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Critical illness can be iatrogenic, arising from the lifesaving measures undertaken during admission to critical care. Early mobilization (EM) of patients receiving intensive care unit (ICU)-level care may reduce the possible iatrogenic effects of critical care following cardiac surgery. While evidence supports the safety and efficacy of physiotherapy in the medical-surgical ICU, few studies have included critically ill patients with complicated, prolonged post-operative recoveries despite the worldwide frequency of cardiac surgery. This has resulted in a lack of clinical practice guidelines or systematic reviews to help guide critical care physiotherapy practice in post-operative cardiac surgery. In-bed cycling is a modality to initiate EM. However, its safety and feasibility have yet to be established in the critically ill cardiac surgery population. There is also a paucity of qualitative research investigating clinicians’ attitudes and beliefs about in-bed cycling as an acceptable rehabilitation modality. Purposes: (1) To describe current physiotherapy practice for critically ill adult patients requiring prolonged admissions to ICU post cardiac surgery in Ontario via an electronic, self-administered survey; (2) To investigate the feasibility of in-bed cycling in a pilot study in a sample of critically ill cardiac surgery patients in Hamilton, Ontario; (3) To explore primary frontline clinicians’ experiences and impressions of their involvement with in-bed cycling in the cardiac surgical ICU via an interpretive description qualitative interview study. With adequate physiotherapy staffing, in-bed cycling was found to be safe and feasible with few adverse events occurring during cycling. With an 80% response rate, our survey results suggest that Ontario critical care physiotherapists provide a variety of interventions ranging from chest physiotherapy to functional mobility. Clinicians supported the use of in-bed cycling. Concerns included how to identify appropriate patients and timing of the intervention. This thesis built upon the current critical care research by increasing the presence of the cardiac surgery population in the rehabilitation literature. / Thesis / Doctor of Rehabilitation (RhD) / Early exercise can help patients rehabilitate after a critical illness. No current research exists examining the role of in-bed cycling with patients who become critically ill after heart surgery (so called “off-track”). The thesis goals were: (1) to conduct a survey of Ontario ICU physiotherapists to understand their role treating off-track patients with a complicated post-operative recovery; (2) to determine if cycling is safe and feasible with sick patients after heart surgery in the intensive care unit (ICU); and (3) to interview staff in the Hamilton heart surgery ICU to understand their experiences with in-bed cycling. Ontario physiotherapists provide a multitude of interventions in the heart surgery ICU. Cycling was found to be safe and feasible with adequate physiotherapy staffing. Intensive care unit staff supported in-bed cycling but were concerned about choosing the right patients and how best to time its introduction. With limited evidence around physiotherapy in the heart surgery ICU, larger studies are needed.

Introduction: Improvements in the delivery of intensive care have led to a growing number of children with chronic medical conditions at significant risk of recurrent and prolonged critical illness. These patients are increasingly described as having pediatric chronic critical illness (CCI). To date, pediatric CCI is without an accepted consensus case definition. Objective: To evaluate how pediatric CCI has been defined in the current literature, including the concept of prolonged PICU admission, and describe the methodologies used to develop any existing definitions. Secondary aims included describing patient characteristics and outcomes evaluated in included studies. Methods: We searched four electronic databases for studies evaluating children identified with “CCI.” We also searched for studies describing prolonged PICU admission, as this concept is related to pediatric CCI. We developed a hybrid crowdsourcing and machine-learning (ML) methodology to complete citation screening. Screening and data abstraction were performed by two reviewers, independently and in duplicate. We completed data abstraction including details of population definitions, demographic and clinical characteristics of children with CCI, and outcomes evaluated. Results: Twenty-eight reviewers from 11 countries performed citation screening, with a mean sensitivity of 92%. Of 24,729 unique citations assessed for eligibility, 453 full-texts were reviewed and 67 studies were included. Of these, 12 studies (18%) defined CCI, most commonly by a prolonged PICU length of stay (LOS), either in isolation or in addition related to medical complexity patient characteristics and/or readmissions rate. The concept of prolonged PICU admission was defined in an additional 55 (82%) studies by a median of 14 days (range, 1 day-6 weeks). Conclusion: To our knowledge, this scoping review provides the most comprehensive epidemiologic evidence addressing pediatric CCI. Our results suggest a uniform consensus definition is needed in order to advance this emerging and important area of pediatric critical care research. / Thesis / Master of Science (MSc)

