M.Cur. (Nursing Management) / The largest and most expensive asset of any health care institution is its human resources. Mol [1984 : 1J quite correctly says that no organization can reach its full potential when these resources are not utilized effectively. The researcher has noticed certain behavior patterns amongst the nursing staff in intensive care units. These behaviour patterns include an increase in staff turnover and absenteeism. The question that arose was whether it could be ascribed to professional burnout and whether nursing managers could be contributing to the cause thereof. Th. burnout syndrome is a slowly developing psychologically destructive process, which is in relation to the effect the work environment· has on the individual. The consequences of professional burnout has many negative effects on the nurse, ·the patient, the profession and the health care delivery system. The concept of professional burnout is described with reference from the literature and by means·of a survey the following was determined, that:- all nurses working in intensive care units in the hospital were the research was conducted, had experienced symptoms of professional burnout; the majority of these nurses perceive their work situation as severely stressful; and - nursing managers are overwhelmingly applying the autocratic leadership style. Some of the important conclusions culminating from this study are that:- all these nurses experience one or other degree of professional burnout as a result of experiences resulting from unresolved stress in the work environment; and the nursing manager possibly uses ineffective management strategies due to a lack of management training, thus contributing to professional burnout.

M.Cur. / Please refer to full text to view abstract

Magister Scientiae (Physiotherapy) - MSc(Physio) / Variability of profile and practices (roles) of the ICU physiotherapists exists globally. The profile and current practices (roles) of the private practice physiotherapist in the private ICU has been minimally explored especially in South Africa (SA). A dearth of survey data and in-depth exploration of the latter exists in the current literature. The aim of this study was to determine and explore the profile and current practices (roles) of the ICU physiotherapists in private ICUs in SA. / 2022

Introduction Paediatric Intensive Care has developed rapidly in recent years with a dramatic increase in survival rates. However, there are increasing concerns regarding the impact that admission to a Paediatric Intensive Care Unit (PICU) has on both the child and their family. Following discharge from PICU, children may be living with complex medical problems as well as dealing with the psychosocial impact that their illness has had on them and their family. Objectives To describe the long-term health outcomes of children admitted to a paediatric intensive care unit (PICU). Methods A full literature search was conducted including the databases; MEDLINE via PubMed, Cochrane Central Register of Controlled Trials, (CENTRAL), Scopus, Web of Science, CINAHL, ERIC, Health Source Nursing/Academic, APA PsycInfo. All studies including children under 18 admitted to a PICU were included. Primary outcome was short- and longerterm mortality. Secondary outcomes were neurodevelopment/cognition/school performance; physical function, psychological function/behaviour impact, quality of life outcomes and social/family implications. Studies focused on Neonatal Intensive Care Admission and articles with no English translation were excluded. Results One hundred and five articles were included in the analysis. Mortality in PICU ranged from 1.3% to 50%. Mortality in high income countries reduced over time but the data did not show the same trend for low- and middle-income countries. Higher income countries were found to have lower Standardised Mortality Rates (SMRs) than low- and middle-income countries. Children had an ongoing risk of death for up to 10 years following PICU admission. Children admitted to PICU also have more ongoing morbidity than their healthy counterparts with more cognitive/developmental problems, more functional health issues, poorer quality of life as well as increased psychological problems. Their parents also have an increased risk of Post Traumatic Stress Disorder (PTSD). Discussion Most of the studies identified are from high income countries and only include short-term follow up. More data is needed from low- and middle-income countries and over longer terms. The studies were markedly heterogenous and were all observational. Agreement is needed regarding which outcomes are most important to measure as well as standardised methods of assessing them. Further research is needed to identify the risk factors which cause children to have poorer outcomes as well as to identify predictive and modifiable factors which could be targeted in practice improvement initiatives.

