This session is developed by, and presenters invited by Speech Sound Disorders in Children. A case-based approach will be used to assess the complexity of SSD through assessment and analysis measures that guide clinical decisions regarding differential diagnosis, intervention planning, and progress monitoring.

Stroke is the fifth leading cause of death in the U.S. with approximately 795,000 Americans experiencing a stroke each year. In addition to common difficulties with communication and physical impairments following stroke, psychosocial impacts warrant assessment and treatment. Experiencing a stroke can lead to depression, mood disorders, and difficulties with emotion regulation. It is well documented that post-stroke depression (PSD) affects a third of stroke survivors. Higher levels of depression and depressive symptoms are associated with a less efficient use of rehabilitation services, poor functional outcomes, greater odds of hospital readmission, negative impacts on social participation, and increased mortality. The acute phase of stroke recovery may be a key factor in influencing the depression trajectory with early depression predicting poor longitudinal outcomes. The current approach to treating PSD is medication. However, psychotherapy approaches have demonstrated more promise in preventing PSD. Investigations into music-based treatments have shown encouraging results following acquired brain injuries with active music therapy interventions demonstrating large effect sizes for mood improvement. Therefore, the purpose of this three-part dissertation was to examine the effects of active music therapy on mood and describe the clinical decision making process of using music therapy to target mood elevation for hospitalized adults following a first-time acute ischemic stroke. The first study examined the effect of one treatment of active music therapy on mood following a first-time ischemic stroke during acute hospitalization. Active music therapy was defined as music making interventions that elicit and encourage active participation from participants. The Faces Scale was used to assess mood immediately prior to and following treatment. Forty-four adults received at least one treatment. A significant change in mood was found following one treatment. Comment analysis indicated that participants viewed music therapy as a positive experience. The second study investigated the impact of receiving two treatments of active music therapy on mood as compared to one. No significant difference was found between those who received one treatment and those who received two. Both dosing groups demonstrated significant mood improvement; however Group 2 (two treatments) had more severe strokes and did not improve until the second session. The purpose of the third study was to describe the clinical decision-making (CDM) process of a music therapist targeting mood elevation for hospitalized patients following a first-time acute ischemic stroke. The Three Phase Process Model of Collaborative Self-Study was selected as a guiding qualitative methodological framework. Data was collected from four sources: (a) electronic medical records, (b) audio recordings of eight music therapy treatments, (c) a researcher journal, and (d) patient and caregiver/visitor comments. Results indicate that factors influencing CDM included progression through a four-stage treatment process, use of a variety of music-based and therapy-based techniques, and the monitoring and influencing of participant levels of arousal, affect, salience, and engagement. In conclusion, active music therapy during acute hospitalization following a first-time ischemic stroke is effective in significantly improving mood. Components of clinical decision making to elevate mood are illustrated in a provided conceptual framework. Continued investigation is warranted with consideration of stroke severity, dosing amounts, and additional outcomes of interest. Longitudinal investigation is needed to evaluate the impact of treatment on the trajectory of post-stroke depression.

Significant research efforts have focused on examining the effect of patient factors on providing diagnoses across clinical settings; however, the influence of clinician demographics have received less attention. This study aimed to understand the impact of nonclinical factors such as clinician characteristics and response time on diagnostic accuracy. The study used data from a WHO field study of the ICD-11 development (n = 1822) that required clinicians to diagnose two case vignettes. Clinicians’ slower response times had a significant positive impact on their rates of diagnostic accuracy. However, there was no evidence that clinicians’ demographic features were directly related to their diagnostic accuracy. Rather, clinicians’ age, years of experience, world region, and their clinical profession indirectly predicted accuracy through their overall response time. Contradictory to decision-making theories, older clinicians and clinicians with more years of experience had higher rates of diagnostic accuracy when they spent more time completing the study. Additionally, clinicians in South America with slower response times had higher accuracy compared to clinicians in North America. Clinicians in Asia had faster response times that negatively impacted their accuracy rates compared to North America clinicians. These findings suggest differences in response time and the applicability of the ICD-11 across cultures. Consistent with previous research, medical professionals with quicker response times had the lowest rates of accuracy compared to psychologists and other clinical professionals. These findings highlight the need for researchers and clinicians to consider the role their dispositional features have in the diagnostic process. Moreover, it is crucial that future research into diagnostic decision-making and accuracy should consider additional mediating factors such as response style, culture, and experience.