Background: Death is a common occurrence in the Intensive Care Unit (ICU), and the circumstances surrounding a patient’s death can have a lasting influence on the wellbeing of families and nursing staff alike. Culture is an important influence on an individual’s perspective of end-of-life (EOL) care and a ‘good death’, and, as such, cultural sensitivity is an essential element of high quality EOL care in the ICU. Nurses are well situated to facilitate culturally sensitive EOL care within the ICU; however, there is a significant paucity of knowledge regarding ICU nurses’ perceptions of a culturally sensitive EOL nursing practice and their experiences delivering this within an adult ICU. Aims: The purpose of this study was to explore ICU nurses’ perceptions of delivering culturally sensitive care within their current EOL practice, and thus better understand how culturally sensitive EOL care can be supported within adult ICUs. Design and Methods: An Interpretive Description methodology was utilized to explore the perceptions of seven (n=7) Canadian ICU nurses regarding culturally sensitive EOL care. Maximum variation and theoretical sampling were used to recruit registered nurses from ICUs in two hospitals in Southern Ontario, Canada. Data were generated using semi-structured interviews and field notes and was concurrently analyzed using a constant comparative and reflexive approach. Study rigour was supported through the use of reflexive journaling/memoing, data triangulation, and peer debriefing. Results: Analysis of the data led to the construction of three themes which described nurses’ perceptions of providing EOL care within the ICU: 1) culturally sensitive EOL care is truly person-centered care, 2) dissonance between culturally sensitive EOL care and the biomedical model of care in the ICU, and 3) needing support to adopt a more relational approach to care in the ICU. Conclusion and Implications: Study findings highlight that ICU nurses perceive that culturally sensitive EOL care primarily involves building a strong therapeutic relationship and being truly person-centered when delivering care. However, the context surrounding nursing practice in the ICU creates many barriers to adopting this relational approach to care; thus, multifaceted support is needed for culturally sensitive EOL nursing practice to be bolstered and sustained. / Thesis / Master of Science in Nursing (MSN) / Patients in the Intensive Care Unit frequently die and the circumstances surrounding these deaths affects both family members’ and nurses’ wellbeing. Culture is an important influence on an individual’s needs during the end-of-life period and on their views about a ‘good death’. As such, when caring for dying patients, healthcare professionals need to be sensitive to the culture of each patient and family. In the Intensive Care Unit, nurses play an important role in making sure end-of-life care is culturally sensitive. The goal of this study was to learn more about nurses’ perceptions and experiences of providing culturally sensitive end-of-life care within adult Intensive Care Units. This study found that nurses working in Intensive Care Units feel culturally sensitive end-of-life care mainly involves being truly person-centered and this requires staying open-minded and building strong relationships with patients and their families. Nurses in this study also indicated that they face many obstacles when trying to be culturally sensitivity during end-of-life care and some of these were created by their practice environment. This research shows that if nurses are to deliver culturally sensitive end-of-life care within critical care settings they need significant support in various forms, which likely includes a change in the unit culture.

Due to the need for concurrent use of N-acetylcysteine (NAC) and ondansetron in the event of acetaminophen overdose, a Y-site intravenous (IV) apparatus for these drugs would be practical. It is known that nausea and vomiting are common side effects of both acetaminophen overdose and NAC administration. Current standard patient care using NAC involves interruption of IV NAC infusion to give an IV bolus dose of ondansetron, which creates an unnecessary opportunity for healthcare staff errors and patient complications. To evaluate the IV compatibility of NAC and ondansetron, medical grade tubing was connected via a closed-circuit IV pump with separate channels. Doses of NAC were circulated in individual channels based on weight-based dosing protocols (30-kg and 100-kg patient does). Ondansetron (4 mg) was introduced into the flow of NAC using the Y-site. Samples of the circulated solutions were gathered in triplicate at time points of 10, 20, and 30 minutes after combination of ondansetron and NAC. Concentrations of NAC were quantified using a validated high performance liquid chromatography (HPLC) method with ultraviolet (UV) detection. Once the collected samples underwent HPLC-UV analysis, data was produced that showed promise for compatibility between ondansetron and NAC with Y-site infusions. Comparison of NAC concentrations for the channels with and without ondansetron yielded no statistically significant difference between the treatments (p-value of 0.05). From this experiment, we concluded that introduction of ondansetron into the flow of NAC IV would not impact NAC concentration. As mentioned before, this study was conducted using only two doses in vitro, which may be a point for further exploration of a varied number of N-acetylcysteine doses.