Antimicrobials are the most frequently used medications in the Neonatal Intensive Care Unit (NICU). Antimicrobial Stewardship (AMS) efforts may be used to mitigate the consequences of antimicrobial overuse while optimizing clinical outcomes through the safe, judicious use of antimicrobials. One target of AMS efforts is to reduce the incidence of necrotizing enterocolitis (NEC), a serious intestinal infection in neonates of which a necessary component is dysbiosis, the development of aberrant intestinal microbiota typically associated with prior antibiotic use. The goal of this ILE is to implement and enhance AMS efforts in the neonatal population with a focus on preventing NEC. The specific aims progress through three relevant, practical examples of AMS in a stepwise manner. Methods: In Aim 1, a systematic review of the literature evaluating the relationship between antimicrobial therapy and subsequent development of NEC and a meta-analysis including non-interventional studies was performed. Data were pooled on adjusted odds ratios (OR) and analyzed using the generic inverse variance method. All analyses were random effects models. A sensitivity analysis was performed based on a range (0-40%) of credibility ceilings. In Aim 2, institutional guidelines for early and late onset neonatal sepsis using the principles of AMS and the evidence for safe restriction of antimicrobials targeted for reduction in use in neonates by the National Healthcare Safety Network (NHSN) were created and implemented . In Aim 3, a reproducible 2-class latent variable model to extract a date-stamped diagnosis of NEC from the Pediatric Health Information System (PHIS) database was created as a tool to enhance research evaluating antibiotic use and NEC from large databases. This model was created using a subset of infants at two PHIS sites that were able to be validated. M plus software was used. Conclusions: For Aim 1, 36 studies met inclusion criteria for the systematic review, with 33 proceeding to quantitative analysis. There were 10 RCTs, the remaining being observational studies. Using the ROBINS-I or RoB 2.0 tools as appropriate, all studies including the RCTs had a least a moderate or high risk of bias respectively. The overall analysis failed to provide evidence of an association between prior antimicrobial use and NEC when all 33 studies were included, with a summary OR of 1.13, CI95 (0.88, 1.45) and significant heterogeneity, I2 = 77%. Multiple subgroup analyses were performed: “intent” of antibiotic use (prophylaxis versus not) drug delivery method (oral versus parenteral) and study type. Subgroup analysis of prophylactic enteral antibiotics showed a reduction in NEC: OR 0.2 CI95 (0.08, 0.54), I2 = 35% while prior use of parental antibiotics showed a positive association with NEC OR 1.48, CI95 (1.18, 1.86), I2 72%; for this subgroup, using a c% shows heterogeneity first reaching an estimate of 0% at a ceiling of 10% with nominal statistical significance is maintained starting at a ceiling of 10%. This shows that consideration of the biologic mechanism of the exposure-disease association, as indicated by the subgroup analyses in this study, must be considered when performing further dataset evaluations lest biased conclusions will be reached. For Aim 2, Four guidelines were created and implemented and are being validated: • The evaluation and management of infants ≥ 35 weeks gestational age at risk for early onset sepsis at Tufts Medical Center • The evaluation and management of infants ≥ 36 weeks gestational age at risk for early onset sepsis at BronxCare Hospital Center • The evaluation and management of infants < 36 weeks gestational age at risk for early onset sepsis at BronxCare Hospital Center • The evaluation and management of infants at risk for late onset sepsis at BronxCare Hospital Center For Aim 3 a model was successfully created that can be used to add an important layer of detail, time-of-event, to patient level variables in a large data set. This model can also be used to tabulate the sensitivity of a disease in the absence of a gold standard. The model is portable and could serve as a template for the PHIS or other large databases where certain important exposures may not be date stamped. The model may be adapted to not only allow for appropriate extraction of variables, but also allow the correct modelling of time-dependent co-variables.

Magister Scientiae (Physiotherapy) - MSc(Physio) / The professional status of physiotherapists in Sudan is reported to be low even though the profession was established in Khartoum, Sudan in 1969. Intensive care units are operating in Khartoum, Sudan. Physiotherapists have been reported to be integral to the management of intensive care patients. Globally, the role of ICU physiotherapists in the management of ICU patients have been explored and described; however, this information is lacking for Khartoum, where the profession is still in its infancy. Therefore, this study aimed to explore and describe the physiotherapists’ perceptions of their role in the management of intensive care patients in Khartoum, Sudan. / 2022

Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / Nurses are subjected to occupational stress factors that can result in the syndrome of burnout. This study compared levels of burnout in nurses in a medical-surgical ICU setting to those in non-ICU medical-surgical settings. A randomized sample of 40 nurses of an urban hospital in Taiwan, twenty nurses in an ICU and 20 in five non-ICU settings (general medical-surgical wards), who returned the questionnaire used to measure burnout, were included in the study. The instrument utilized was the Staff Burnout Scale for Health Professionals. The study found no significant difference in levels of burnout in the two groups. Both groups in this study experienced a higher level of burnout than was reported in other studies in United States literature. In particular, two general medical-surgical wards which had high patient/nurse ratios, had very high levels of burnout. The study also found that all nurses with lower educational levels and ICU nurses with more years of work experience had more burnout. / 2031-01-01

The overuse of antibiotics is a large problem in healthcare today, accelerating the development of microbial resistance to antibiotics. Antibiotic stewardship campaigns have been implemented to help clinicians curb their use. Procalcitonin is a serum peptide and marker of inflammation secreted in response to microbial toxins. For this reason it is more specific to bacterial infections than other markers of general inflammation , like Creactive protein. The population of patients with sepsis in the Intensive Care Unit is one in which extended durations of antibiotics are used. The FDA has approved use of procalcitonin to guide de-escalation of antibiotic therapy in critically ill patients with sepsis to avoid both antibiotic overuse and antibiotic related side effects. Review of current literature shows that procalcitonin is efficacious in reducing duration of antibiotic therapy in patients with sepsis in the ICU setting. This result, however, is not being observed in clinical practice. This discrepancy is due to the inappropriate use of procalcitonin that does not align with use outlined in randomized control trials. We propose a study to determine how procalcitonin is being used in clinical practice in four Boston area hospital Intensive Care Units. Through chart review, we will identify patients in the Intensive Care Unit with sepsis from 2013-2018 recording patient demographic information and patient characteristics. We will determine whether they had PCT measured during their stay, and if they did, whether or not discontinuation of antibiotics was in accordance with FDA’s proposed algorithm. We will aim to compare whether discontinuing antibiotic therapy in accordance with the FDA’s procalcitonin deescalation algorithm is associated with reduced duration of antibiotic therapy or incidence of Clostridium Difficile infection. In conducting this study, we hope to identify patterns of procalcitonin use in clinical practice and provide further evidence that using the algorithm to guide therapy can serve as an effective tool in reducing exposure to unnecessary antibiotics and the complications from their use.