In the United States nearly 1 million annual new and recurrent myocardial infarctions (MI) occur with 10% of patients hospitalized with MI having unrecognized ischemic symptoms. Inexperienced nurses are expected to accurately interpret cardiac symptom cues, possibly without ever having experienced care of patients with MI, yet have been shown to be less able to classify symptom cues and reach accurate conclusions than experienced nurses. The purpose of this study was to test an educational intervention using theories of pattern recognition to develop CT in MI and improve nursing students’ clinical decision-making and clinical judgment using high fidelity patient simulation. This study used a quasi-experimental three group pre-/post-test design and qualitative data to triangulate information on critical thinking, clinical decision-making, and clinical judgment in MI. A sample of junior baccalaureate in nursing students (N = 54) from a large metropolitan university were divided in pairs and randomized to one of two control groups. Data were collected with instruments which measured pattern recognition in MI, critical thinking in MI, and self-perception of clinical decision-making. In addition, diagnostic efficiency and accuracy were measured. Triangulation on clinical decision making with semi-structured interviews using ‘thinking aloud’ technique was conducted. Data were analyzed as qualitative data and compared among groups. Students who were given prototypes for MI using simulation significantly improved critical thinking as measured by pattern recognition in MI (t(3.153(2), p = .038) compared with the non-simulation control group. Qualitative findings showed that students receiving the experimental simulation with a non-MI scenario and feedback-based debriefing had greatest gains in clinical reasoning which included development of clinical decision-making using analytic hypothetico-deductive and Bayesian reasoning processes and learned avoidance of heuristics. Students receiving the experimental simulation learned to identify salient symptom cues, analyzed data more complexly, and reflected on their simulation experience in a way which students reported improved learning. Students who were given MI only simulation scenarios developed deleterious heuristics and showed fewer gains in clinical reasoning, though both simulation groups demonstrated greater critical thinking ability than the non-simulation control group. Findings support the use of simulation to improve clinical reasoning including pattern recognition and clinical decision-making, and emphasize the significance of simulation scenario construction and debriefing to achieving learning outcomes. The findings could be used to guide further research to improve critical thinking, clinical decision-making, and clinical judgment in nursing students using simulation. Funding for this study was provided by the American Association of Critical Care Nurses and Philips Medical Systems and a testing grant from Elsevier, Assessment.

Syfte: Att undersöka hur sjuksköterskor på medicinska vårdavdelningar värderar sina arbetsuppgifter och hur de upplever sin psykosociala arbetsmiljö. Metod: En kvantitativ, komparativ tvärsnittsstudie. Enkäter delades ut till 57 sjuksköterskor på två medicinska vårdavdelningar på Akademiska sjukhuset. Resultat: Trettiofyra sjuksköterskor (60%) besvarade enkäten. Få sjuksköterskor upplevde sitt arbete som lugnt och rofyllt och flera sjuksköterskor uppgav att de sällan eller aldrig hinner med det som ska utföras under ett arbetspass. Sjuksköterskorna uppgav överlag att det är mycket viktigt att känna till sina patienters vitalparametrar. Den arbetsuppgift som påverkades mest av hög arbetsbelastning var dock att känna till sina patienters urinproduktion, vilket endast 17 sjuksköterskor (50%) uppgav att de hinner med. Den arbetsuppgift som flest antal sjuksköterskor (n=28, 82%) uppgav att de hinner med är att känna till sina patienters medvetandegrad, följt av att ronda med läkare (n=27, 79%). Den arbetsuppgift som flest sjuksköterskor uppgav att de inte hinner med var att ge sina patienter munvård (n=20, 59%), följt av att känna till hur mycket de har ätit (n=16, 47%). Sjuksköterskor som hade arbetat kortare än 2,5 år värderade vissa administrativa och patientnära arbetsuppgifter högre än sjuksköterskor som hade arbetat längre än 2,5 år. / Aim: To explore how nurses in medical wards evaluate their work and how they experience their psychosocial work environment. Method: A quantitative, comparative cross-sectional study. Questionnaires were distributed to 57 nurses on two medical wards at Akademiska hospital. Results: Thirtyfour nurses (60%) participated. Few nurses considered their work as calm and peaceful, and several nurses said they rarely or never had time to do the tasks that should be performed during a shift. The nurses generally stated that it’s very important to know patients' vital signs. The task that was most affected by high workload was to know patients' urine output, which only 17 nurses (50%) said they had time to check. The task that most nurses (n=28, 82%) said they had time for is to know patients' level of consciousness, followed by the physicians round  (n=27, 79%). The task that most nurses said that they did not have time for was to give patients oral care (n=20, 59%), followed by knowing how much patients have eaten (n=16, 47%). Nurses who had worked under 2,5 years valued certain administrative and patient-related duties higher than nurses who had worked over 2,5 years.

