression models were utilized to identify factors associated with mortality during the 3 examined periods. Results: 83,439 elderly patients (4.2%) were admitted with new injuries. 63,628 met inclusion criteria. 1,936 patients (3.0%) died during their index hospitalization, 2,410 (3.8%) died within 0-30 days, 3,084 (4.8%) died within 31-90 days, and 5,718 (9.0%) died within 91- 365 days after discharge. In multivariable adjusted models, advanced age, male sex, and higher Elixhauser score were associated with post-discharge mortality. The presence of critical injury had the greatest effect on mortality early after injury (0-30 days, OR 1.81, CI 1.64-2.00). Discharge to anywhere other than home without services was associated with an increased odds of dying. Conclusions: Socio-demographic characteristics, disposition, and co-morbid factors were the strongest predictors of post-discharge mortality. Efforts to reduce injury-related mortality should focus on injury prevention and modification of co-morbidities.

The Institute for Healthcare Improvement (IHI) has promoted implementing a RRS to provide safer care for hospitalized patients. Additionally, the Joint Commission made implementing a RRS a 2008 National Patient Safety Goal. Although mandated, the evidence to support the effectiveness of a RRS to reduce cardiac arrests on hospital medical or surgical floors and un-anticipated ICU transfers remains inconclusive, partly because of weak study designs and partly due to a failure of published studies to report all critical aspects of their intervention. This study attempted to evaluate the effectiveness and the implementation of a RRS on the two campuses of the UMass Memorial Medical Center (UMMMC). The first study presented was an attempt to identify the preventability and timeliness of floor to ICU transfers. This was done using 3 chief residents who reviewed 100 randomly selected medical records. Using Cohen’s kappa to assess the inter-rater reliability it was determined that 13% of the cases could have possibly been preventable with earlier intervention. The second study was an evaluation of the effectiveness of the Rapid Response System. Outcomes were cardiac arrests, code calls and floor to ICU admissions. There were two study periods 24 months before the intervention and 24 months after. A Spline regression model was used to compare the two time periods. Though there was a consistent downward trend over all 4 years there were no statistically significant changes in the cardiac arrests and ICU transfers when comparing the before and after periods. There was a significant reduction in code calls to the floors on the University campus. The third study was a modified process evaluation of the Rapid Response intervention that will assess fidelity of RRS implementation, the proportion of the intended patient population that is reached by the RRS, the overall number of RRS calls implemented (dose delivered) and the perceptions of the hospital staff affected by the RRS with respect to acceptability and satisfaction with the RRS and barriers to utilization. The process evaluation showed that that the Rapid Response System was for the most part being used as it was designed, though the nurses were not using the specific triggers as a deciding factor in making the call. Staff satisfaction with the intervention was very high. Overall these studies demonstrated the difficulty in clearly defining outcomes and data collection in a large hospital system. Additionally the importance of different study designs and analysis methods are discussed.