Muscle weakness is the most common and persistent problem after a critical illness. Early mobilization of the critically ill patient, beginning with passive exercise and progressing to ambulation, may mitigate muscle effects of the critical illness. However, mobilization may produce adverse effects, especially early in the illness when risk for physiologic deterioration is common. If safe, introducing a mobility intervention early in the illness may facilitate ventilator weaning, shorten intensive care unit and hospitals stays, and improve functional status and quality of life for mechanically ventilated critically ill patients. The aim of this study was assess the cardiopulmonary and inflammatory responses to an early standardized passive exercise protocol (PEP) in mechanically ventilated critically ill patients. Using a quasi-experimental within-subjects repeated measures design, mechanically ventilated critically ill adults who were physiologically stable received a single standardized PEP within 72 hours of intubation. The PEP consisted of 20 minutes of bilateral passive leg movement delivered by continuous passive motion machines at a rate of 20 repetitions per minute, from 5-75 degrees, to simulate very slow walking. Physiologic parameters evaluated included heart rate (HR), mean blood pressure (MBP), oxygen saturation, and cytokine levels (IL-6 and IL-10), obtained before, during, and after the intervention. The Behavioral Pain Scale (BPS), administered before, during and after the intervention was used as a measure of participant comfort. The study sample was comprised of 18 (60%) males and 12 (40%) females, with a mean age of 56.5 years (SD 16.9 years), who were primarily Caucasian (N=18, 64%). Mean APACHE II scores for the sample were 23.8 (SD 6.2) with a mean predicted death rate of 48.8 (SD 19.8), indicating moderate mortality risk related to illness severity. Number of comorbidities ranged iv from 1-10 (X=4). All participants completed the intervention with no adverse events. Using repeated measures analysis of variance (rmANOVA), no significant differences were found in HR, MBP, or oxygen saturation at any of the four time points in comparison to baseline. BPS scores were significantly reduced (F(2.43, 70.42)=4.08, p=.02) at 5 and 10 minutes after the PEP was started, and were sustained at 20 minutes and for one hour after the PEP was completed. IL-6 was significantly reduced (F(1.60, 43.1)=4.351, p=.03) at the end of the intervention but not at the end of the final rest period. IL-10 values were not significantly different at any of the three time points, but IL-6 to IL-10 ratios did decrease significantly (F(1.61, 43.38)=3.42, p=.05) at the end of the PEP and again after a 60 minute rest period. Passive leg exercise was well tolerated by study participants. HR, MBP, and oxygen saturation were maintained within order set-specified ranges during and for one hour after activity, and patient comfort improved during and after the intervention. A downward trend in HR was noted in participants, which is contrary to usual HR response during exercise, and may represent clinical improvement in this population related to reduction in pain. Reduction of mean IL-6 values at the end of the PEP, but not after the rest period, suggests that the PEP was responsible for the initial IL-6 improvement. Improvement of IL-6 to IL-10 ratios from the end of the PEP to the end of the final rest period suggests that IL-10, although non-significant, may have had some effect, indicating that IL-10 increases may occur later than the time period of study. Passive exercise can be used as an approach to facilitating mobilization in mechanically ventilated critically ill adults until they are ready to participate in more active exercise. It could be that more frequent and aggressive exercise, such as passive cycling at faster rates, four times daily, will be tolerated in this population. While the understanding of clinical significance of cytokine profiles in critically ill patients is still evolving, cytokine levels may be useful in v explaining benefits of mobilization in this population. Further study is required to replicate the impact of passive exercise on pain, and it may represent a novel approach to pain management in critically ill patients.