Abstract Both qualitative and quantitative limitations of two-dimensional (2DE) imaging have lead to the emergence of the three-dimensional echo (3DE) technique. Until recently the development of 3DE technology has been slow due to inferior image quality and longer processing and acquisition times compared with 2DE. However, in recent times 3DE technology has advanced to “real-time” (RT3D) and has become feasible as a standard clinical tool. The overall hypothesis of the studies undertaken in this thesis is that the increased accuracy of left ventricular (LV) assessment using RT3D justifies its use in clinical decision-making based on both single and sequential measurements in routine echocardiographic practice. It shows the increased accuracy and feasibility of 3DE using online and offline techniques and opacification, and evaluates the prognostic implications of LV measurements globally and regionally using 3DE compared with 2DE. Further, it assesses the accuracy of LV assessment using 3DE and demonstrates its superior accuracy to 2DE in cross-sectional studies. The thesis initially reviews the use of physiologic parameters used for clinical decision making and looks at the principles of incremental value in diagnostic testing. The assessment of ventricular structure and function is discussed as well as the current problems with clinical echocardiography, which have lead to the evolution and development of 3DE. The second chapter describes the methodologies used in this thesis, with particular emphasis on new technologies used in the studies. Chapter 3 looks at the role of experience as a barrier to incorporation of 3DE into standard practice. We tested attendees before and after an intensive interactive training course to evaluate the learning curve. An interactive teaching course with rehearsal and direct mentoring appears to overcome this limitation and may improve the uptake of the 3DE technique. Chapters 4 to 6 validate the use of 3DE by comparing it to 2DE and magnetic resonance imaging (MRI) with respect to online and offline techniques, the use of left ventricular opacification (LVO) and the serial follow-up of patients. The availability of automated on-line software may increase the feasibility of real-time 3DE for LV volume calculation in clinical practice. Chapter 4 looks at the comparison of off- and on-line approaches with magnetic resonance imaging. Online measurement of LV volumes was found to be feasible and more accurate than with 2DE, however the offline approach was more accurate - although more time-consuming. Chapter 5 involves two studies which sought to validate 3DE in a multicentre setting. They examine the variability of LV measurements across multiple sites and to validate 3DE against MRI. The first study found that the semi-automated measurement of 3DE reduces the variation of LV volume between centers. The second study provides information on the role of different potential sources of error and provides guidelines for future users on how to minimize these errors as well as how to interpret their findings. The next chapter further validates 3DE with use of LVO as a technique to improve the accuracy of LV volume measurements. We sought to examine the accuracy of non-contrast and contrast enhanced 2DE and 3DE for calculation of LV volumes and ejection fraction (EF), relative to cardiac magnetic resonance imaging. 2DE with LVO was analogous to 3DE in accurate categorization of LV function. However, 3DE with LVO was feasible and superior to other non-contrast and contrast enhanced techniques in patients with previous infarction. Chapter 7 examines the technical details of regional volume measurements. The use of a fixed external frame of reference in analyses of regional wall motion in the apical four-chamber view is prone to a systematic error and the use of a floating-axis analysis corrects for this, but this is based on landmarks by MRI (apex, annulus) and center of mass by 3DE. The axis is likely to be influenced by reverse remodeling after intervention and therefore we sought to evaluate 3DE regional volume assessment vs. cardiac MRI over follow-up. The use of a center-line based on center of mass with RT3D may contribute to problems with use of this modality to track regional volumes over time. Although global 3DE volumes compare well with MRI volumes, new developments in image quality and automated software will be needed before changes in regional volumes can be reliably followed with 3DE. 2DE ESE is limited by sampling in standard imaging planes and suboptimal acquisition may cause poor matching of pre- and post-stress images. 3DE may avoid these orientation problems and contraction front mapping (CFM) may also provide a method for defining the temporal homogeneity of contraction. Chapter 8 examines the incremental benefit of 3DE CFM to 2DE and 3DE, using coronary angiography as the reference standard. It found that analysis of the temporal distribution of contraction may be an alternate means than 3DE wall motion assessment for identification of ischemia for ESE. Another significant validation needed for 3DE is not only for the LV but for the right ventricle (RV). The non-geometric nature of the RV makes it difficult to measure. Chapter 9 shows that 3DE is superior to 2DE for follow-up of RV function by validation vs. cardiac MRI. It was found that 3DE was indeed more accurate than 2DE approaches and reduces test-retest variation of RV volumes and EF measurements in follow-up RV assessment. Chapter 10 investigates the accuracy and reproducibility of the use of 3DE for serial follow-up of LV measurements. Echocardiographic follow-up of LV volumes is difficult because of the test-retest variation of 2DE. In this follow-up study, sequential 3DE measurements of change of volumes and EF were similar to those obtained using MRI, but 2DE overestimated change in EDV. As MRI is expensive, of limited availability and cannot be performed on patients with implanted devices, 3DE appears to be an effective long-term follow-up imaging tool for when sequential measurement of LV volumes is sought to guide management decisions. Chapter 11 investigates whether 3DE is more predictive of outcome than 2DE. In this outcome study, 3DE measurements of ESV and EF showed a stronger prediction of outcomes than 2DE. 3DE now appears to be the measurement of choice for when LV volumes and EF are sought to guide management decisions. In conclusion, the work reported in this thesis demonstrates that 3DE increases the accuracy of LV assessment and justifies its use in clinical decision-making based on both single and sequential measurements in routine echocardiographic practice.