Contexte: L’utilisation efficiente des ressources en soins intensifs représente un défi potentiellement surmontable dans un contexte de régionalisation des services. Conséquemment, il importe de convenir de critères homogènes et transparents permettant de trier et de transporter les patients là où ils peuvent recevoir les soins nécessaires à leur condition. Objectif: L’objectif principal de cette étude est d’identifier et d’évaluer les publications définissant les critères utilisés pour prioriser ou refuser une admission aux soins intensifs. Méthodes: Nous avons entrepris une revue systématique en accord avec les lignes directrices PRISMA. Nous avons identifié tous les articles pertinents publiés jusqu’au 8 novembre 2016 au moyen des bases de données PubMed, Embase, Medline, EBM Reviews, CINAHL Complete, les bases de données recensant la littérature grise ainsi qu’en effectuant une revue manuelle d’articles supplémentaires. Nous avons ensuite évalué la qualité des articles retenus selon une échelle d’appréciation que nous avons développée. Finalement, nous avons extrait puis évalué chaque critère individuel en plus de les regrouper par thème. Résultats: L’étude nous a permis d’identifier 5818 abrégés. Nous avons révisé 416 articles exhaustivement pour en retenir 129 qui correspondent aux critères d’inclusion. Il s’agit d’articles de recherche originale (34%), de lignes directrices (26 %) ou de revues de la littérature (21 %). Nous avons extrait 200 critères de triage et de transport au sein des 129 articles. Ceux-ci proviennent surtout des États-Unis (43 %) et privilégient un mécanisme d’exclusion (71 %) plutôt que de priorisation (17 %) des clientèles. Peu d’articles abordent les critères de transport (4 %). Nous avons classifié les critères selon qu’ils soient reliés à l’un ou l’autre des quatre thèmes qui ont émergé de notre analyse : au patient; à la condition clinique; au médecin qui évalue le cas; ou au contexte. Le critère le plus fréquemment cité est celui de la préférence du patient suivi de l’évaluation du médecin. Conclusion: Une revue systématique a permis de générer une liste de 200 critères utilisés pour prioriser ou exclure certains types de patients dans un état critique. Malgré les limites de notre étude, celle-ci peut permettre aux cliniciens et aux preneurs de décision de concevoir des politiques de triage et d’admission au niveau local, régional ou national. De plus, l’étude identifie des champs de recherche potentiels où le développement de critères spécifiques et mesurables pourrait contribuer au développement de lignes directrices diminuant la variabilité dans les pratiques et améliorant le processus d’admission aux soins intensifs. / Context: Intensive care bed unavailability negatively affects patients' outcomes. Strategies that reduce inefficient use of resources and reduce unavailability may increase quality and accessibility of critical care. As advocacy for regionalization of critical care resources increases, there is a need for agreed triage and transport criteria. However, outside of the trauma population, such agreed criteria and recommendations are lacking. Objective: We aimed to identify and appraise articles defining criteria used to prioritize or withhold a critical care admission. Methods: We undertook a systematic review according to PRISMA guidelines. Relevant articles were identified through searches of PubMed, Embase, Medline, EBM Reviews, CINAHL Complete from inception until November 8th, 2016. We also undertook searches through gray literature as well as a manual review of references. We then assessed the quality of identified articles through an appraisal scale we developed. Finally, we extracted and evaluated all criteria within the articles and grouped them by theme. Results: A total of 5818 abstracts were identified. After screening, we reviewed 416 articles in full and 129 articles met study criteria. These articles were mainly original research (34%), guidelines (26%) and reviews (21%). Amongst them, we identified 200 unique triage and transport criteria. Most articles were published in the United States (43%) and highlighted exclusion criteria (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). We classified criteria as they related to one of four emerging themes: patient, condition, physician and context. The most commonly found triage criteria was patient preference followed by physician’s assessment that the patient was too well to benefit from ICU admission. Conclusion: A systematic review aimed at identifying triage and transport criteria used to prioritize or exclude certain patient populations under different settings helped to generate a list of 200 criteria classified within 4 themes. Despite its limitations, this study may help clinicians and decision makers devise local, regional or national ICU triage criteria. It also identifies gaps in knowledge where future clinical research yielding specific and measurable criteria tailored to clearly defined patient populations may help to decrease ICU triage variability.

There are few recommendations on how best to apply certain modes of mechanical ventilation. The application of Airway Pressure Release Ventilation (APRV) includes strategic implementation of specific inspiratory times (I-times) and particular mean airway pressures (MAWP) neither of which is standardized. This study utilized a retrospective analysis of archived electronic health record data to evaluate the clinical outcomes of adult patients that had been placed on APRV for at least 8 hours. 68 adult subjects were evaluated as part of a convenient purposive sample. All outcomes of interest (surrogates) for short-term clinical outcomes to include the PaO2/FiO2 (P/F) ratio, Oxygen Index and Oxygen Saturation Index (OI; OSI), and Modified Sequential Organ Failure Assessment (MSOFA) scores showed improvement after at least 8 hours on APRV. Most notably, there was significant improvement in P/F ratio (p = .012) and OSI (p = .000). Results of regression analysis showed P low as a statistically significant negative predictor of pre-APRV P/F ratio with a higher initial P low coinciding with a lower P/F ratio. The regression analysis also showed MAWP as a significant positive predictor of post-APRV OSI and P high and P low as significant negative predictors of post-APRV MSOFA scores. In summary, it was found that settings for P high, Plow, and T low in addition to overall MAWP and Body Mass Index (BMI) had significant correlation to impact at least one of the short-term clinical outcomes measured.

Indiana University-Purdue University Indianapolis (IUPUI) / Healthcare workers are responsible for providing evidence-based care to patients; however, many patients receive unnecessary or harmful care. Successful implementation of evidence-based guidelines can improve patient outcomes, particularly among vulnerable neuroscience patients. Focused efforts to improve nursing knowledge of and adherence to these guidelines are warranted. The purpose of this dissertation was to determine the most effective strategies for implementing evidence-based guidelines into nursing practice. First, an integrative review of the literature was conducted to explore studies addressing implementation of evidence-based guidelines in nursing. Implications from the review suggested further research to better understand which strategies should be utilized to best implement evidence-based nursing practices. Two pre- and posttest studies were then designed to identify a bundle of implementation strategies to improve neurocritical care nurses' knowledge of and adherence to stroke and spinal cord injury guidelines. The tailored, multi-faceted strategies consisted of local opinion leaders, printed educational materials, and educational outreach. Improvements in nursing knowledge of and adherence to these guidelines were noted. Lastly, program evaluations were conducted using a mixed-methods study to understand neurocritical care nurses' perceptions of the usefulness of the strategies employed during the two studies. Findings from this research provided support for the most effective implementation strategies to enhance knowledge development and guideline adherence among neurocritical care nurses for implementation of stroke and spinal cord guidelines.