Problem/Purpose: Critical care nurses are frequently exposed to the stress experienced by their patients' families, yet they often do not have the knowledge or skills to help family members cope with the stress of critical illness. While needs and stressors of families of the critically ill have been researched extensively, no prior studies have been conducted to determine the effects of an evidence-based nursing intervention for reducing family members' stress and improving their coping skills. The purpose of this study was to determine if an evidence-based nursing intervention designed to address the needs of family members would reduce stress and improve coping skills in family members of critically ill trauma patients. Additionally, the study assessed the family members' perceptions of how well their needs were met while their loved one was hospitalized in the surgical intensive care unit (SICU). Methods: Using a quasi-experimental, nonequivalent control group design, an evidence-based intervention for critical care nurses was implemented to test its effect on stress and coping of family members of critically ill trauma patients. The study setting was the SICU at a tertiary university hospital in north central Florida. Subjects were family members of critically ill trauma patients who had been hospitalized in the SICU for at least 48 hours. Participants in the control group were given a packet containing instruments that measured 1) anxiety as an indicator of stress (Spielberger's State-Trait Anxiety Inventory ); 2) coping (Lazarus and Folkman's Ways of Coping Questionnaire ); and 3) assessment of family members' perception of having their needs met while their family member was in the SICU (Family Care Survey ). An evidence-based family bundle was implemented over an eight-week period and included an educational program for the nurses. After eight weeks, participants in the experimental group were given the same instruments previously administered to the control group. Anxiety levels, coping skills, and family members' perception of having needs met were compared between the two groups to determine the effectiveness of the evidence-based intervention. Results: A total of 84 family members participated in the study (control = 39; experimental = 45). The majority were women (n=60), spouse or parent of the patient (n=47), and Caucasian (n=70). Mean ages were 45.9 years for the control group and 47.4 years for the experimental group. No differences were noted in the demographic characteristics between the control and experimental groups. Using an independent samples t-test, no significant differences (p > .05) were noted between groups for either state or trait anxiety, although the mean anxiety score was lower in the experimental group. Significant differences between groups were noted on two of the eight coping subscales: Distancing and Accepting Responsibility. Improved coping, although not statistically significant, was noted on four additional subscales: Confrontive Coping, Self-Controlling, Planful Problem-Solving, and Positive Reappraisal. Overall coping scores also improved, but not statistically, for the total Ways of Coping Scale (both 50 and 66 item totals). Although not statistically significant, participants in the experimental group rated four out of eight items higher on the FCS, indicating an increased perception that more of their needs were met, greater overall satisfaction with the care that family members received, increased nurses' consideration of family members' needs and the inclusion of those needs in planning nursing care, and greater encouragement for family members to participate in care. Although findings were not statistically significant, the trend implies increased satisfaction with family care in areas involving family care and family member needs, including needs in planning care and encouragement to participate in care. In areas regarding information and communication, there was overall less satisfaction in both groups. Conclusions: This study provides data that can be used as a guide in developing programs that help families function and adapt to the extremely stressful experience of having a loved one who is critically ill. The information can be used to develop future research on larger scales with a longer and more extensive plan for implementation of the intervention to assist in a unit culture change. Nurses can use the results to facilitate practice changes in caring for families of critically ill patients. Modifying the interventions to focus on an interdisciplinary approach to meet families' needs, reduce stress, and improve coping also warrants further development and testing. Funding acknowledgement: Florida Nurses Foundation and the American Association of Critical Care Nurses. College of Nursing, University of Central Florida

Background: Nursing overtime is being integrated into the normal landscape of practice to ensure optimal staffing levels and address variations in patient volume and acuity. This is particularly true in critical care where fluctuations in either are difficult to predict. Research exploring nurses’ perceptions of the outcomes of overtime has not been conducted, and studies exploring the relationship between nursing overtime and patient outcomes have produced conflicting results. Objectives: This study aims to explore critical care nurses’ perceptions of the outcomes of overtime, their reasons for working or not working it, and to determine the relationship between critical care nursing overtime and specific nurse (sick time) and patient (infections/mortality) outcomes. Methods: This thesis is comprised of two discrete components. Thorne’s interpretive description guided the qualitative component and multilevel regression models