Background: Mechanical ventilation and sedation are common in intensive care and can be stressful for the patient as many experience physical and mental complications such as delirium. Nurses in intensive care play an important role in assessing the need for pain relief and sedation. The care environment and communication opportunities are also factors that affect patients' experiences. Aim: The aim of the study was to make patients' experiences of having been mechanically ventilated and/or sedated in an intensive care unit visible. Method: A literature study was chosen to get a picture of the current state of knowledge. Based on a thematic analysis method 15 articles were analyzed. Results: The analysis resulted in the following themes: fear and anxiety with subthemes physical and psychological experiences, security and trust with subthemes environment and communication as well as cognition and memories with subthemes confusion and dreams. Conclusion: It is a difficult experience to be mechanically ventilated and/or sedated in an intensive care unit. Communication difficulties were a prominent experience that affected many patients. Continued research: Continued research is necessary in the subject matter of the study. There is also a need for research on the care environment and communication aids for intensive care patients.  Keywords: Sedation, mechanical ventilation, intensive care and experiences. / Bakgrund: Mekanisk ventilation och sedering är vanligt förekommande inom intensivvården och kan vara påfrestande för patienten då många upplever fysiska och psykiska komplikationer som till exempel delirium. Specialistsjuksköterskor inom intensivvård har en viktig roll vid bedömning av behov av smärtlindring och sedering. Även vårdmiljö och kommunikationsmöjligheter är faktorer som påverkar patienters upplevelser. Syfte: Syftet med studien var att synliggöra patienters upplevelser av att ha varit mekaniskt ventilerade och/eller sederade på en intensivvårdsavdelning. Metod: En litteraturstudie valdes för att få en bild av det aktuella kunskapsläget. Utifrån tematisk analysmetod analyserades 15 artiklar. Resultat: Analysen resulterade i följande teman: rädsla och ångest med subteman fysiska- och psykologiska upplevelser, trygghet och tillit med subteman omgivning och kommunikation samt kognition och minnen med subtema förvirring och drömmar. Slutsats: Det är en svår upplevelse att vara mekaniskt ventilerad och/eller sederad på en intensivvårdsavdelning. Kommunikationssvårigheter var en framträdande upplevelse som påverkade många patienter. Fortsatt forskning: Fortsatt forskning är nödvändig inom ämnet som studien berör. Det finns även behov av forskning kring vårdmiljön samt kommunikationshjälpmedel för intensivvårdspatienter.  Nyckelord: Sedering, mekanisk ventilering, intensivvård och upplevelser.

Background: To efficiently capture evaluation and management (E&M) and procedural billing in our surgical intensive care unit (SICU), we have developed an electronic billing system that links to the electronic medical record (EMR). In this system, only notes electronically signed and coded by an attending generate billing charges. We hypothesized that capture of missed billing during nighttime and weekends might be sufficient to subsidize 24/7 in-house attending coverage. Methods: A retrospective chart EMR review was performed of the EMRs for all SICU patients during a 2-month period. Note type, date, time, attending signature, and coding were analyzed. Notes without attending signature, diagnosis, or current procedural terminology (CPT) code were considered incomplete and identified as "missed billing." Results: Four hundred and forty-three patients had 465 admissions generating 2,896 notes. Overall, 76% of notes were signed and coded by an attending and billed. Incomplete (not billed) notes represented an overall missed billing opportunity of $159,138 for the 2-month time period (∼$954,000 annually). Unbilled E&M encounters during weekdays totaled $54,758, whereas unbilled E&M and procedures from weeknights and weekends totaled $88,408 ($44,566 and $43,842, respectively). Missed billing after-hours thus represents ∼$530K annually, extrapolating to ∼$220K in collections from our payer mix. Surprisingly, missed E&M and procedural billing during weekdays totaled $70,730 (∼$425K billing, ∼$170K collections annually), and typically represented patients seen, but transferred from the SICU before attending documentation was completed. Conclusions: Capture of nighttime and weekend ICU collections alone may be insufficient to add faculty or incentivize in-house coverage, but could certainly complement other in-house derived revenues to such ends. In addition, missed daytime billing in busy modern ICUs can be substantial, and use of an EMR to identify missed billing opportunities can help create solutions to recover these revenues.