Background: “Nurses provide essential care to the millions of people who are hospitalized each year as a result of illness or injury” (Smith, 2012, p. 172). The Institute of Medicine reported approximately 44,000-98,000 patients die annually resulting from a medical error, and health care errors ranked among the top 10 for the leading causes of death in the United States (Smith, 2012). Problem: Nurse competence impacts safe and quality nursing, and several research studies investigated the measurement of nurse competence among nurses in various nursing settings (Flinkman et al., 2016). However, a review of the research revealed limited studies in the emergency department (ED) setting and in the United States (O’Leary, 2012). Method: This study implemented a quantitative nonexperimental research design using the combination of an instrumental case study and a cross-sectional survey for this study’s sample. An Internet-based SurveyMonkey questionnaire collected data on nurse competence from registered nurses (RNs) working in the ED at a San Francisco Bay Area hospital. Part I of the questionnaire integrated Meretoja, Isoaho, and Leino-Kilpi’s (2004) Nurse Competence Scale (NCS) consisting of 73 closed-ended clinical indicators divided into seven competence areas. Participants rated their level of competence and frequency of use for each clinical indicator. Part II of the questionnaire obtained background information about participants. A total of 21 out of 110 potential participants completed the survey. Results: The data analysis using Statistical Package for Social Sciences (SPSS) provided descriptive and nonparametric correlation statistics. Descriptive statistics described survey respondents. The least and most competent areas were ensuring quality and managing situations, respectively. The most frequent length of nursing experience was at least 60 months and the most frequent number of hours worked was at least 65 hours per 2-week period. Nonparametric correlation statistics, including Kendell’s tau-b and Spearman’s rho, identified significant relationships. A significant relationship existed between the frequency of using clinical skills and level of competence for four of the seven competence areas. A significant relationship existed between the background factor of experience, both as an RN and an ED RN, and level of competence for many clinical indicators. A significant relationship existed between the background factor of hours worked and level of competence for one clinical indicator. Conclusion: Despite the small sample size of 21 survey respondents, this study revealed findings consistent with the existing research on nurse competence. This study offers implications and recommendations for practice relative to nurse competence, nurse competence assessment, and transitions to new settings of nursing practice to support the nursing profession and safe and quality nursing.

No description available.

Bakgrund: Interhospital transport [IHT] ökar inom intensivvården i Sverige. Framför allt på grund av att patienterna har ett komplext sjukdomstillstånd som kräver högspecialiserad vård men även på grund av resurs- och vårdplatsbrist. Intensivvårdssjuksköterskan ska identifiera problem och risker i förväg samt förbereda en handlingsplan utifrån oförutsedda händelser som påverkar omvårdnaden och patientsäkerheten hos den intuberade patienten. Syfte: Att beskriva intensivvårdssjuksköterskans erfarenhet av att förberedelse en intuberad patient inför interhospital transport. Metod: En intervjustudie av kvalitativ metod med induktiv ansats. Tio intervjuer genomfördes och analyserades. Analysen genomfördes utifrån Graneheim och Lundmans innehållsanalys. Resultat: Fyra huvudkategorier sammanställdes som beskriver intensivvårdssjuksköterskans erfarenhet av att förbereda en intuberad patient inför IHT. Kategorierna var: Erfarenhet ger kunskap, Teamarbete skapar överblick och En utmanade arbetssituation. Slutsats: Intensivvårdssjuksköterskans förberedelser av en intuberad patient inför IHT är en komplicerad situation och förutsätter ett gott samarbete. Erfarenheten hos intensivvårdssjuksköterskan har en stor betydelse för förberedelserna. Genom ökad erfarenhet hos intensivvårdssjuksköterskan växer egna strategier fram. Dock är den intuberade patientens tillstånd dynamiskt vilket kan leda till oförutsedda händelser. Nyexaminerade intensivvårdssjuksköterskor behöver stöttning och riktlinjer/checklistor som verktyg i sitt arbete samt kontinuerlig träning för att utveckla och upprätthålla kompetens. / Introduction: Interhospital transport [IHT] is increasing in critical care in Sweden. Mainly because the patients have a complex medical condition that requires highly specialized care, but also because of a lack of resources and care places. The critical care nurse must identify problems and risks in advance and prepare an actionplan based on unforeseen events that affect the care and patient safety of the intubated patient. Aim: To describe the critical care nurse's experience of preparing an intubated patient for interhospital transport. Method: An interview study of a qualitative method with an inductive approach. Ten interviews were conducted and analyzed. The analysis was carried out based on Graneheim and Lundman's content analysis. Result: Four main categories were compiled that describe the critical care nurse's experience of preparing an intubated patient for IHT. The categories were: Experience gives knowledge, Teamwork creates an overview, and A challenging work situation. Conclusion: Our conclusion is that the critical care nurse's preparation for IHT of an intubated patient is a team effort and a complicated situation. The experience of the critical care nurse is of great importance for the preparations. Through increased experience for the critical care nurse, own strategies develop. However, the intubated patient clinical condition is dynamic, which can lead to unpredictable events. Newly graduated critical care nurses need support and guidelines/checklists as tools in their work as well as continuous training to develop and maintain competence.

Introduktion: Hos barn med flerfunktionsvariation förekommer en medicinsk sårbarhet och ett ökat behov av intensivvård. Forskning visar att vid intensivvård av barn med flerfunktionsvariation bör familjen inkluderas i vårdteamet och ses som expert på barnet. Forskning visar även att familjecentrerad omvårdnad är viktigt för att främja hälsa och öka vårdkvalitén hos barn med flerfunktionsvariation och deras familj. Syfte: Syftet var att beskriva intensivvårdssjuksköterskans erfarenheter av omvårdnad tillsammans med familjen till barn med flerfunktionsvariation. Metod: Studien var en kvalitativ intervjustudie med deduktiv ansats. Semistrukturerade intervjuer utfördes. För dataanalysen valdes teoridriven tematisk analys. Resultat: Resultatet bildade två huvudteman: ”Familjen är en förutsättning för omvårdnaden” och ”Familjen distanseras från omvårdnaden”. Konklusion: Familjen var en förutsättning i omvårdnaden, då de var specialister på att ge omsorg till sitt barn. Samtidigt kunde familjen ibland distanseras från omvårdnaden. Det behövs ett familjecentrerat omvårdnadsperspektiv på IVA för att vårda barn med flerfunktionsvariation och deras familjer. / Introduction: Children with medical complexity (CMC) have a medical vulnerability and an increased need for critical care. Research shows that when CMC are being treated in the critical care unit, the family should be included in the care team and be seen as an expert of the child. Research also shows that family centered care is important for promoting health and increasing the quality of care for CMC and their families. Aim: The aim was to describe the critical care nurses’ experiences of nursing care with the family of children with medical complexity. Method: The study was a qualitative interview study with a deductive approach. Semi-structured interviews were conducted. For the data analysis, theoretical thematic analysis was chosen. Result: The result formed two main themes: "The family is a prerequisite in the nursing care" and ”The family becomes distanced in the nursing care". Conclusion: The critical care nurses’ described that the family is a prerequisite for the nursing care, due to the family’s specialist knowledge of their child’s needs. On the other hand, sometimes the family are distanced from nursing care due to various circumstances. In the nursing care of CMC and their families, a family-centered nursing perspective is required.

Thesis (Ph.D. (Psychology)) -- University of Limpopo, 2022 / This thesis is about evaluating the effectiveness of a self-care programme for intervention in burnout and compassion fatigue among nurses working in critical care areas. A convenient sampling method of all the nurses who work in the critical care areas as per the operational definition of terms for this study was used. A total of 154 nurses in a critical care area participated in this pre-post study, of which (n=83) were CTOP Nurses and (n=71) were Forensic Nurses. The nurses completed a biographical questionnaire, the Professional Quality of Life Scale (ProQOL R-IV), the Empathy Assessment Index Scale (EAI). Nurses were divided into groups of 6 to 10 people for focus group discussions on their work experiences. The results of the current study indicated moderate to high levels of burnout and compassion fatigue occurring with high compassion satisfaction among the nurses. However, the mean burnout scores for CTOP nurses and Forensic nurses and details indicated lack of statistically significant difference post-intervention (p>0.05). The study utilized the Context Process Outcome (CPO) model as its framework. The proximal outcomes centred around safe holding, development of awareness and self-care. Intermediate outcomes consisted of drop in burnout and compassion fatigue and the distal outcomes showed increase in empathy and revived motivation to continue work in critical areas as well as a drop in distress and increase in compassion satisfaction. The project was ground-breaking work of research with nurses in the critical areas with regards to health promotion with promise in healthier ways of caring for the carers and their empowerment and intervention outlook on the challenges around working environment stressors and interventions. Such work could in future benefit health care professionals by predicting possible decrease in their productivity by measuring other non-invasive constructs like empathy which has shown probable predictive power on development of burnout and compassion fatigue as well as improvement of satisfaction. Future research is recommended for inclusion of other health professions in such work and not only nurses, as well as doing evaluation that allows intermittent re-alignment whenever indicated in the process of intervention