Introdução: Descontinuação prematura ou tardia da ventilação mecânica invasiva (VM) associa-se a maior morbimortalidade. Redução da pressão intratorácica durante o teste de respiração espontânea (TRE) pode precipitar disfunção cardíaca através da elevação abrupta do retorno venoso e da pós-carga do ventrículo esquerdo. Da mesma maneira, alterações na demanda respiratória e cardíaca que ocorrem ao longo do TRE também podem manifestar-se à ultrassonografia pulmonar. O padrão B é um artefato sonográfico que se correlacionada com edema intersticial. Um ensaio clínico randomizando concluiu que a ultrassonografia pulmonar foi capaz de prever insuficiência ventilatória pós extubação através de variações na aeração pulmonar observadas durante o procedimento de desmame; contudo, a ferramenta não pôde rastrear pacientes antes da submissão ao TRE. O impacto do balanço hídrico (BH) e de sinais radiológicos de congestão pulmonar antes do TRE sobre os desfechos no desmame também precisam ser determinados. Métodos: Cinquenta e sete indivíduos elegíveis para o desmame ventilatório foram recrutados. Traqueostomizados foram excluídos. Realizou-se avaliação ultrassonográfica de seis zonas pulmonares imediatamente antes e ao final do TRE. Predominância B foi definida como qualquer perfil com padrão B presente bilateralmente em região torácica anterior. Os pacientes foram seguidos por até 48 horas depois da extubação. Após esse estudo piloto, foi conduzido um estudo observacional, prospectivo, multicêntrico em duas unidades de terapia intensiva (UTIs) clínico-cirúrgicas ao longo de dois anos. Os mesmos critérios de inclusão e de exclusão foram aplicados; contudo, a ultrassonografia foi realizada apenas antes do TRE. O desfecho primário foi falha no TRE, definido como incapacidade de tolerar o teste T durante 30 a 120 minutos e, nesse caso, o paciente não era extubado. Dados demográficos e fisiológicos, BH das 48 horas antecedendo o TRE (entrada de fluidos menos débitos durante 48 horas) e desfechos foram coletados. Em uma análise post hoc de 170 procedimentos de desmame, um radiologista aplicou um escore radiológico na interpretação de radiografias digitais de tórax realizadas previamente ao TRE – o exame mais recente disponível foi avaliado em termos de congestão pulmonar. Resultados: No estudo piloto, 38 indivíduos foram extubados com sucesso, 11 falharam no TRE e 8 necessitaram de reintubação em até 48 horas após a extubação. No início do teste T, padrão B ou consolidação já estava presente em porções inferiores e posteriores dos pulmões em mais da metade dos casos, e tais regiões mantiveram-se não aeradas até o final do teste. Perda de aeração pulmonar durante o TRE foi observada apenas no grupo que falhou no mesmo (p= 0,07). Esses pacientes também demonstraram maior predominância B ao final do teste (p= 0,019). Antes do procedimento de desmame, todavia, não foi possível discernir indivíduos que falhariam no TRE, tampouco aqueles que necessitariam de reintubação dentro de 48 horas. Posteriormente, de 2011 a 2013, 250 procedimentos de desmame foram avaliados. Falha no TRE ocorreu em 51 (20,4%). Cento e oitenta e nove pacientes (75,6%) foram extubados na primeira tentativa. Indivíduos que falharam no TRE eram mais jovens (mediana de 66 versus 75 anos, p= 0,03) e apresentaram maior duração de VM e maior prevalência de doença pulmonar obstrutiva crônica (DPOC) (19,6 versus 9,5%, p= 0,04). Predominância B mostrou-se um preditor muito fraco para falha no TRE, exibindo sensibilidade de 47%, especificidade de 64%, valor preditivo positivo de 25% e valor preditivo negativo de 82%. Não houve diferença estatisticamente significativa no BH das 48 horas antecedendo o TRE entre os grupos (falha no TRE: 1201,65 ± 2801,68 ml versus sucesso no TRE: 1324,39 ± 2915,95 ml). Entretanto, em pacientes portadores de DPOC, ocorreu associação estatisticamente significativa entre BH positivo nas 48 horas antes do TRE e falha no TRE (odds ratio= 1,77 [1,24 – 2.53], p= 0,04). O escore radiológico, obtido em 170 testes T, foi similar entre os pacientes com falha e sucesso no TRE (mediana de 3 [2 – 4] versus 3 [2 – 4]), p= 0, 15). Conclusão: Maior perda de aeração pulmonar observada à ultrassonografia durante o TRE pode sugerir disfunção cardiovascular e aumento na água extravascular, ambos induzidos pelo processo de desmame. BH, sinais radiológicos de congestão pulmonar ou padrão B documentado através de um protocolo ultrassonográfico simplificado não devem contraindicar o TRE em pacientes estáveis hemodinamicamente e adequadamente oxigenados, haja vista o fato de tais variáveis não terem predito maior probabilidade de falha de desmame em pacientes críticos clínico-cirúrgicos. Ainda assim, evitar BH positivo em pacientes com DPOC parece otimizar os desfechos do desmame. / Introduction: Both delayed and premature liberation from mechanical ventilation (MV) are associated with increased morbi-mortality. Inspiratory fall in intra-thoracic pressure during spontaneous breathing trial (SBT) may precipitate cardiac dysfunction through abrupt increase in venous return and in left ventricular afterload. Changes in respiratory and cardiac load occurring throughout SBT might manifest with dynamic changes in lung ultrasound (LUS). B-pattern is an artifact that correlates with interstitial edema. A randomized controlled trial concluded that bedside LUS could predict post extubation distress due to changes in lung aeration throughout weaning procedure; however, it could not screen patients before submission to SBT. The impact of fluid balance (FB) as well as of radiological signs of pulmonary congestion prior to SBT on weaning outcomes must also be determined. Methods: Fifty-seven subjects eligible for ventilation liberation were enrolled. Patients with tracheostomy were excluded. LUS assessment of six thoracic zones was performed immediately before and at the end of SBT. B-predominance was defined as any profile with anterior bilateral B-pattern. Patients were followed up to 48 hours after extubation. After this pilot report, we conducted a 2-year prospective, multicenter, observational study in two adult medical surgical intensive care units (ICUs). Same inclusion and exclusion criteria were applied; however, LUS was performed only immediately before SBT. The primary outcome was SBT failure, defined as inability to tolerate a T-piece trial during 30 to 120 minutes, in which case patients were not extubated. Demographic, physiologic, FB in the preceding 48 hours of SBT (fluid input minus output over the 48-hour period), and outcomes data were collected. As a post hoc analysis in 170 weaning procedures performed in one of the ICUs, an attending radiologist applied a radiological score on interpretation of digital chest x-rays performed before SBT - the most recent available exam was analyzed regarding degree of lung fluid content. Results: In the pilot study, 38 subjects were successfully extubated, 11 failed the SBT and 8 needed reintubation within 48 hours of extubation. At the beginning of T-piece trial, B-pattern or consolidation were already found at lower and posterior lung regions in more than half of the individuals and remained nonaerated at the end of the trial. Loss of lung aeration during SBT was observed only in SBT-failure group (p= 0.07). These subjects also exhibited higher B-predominance at the end of trial (p= 0.019). Prior to weaning procedure, however, we were not capable to discriminate individuals who would fail SBT, nor who would need reintubation within 48 hours. Afterwards, from 2011 to 2013, 250 weaning procedures were evaluated. SBT failure occurred in 51 (20.4%). One hundred eighty-nine patients (75.6%) were extubated at first attempt. Individuals who failed SBT were younger (median 66 versus 75 years, p= 0.03), had higher duration of MV (median 7 versus 4 days, p< 0.0001) and higher prevalence of chronic obstructive pulmonary disease (COPD) (19.6 versus 9.5%, p= 0.04). B-predominance was a very weak predictor for SBT failure, showing 47% sensitivity, 64% specificity, 25% positive predictive value, and 82% negative predictive value. There were no statistically significant differences in 48 hour-FB prior to SBT between groups (SBT failure: 1201.65 ± 2801.68 mL versus SBT success: 1324.39 ± 2915.95 mL). However, in COPD subgroup, we found significant association between positive FB in the 48 hours prior to SBT and SBT failure (odds ratio = 1.77 [1.24 – 2.53], p= 0.04). Radiological score, obtained in 170 T-piece trials, was similar between SBT failure and success subjects (median 3 [2 - 4] vs 3 [2 - 4], p= 0.15). Conclusion: Higher loss of lung aeration observed by LUS during SBT might suggest cardiovascular dysfunction and increases in extravascular lung water, both induced by weaning. Neither FB, nor radiological findings of pulmonary congestion, nor B-pattern detected by a simplified LUS protocol should preclude hemodynamically stable, sufficiently oxygenated patients from performing an SBT, since such variables did not predict greater probability of weaning failure in medical-surgical critically ill population. Notwithstanding, avoiding positive FB in COPD patients might improve weaning outcomes.

Introdução: Descontinuação prematura ou tardia da ventilação mecânica invasiva (VM) associa-se a maior morbimortalidade. Redução da pressão intratorácica durante o teste de respiração espontânea (TRE) pode precipitar disfunção cardíaca através da elevação abrupta do retorno venoso e da pós-carga do ventrículo esquerdo. Da mesma maneira, alterações na demanda respiratória e cardíaca que ocorrem ao longo do TRE também podem manifestar-se à ultrassonografia pulmonar. O padrão B é um artefato sonográfico que se correlacionada com edema intersticial. Um ensaio clínico randomizando concluiu que a ultrassonografia pulmonar foi capaz de prever insuficiência ventilatória pós extubação através de variações na aeração pulmonar observadas durante o procedimento de desmame; contudo, a ferramenta não pôde rastrear pacientes antes da submissão ao TRE. O impacto do balanço hídrico (BH) e de sinais radiológicos de congestão pulmonar antes do TRE sobre os desfechos no desmame também precisam ser determinados. Métodos: Cinquenta e sete indivíduos elegíveis para o desmame ventilatório foram recrutados. Traqueostomizados foram excluídos. Realizou-se avaliação ultrassonográfica de seis zonas pulmonares imediatamente antes e ao final do TRE. Predominância B foi definida como qualquer perfil com padrão B presente bilateralmente em região torácica anterior. Os pacientes foram seguidos por até 48 horas depois da extubação. Após esse estudo piloto, foi conduzido um estudo observacional, prospectivo, multicêntrico em duas unidades de terapia intensiva (UTIs) clínico-cirúrgicas ao longo de dois anos. Os mesmos critérios de inclusão e de exclusão foram aplicados; contudo, a ultrassonografia foi realizada apenas antes do TRE. O desfecho primário foi falha no TRE, definido como incapacidade de tolerar o teste T durante 30 a 120 minutos e, nesse caso, o paciente não era extubado. Dados demográficos e fisiológicos, BH das 48 horas antecedendo o TRE (entrada de fluidos menos débitos durante 48 horas) e desfechos foram coletados. Em uma análise post hoc de 170 procedimentos de desmame, um radiologista aplicou um escore radiológico na interpretação de radiografias digitais de tórax realizadas previamente ao TRE – o exame mais recente disponível foi avaliado em termos de congestão pulmonar. Resultados: No estudo piloto, 38 indivíduos foram extubados com sucesso, 11 falharam no TRE e 8 necessitaram de reintubação em até 48 horas após a extubação. No início do teste T, padrão B ou consolidação já estava presente em porções inferiores e posteriores dos pulmões em mais da metade dos casos, e tais regiões mantiveram-se não aeradas até o final do teste. Perda de aeração pulmonar durante o TRE foi observada apenas no grupo que falhou no mesmo (p= 0,07). Esses pacientes também demonstraram maior predominância B ao final do teste (p= 0,019). Antes do procedimento de desmame, todavia, não foi possível discernir indivíduos que falhariam no TRE, tampouco aqueles que necessitariam de reintubação dentro de 48 horas. Posteriormente, de 2011 a 2013, 250 procedimentos de desmame foram avaliados. Falha no TRE ocorreu em 51 (20,4%). Cento e oitenta e nove pacientes (75,6%) foram extubados na primeira tentativa. Indivíduos que falharam no TRE eram mais jovens (mediana de 66 versus 75 anos, p= 0,03) e apresentaram maior duração de VM e maior prevalência de doença pulmonar obstrutiva crônica (DPOC) (19,6 versus 9,5%, p= 0,04). Predominância B mostrou-se um preditor muito fraco para falha no TRE, exibindo sensibilidade de 47%, especificidade de 64%, valor preditivo positivo de 25% e valor preditivo negativo de 82%. Não houve diferença estatisticamente significativa no BH das 48 horas antecedendo o TRE entre os grupos (falha no TRE: 1201,65 ± 2801,68 ml versus sucesso no TRE: 1324,39 ± 2915,95 ml). Entretanto, em pacientes portadores de DPOC, ocorreu associação estatisticamente significativa entre BH positivo nas 48 horas antes do TRE e falha no TRE (odds ratio= 1,77 [1,24 – 2.53], p= 0,04). O escore radiológico, obtido em 170 testes T, foi similar entre os pacientes com falha e sucesso no TRE (mediana de 3 [2 – 4] versus 3 [2 – 4]), p= 0, 15). Conclusão: Maior perda de aeração pulmonar observada à ultrassonografia durante o TRE pode sugerir disfunção cardiovascular e aumento na água extravascular, ambos induzidos pelo processo de desmame. BH, sinais radiológicos de congestão pulmonar ou padrão B documentado através de um protocolo ultrassonográfico simplificado não devem contraindicar o TRE em pacientes estáveis hemodinamicamente e adequadamente oxigenados, haja vista o fato de tais variáveis não terem predito maior probabilidade de falha de desmame em pacientes críticos clínico-cirúrgicos. Ainda assim, evitar BH positivo em pacientes com DPOC parece otimizar os desfechos do desmame. / Introduction: Both delayed and premature liberation from mechanical ventilation (MV) are associated with increased morbi-mortality. Inspiratory fall in intra-thoracic pressure during spontaneous breathing trial (SBT) may precipitate cardiac dysfunction through abrupt increase in venous return and in left ventricular afterload. Changes in respiratory and cardiac load occurring throughout SBT might manifest with dynamic changes in lung ultrasound (LUS). B-pattern is an artifact that correlates with interstitial edema. A randomized controlled trial concluded that bedside LUS could predict post extubation distress due to changes in lung aeration throughout weaning procedure; however, it could not screen patients before submission to SBT. The impact of fluid balance (FB) as well as of radiological signs of pulmonary congestion prior to SBT on weaning outcomes must also be determined. Methods: Fifty-seven subjects eligible for ventilation liberation were enrolled. Patients with tracheostomy were excluded. LUS assessment of six thoracic zones was performed immediately before and at the end of SBT. B-predominance was defined as any profile with anterior bilateral B-pattern. Patients were followed up to 48 hours after extubation. After this pilot report, we conducted a 2-year prospective, multicenter, observational study in two adult medical surgical intensive care units (ICUs). Same inclusion and exclusion criteria were applied; however, LUS was performed only immediately before SBT. The primary outcome was SBT failure, defined as inability to tolerate a T-piece trial during 30 to 120 minutes, in which case patients were not extubated. Demographic, physiologic, FB in the preceding 48 hours of SBT (fluid input minus output over the 48-hour period), and outcomes data were collected. As a post hoc analysis in 170 weaning procedures performed in one of the ICUs, an attending radiologist applied a radiological score on interpretation of digital chest x-rays performed before SBT - the most recent available exam was analyzed regarding degree of lung fluid content. Results: In the pilot study, 38 subjects were successfully extubated, 11 failed the SBT and 8 needed reintubation within 48 hours of extubation. At the beginning of T-piece trial, B-pattern or consolidation were already found at lower and posterior lung regions in more than half of the individuals and remained nonaerated at the end of the trial. Loss of lung aeration during SBT was observed only in SBT-failure group (p= 0.07). These subjects also exhibited higher B-predominance at the end of trial (p= 0.019). Prior to weaning procedure, however, we were not capable to discriminate individuals who would fail SBT, nor who would need reintubation within 48 hours. Afterwards, from 2011 to 2013, 250 weaning procedures were evaluated. SBT failure occurred in 51 (20.4%). One hundred eighty-nine patients (75.6%) were extubated at first attempt. Individuals who failed SBT were younger (median 66 versus 75 years, p= 0.03), had higher duration of MV (median 7 versus 4 days, p< 0.0001) and higher prevalence of chronic obstructive pulmonary disease (COPD) (19.6 versus 9.5%, p= 0.04). B-predominance was a very weak predictor for SBT failure, showing 47% sensitivity, 64% specificity, 25% positive predictive value, and 82% negative predictive value. There were no statistically significant differences in 48 hour-FB prior to SBT between groups (SBT failure: 1201.65 ± 2801.68 mL versus SBT success: 1324.39 ± 2915.95 mL). However, in COPD subgroup, we found significant association between positive FB in the 48 hours prior to SBT and SBT failure (odds ratio = 1.77 [1.24 – 2.53], p= 0.04). Radiological score, obtained in 170 T-piece trials, was similar between SBT failure and success subjects (median 3 [2 - 4] vs 3 [2 - 4], p= 0.15). Conclusion: Higher loss of lung aeration observed by LUS during SBT might suggest cardiovascular dysfunction and increases in extravascular lung water, both induced by weaning. Neither FB, nor radiological findings of pulmonary congestion, nor B-pattern detected by a simplified LUS protocol should preclude hemodynamically stable, sufficiently oxygenated patients from performing an SBT, since such variables did not predict greater probability of weaning failure in medical-surgical critically ill population. Notwithstanding, avoiding positive FB in COPD patients might improve weaning outcomes.

The overall aim of the thesis was to study clinical decision making in nursing. This was performed by evaluation of the quality of nurses’ diagnostic statements and comparison of the concordance between nurses and patients’ perceptions of the patients’ nursing needs, as well as patient preferences for participation in clinical decision making. Further, predictors regarding patients’ active participation were investigated. Quasi-experimental, comparative and cross-sectional descriptive study designs were used to collect data in acute care settings from randomly selected patient records (n = 140), nurse-patient dyads (n = 80), and patients discharged from hospital care (n = 428). Data were gathered using questionnaires and review of patient records. The quality of nurses’ diagnostic statements improved by the means of education directed to nurses and implementation of new forms for recording supporting nursing care planning (I). Discrepancies were found concerning patients and nurses’ perceptions about what constitutes a problem for the patient as well as the severity and importance of acting on the problem (II). Further, nurses perceived that their patients preferred to be more active in clinical decision making compared with the patients’ own preferences for participation (III). Gender, education, living situation, and occupation were identified as predictors for preferring an active role in clinical decision making (IV). The conclusions are that the accuracy of diagnostic statements needs to be addressed and validated further through systematic assessment of the patients’ perceptions and preferences concerning the health situation and preferences for participation in clinical decision making. Clinical implications are that nurses need to involve patients in identifying patient problems of relevance for nursing. Further, nurses also need to be aware of patients’ preferences for participation in clinical decision making in order that they can plan care in accordance with patient preferences and allow participation to the degree preferred by the patient. / Patientens delaktighet i kliniskt beslutsfattande i omvårdnad – ett gemensamt ansvar för patienter och sjuksköterskor Bakgrund Patienten har, med bas i lagstiftning och förordningar, en stark ställning inom svensk hälso- och sjukvård. Det grundas delvis på en samhällelig uppfattning om betydelsen av patientens delaktighet i såväl planering som genomförande av sin egen vård. I ett etiskt perspektiv har delaktigheten ett värde i sig själv, som en förutsättning för individens autonomi och integritet. Sjuksköterskan identifierar patientens behov och problem i syfte att kunna ge en individuellt anpassad omvårdnad. Sjuksköterskan har ofta djupgående professionell kunskap om patientens omvårdnadsproblem, medan patienten har preferenser och värderingar om vårdens genomförande. Om planeringen av omvårdnaden inte utgår från patientens preferenser så finns det stor risk att patientens perspektiv inte kommer med som bedömningsgrund. En samsyn mellan patient och sjuksköterska om patientens behov av omvårdnad och roll i beslutsfattandet kan öka möjligheten att optimera omvårdnadsinsatserna och främja en hög kvalitet på omvårdnaden. Kunskapen om kliniskt beslutsfattande inom omvårdnad är bristfällig, framförallt med fokus på patientens delaktighet och graden av samsyn mellan patienternas och sjuksköterskornas subjektiva perspektiv. Syfte Avhandlingens övergripande syfte var att undersöka kliniskt beslutsfattande inom omvårdnad med speciellt fokus på omvårdnadsdiagnosers kvalitet, patientens delaktighet i beslutsprocessen och överensstämmelsen mellan patienters och sjuksköterskors uppfattningar om behov och problem inom omvårdnad. Specifika syften för respektive delarbeten var att I) undersöka effekten av utbildning i omvårdnadsdiagnostik riktad till sjuksköterskor och utveckling av journaldokument på omvårdnadsdiagnosers kvalitet; II) beskriva överensstämmelse i patienters och sjuksköterskors bedömningar av förekomst, svårighetsgrad och betydelse av problem inom omvårdnaden; III) beskriva samstämmighet mellan patienters och sjuksköterskors uppfattning om patientens preferenser för delaktighet i kliniskt beslutsfattande i omvårdnaden, samt samstämmighet mellan patienters preferenser och faktiska erfarenhet av delaktighet; och IV) identifiera prediktorer för patienters preferenser att delta i kliniskt beslutsfattande om den egna omvårdnaden. Material och metod Studier har genomförts med beskrivande, jämförande och kvasi-experimentell design på avdelningar inom somatisk sjukhusvård. Urvalet består av 140 patientjournaler (studie I), 80 patient-sjuksköterskepar (studie II och III), samt 428 patienter som nyligen blivit utskrivna från somatisk sjukhusvård (studie IV). Data har insamlats genom granskning av innehåll i patientjournaler samt genom enkäter till patienter och sjuksköterskor. Instrumenten CAT-CH-ING och Control Preference Scale har använts tillsammans med frågeformulär som utvecklats specifikt för studien. Resultat Delarbete I Kvaliteten på omvårdnadsdiagnoserna förbättrades signifikant efter att sjuksköterskorna på experimentavdelningen genomgått en utbildning och nya journaldokument hade introducerats. Störst kvarvarande svårigheter var förknippade med hur etiologin i omvårdnadsdiagnosen formulerades. Omvårdnadsdiagnosernas kvalitet förbättrades inte på motsvarande sätt på kontrollavdelningarna. Delarbete II Sjuksköterskorna identifierade de omvårdnadsbehov och problem som patienterna uppfattade sig ha med en sensitivitet på 0.53 och ett prediktivt värde på 0.50. Det innebär att patienterna delvis identifierade andra problem än sjuksköterskorna, framför allt var det vanligt inom områdena nutrition, sömn, smärta och känslor/andlighet. Sjuksköterskorna underskattade problemens svårighetsgrad för 47 % av de behov och problem som hade identifierats gemensamt av patienter och sjuksköterskor. En gemensam uppfattning om betydelsen av att få stöd och hjälp med att lösa omvårdnadsproblemet fanns i knappt hälften av fallen. Delarbete III En majoritet av sjuksköterskorna uppfattade att patienterna föredrog att vara mer aktiva i det kliniska beslutsfattandet om omvårdnad än vad patienterna själv uppgav. Sammanlagt 61 % av patienterna föredrog en passiv roll i beslutsfattandet medan sjuksköterskorna angav att 24 % ville vara passiva. Preferenser om en aktiv roll i beslutsfattande angavs av 9 % av patienterna medan sjuksköterskorna hade uppfattat att 45 % av patienterna föredrog en aktiv roll. Totalt 71 % av patienterna upplevde att de inte hade varit delaktiga i den utsträckning de själva hade föredragit, 37 % hade varit mer passiva och 34 % mer aktiva. Patienterna uppgav att de intagit en mer passiv roll än vad de hade önskat i samband med behov och problem inom områdena kommunikation, andning och smärta, medan en mer aktiv roll än önskat förekom i samband med behov och problem inom områdena aktivitet och känslor/roller. Delarbete IV En majoritet av patienterna i sluten somatisk vård föredrog att inledningsvis under vårdperioden inta en passiv roll i kliniskt beslutsfattande om omvårdnad. Sammanlagt 22 % av patienterna föredrog en aktiv roll. Faktorer som predicerade preferenser för att inta en aktiv roll var kön (Odds ratio [OR] = 1.8), utbildning (OR = 2.2), levnadsförhållanden (OR = 1.8) och sysselsättning, d.v.s. om personen var yrkesarbetande eller pensionär (OR = 2.0). Sannolikheten var 53 % att en pensionerad högutbildad kvinna som levde ensam föredrog att vara aktiv i beslutsfattandet om sin egen omvårdnad. Sannolikheten för att en yrkesarbetande lågutbildad man som levde tillsammans med någon annan föredrog att vara aktiv var 8 %. Slutsats Kvaliteten på de omvårdnadsdiagnoser som sjuksköterskan ställer kan förbättras genom utbildning men orsakerna till omvårdnadsproblemet behöver identifieras på ett tydligare sätt. Det fanns en skillnad i hur patienter och sjuksköterskor uppfattade vad som utgjorde ett omvårdnadsbehov eller problem samt problemets svårighetsgrad och betydelse. Sjuksköterskan identifierade 53 % av de omvårdnadsproblem som patienten själv identifierade, samtidigt som sjuksköterskan identifierade andra omvårdnadsproblem som inte patienten uppfattade. Uppfattningarna skiljde sig också åt om vilken roll patienten föredrog att ha i det kliniska beslutsfattande om omvårdnad. Faktorer som kunde predicera patientens preferenser att ha en aktiv roll i kliniskt beslutsfattande var kön, utbildningsnivå, boendesituation och om personen yrkesarbetade eller var pensionär. En slutsats av den påvisade diskrepansen i uppfattningar är att sjuksköterskor i högre grad behöver involvera patienterna i en diskussion om hälsotillståndet, behovet av omvårdnad och patientens önskan att delta i beslut om sin omvårdnad. Det är nödvändigt för att så långt det är möjligt kunna uppnå en samsyn som grund för planering och genomförande av omvårdnaden. Om sjuksköterskan validerar sina egna bedömningar om behovet av omvårdnad med patienten kan kvaliteten på bedömningarna förbättras. Patientens perspektiv blir en explicit del av beslutsunderlaget vid planering av omvårdnad vilket sannolikt också påverkar omvårdnadens innehåll och därmed även omvårdnadens kvalitet. Det bästa sättet att identifiera det individuella perspektivet är genom en systematisk bedömning i dialog mellan sjuksköterskan och den enskilde patienten. Mötet och dialogen mellan patienten och sjuksköterskan är en förutsättning för en god omvårdnad men är också en central del av själva omvårdnaden.

Följande uppsats är en begreppsanalys med syftet att studera och beskriva innebörden av begreppet ”partnerskap” ur ett vårdvetenskapligt perspektiv. Begreppsanalysen gjordes för att bidra till en djupare kunskap och förståelse samt tydlig innebörd av begreppet inom hälso- och sjukvård. Metoden som användes var granskning av ordböcker, synonymordböcker och vetenskapliga artiklar där karaktäristiska, förutsättningar och konsekvenser av begreppet beskrevs. Genom att studera de vetenskapliga artiklarna fick vi en djupare förståelse för innebörden av begreppet i relation till kontext. Tre fallbeskrivningar utformades som illustration och förtydliga resultatet. I analysen identifierades fyra framträdande attribut av begreppet, patienten som ansvarstagande partner, förutsättningar för partnerskap, delta i beslutfattande och delad makt. Resultatet visar att partnerskap inom hälso- och sjukvård innebär ett delat ansvar mellan patient och vårdgivare, och vården måste anpassas efter båda parters respektive mål, expertis, och resurser. Partnerskapet skall förstås som en djupare relation av jämlika parter med ett gemensamt ansvarstagande och åtagande för de handlingar som ingår i partnerskapet. Parterna utbyter kunskap, expertis, teknik, erfarenheter, finansiella och emotionella resurser, för att bidra till att målen uppfylls. I diskussionen visar vi att begreppet används inom skilda områden och med liknande betydelse. Partnerskap i Hälso- och sjukvården bygger på ett samarbete mellan vårdgivare och patient där patientens berättelse är utgångspunkten. Detta påvisas i fallbeskrivningar och innebär att sjuksköterskan ansvarar att förvalta berättelsen och att bjuda in till delaktighet.