tested relationships in the quantitative portion. Qualitative and quantitative methods were selected because of their complementarity and ability to explore both perceptions of overtime in addition to the relationship between nursing overtime and outcomes for nursing staff and their patients. Results: Participants’ reasons for working overtime included: (a) financial gain, (b) helping and being with colleagues, (c) continuity for nurses and patients, and (d) accelerated career development. Their reasons for not working overtime were: (a) tired and tired of being there, (b) established plans, and (c) not enough notice. Major themes highlighting the perceived outcomes of overtime included: (a) physical effects, (b) impact on patient centered care, (c) the issue of respect, (d) balancing family and work, (e) the issue of guilt, (f) financial gain, and (g) safety is jeopardized. Regression analysis revealed that for every 10 hours of nursing overtime, sick time increased by 3.3 hours (p<0.0001). Overtime was not associated with patient outcomes (infections and mortality). Conclusion: There are negative and positive consequences of nursing overtime for nurses and patients. Future research needs to focus on the collection of accurate patient level data, as well as tracking and exploring the effects of unpaid overtime (missed breaks/staying late). Nurses should work to proactively lobby governments to fund adequate staffing in order to reduce the need for overtime and provide safer patient care. / Dissertation / Doctor of Philosophy (PhD) / This study explores critical care nurses’ perceptions of the outcomes of working overtime, their reasons for working or not working overtime, and the relationship between nursing overtime and specific nurse and patient outcomes. Qualitative and quantitative methods were used involving 28 nurses on 11 units in three tertiary care academic health science centers. The four original contributions to nursing knowledge are: (a) physical effects overtime has on nurses, (b) feelings of disrespect overtime engenders, (c) loss of patient-centered care that results from overtime, and, (d) the positive relationship between nursing overtime and nursing sick time. Quantitative findings revealed that for every 10 hours of nursing overtime, sick time increased by 3.3 hours (p<0.0001), which participants attested to qualitatively. It will be important to track both paid and unpaid overtime hours per individual nurse to enhance future research, ensure institutional accountability and staff well-being.

Importance: Evidence from randomized controlled trials (RCTs) is required to guide treatment of critically ill children. Unfortunately such evidence is not always available. Objectives: To describe the RCT research enterprise in pediatric critical care — the evidence and the process of creating it, along with problems and some solutions. Methods: To meet these objectives I undertook a series of 5 related studies. First a scoping review to describe the output of the research enterprise. Second, a social network analysis of coauthorship patterns to describe the community of researchers who produce this evidence. Third, a survey to investigate the importance of RCTs in clinicians’ decision-making. Fourth, a survey of trialists to identify barriers and facilitators of high quality RCTs. Fifth, a qualitative interview study to identify acceptable, feasible and effective strategies to improve the evidence available from RCTs in pediatric critical care. Results and conclusions: The number of RCTs in pediatric critical care is increasing but there is a preponderance of small, single-centred RCTs focusing on laboratory or physiological outcomes that are often stopped early because of feasibility problems or futility. The research community is highly fragmented and highly clustered. Experienced trialists identified approaches to improve the pediatric critical care research enterprise, including building a sense of community and ensuring key training and relevant practical experiences for new investigators. Because of the barriers that researchers face and their ethical obligation to undertake trials that are feasible and make a meaningful contribution to advancing the care of critically ill children, individuals and groups must take an active role in building a healthy research community. Only by changing how we function as a research community can we train the next generation of investigators and undertake the type of trials needed to improve the care of critically ill children. / Thesis / Doctor of Philosophy (PhD) / Evidence from randomized controlled trials (RCTs) is required to guide treatment of critically ill children. Unfortunately such evidence is not always available. My objectives in this thesis are to describe the RCT research enterprise in pediatric critical care — the evidence and the process of creating it, along with problems and some solutions. To meet these objectives I undertook a series of 5 related studies: to identify and describe the RCTs, describe how researchers collaborate, understand how clinicians use RCTs, identify barriers and facilitators of conducting high quality RCTs, and understand how we can improve the evidence available from RCTs in pediatric critical care. We found that the number of RCTs is increasing but there are opportunities to improve the methods, outcome measures, and quality of reporting. We identified strategies that researchers can adopt to facilitate the rigorous RCTs that are needed to improve the care of critically ill children.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24968号 / 医博第5022号 / 新制||医||1069(附属図書館) / 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 佐藤 俊哉, 教授 江木 盛時 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM