Bakgrund: Delirium hos intensivvårdspatienten är ett komplext neuropsykiatriskt syndrom med fluktuerande karaktär som kan leda till sämre prognos och ökat vårdlidande för patienten. Dessutom leder tillståndet till ökade samhällskostnader. Genesen tros vara multifaktoriell där risk och utlösande faktorer kan påverka förekomsten. Farmakologiska åtgärder har hittills tillämpats med otillräcklig framgång varför även omvårdnadsåtgärder rekommenderas. Syfte: Att sammanställa evidens för omvårdnadsåtgärder som kan förebygga delirium hos patienten på intensivvårdsavdelningen. Metoden: Metoden utgjordes av en integrativ litteraturstudien för att kartlägga och sammanställa aktuell forskning om omvårdnadsåtgärder som kan förebygga delirium. Totalt 15 artiklar från CINAHL och PubMed inkluderades. Resultat: Utifrån de inkluderade artiklarnas resultat kunde preventiva omvårdnadsåtgärder identifieras vilka presenteras i fyra huvudkategorier; Involvera närstående, Kognitivt stimulera patienten, Fysiskt stimulera patienten och Främja patientens sömn. Konklusion: Det framkommer att intensivvårdssjuksköterskan med till synes enkla omvårdnadsåtgärder kan förebygga delirium hos patienten. Flertalet omvårdnadsåtgärder kan ses som kopplade till människans fundamentala omvårdnadsbehov som idag redan är implementerade i vården. En viktig del i intensivvårdssjuksköterskans preventiva arbete är således att identifiera faktorer som kan utlösa delirium, och ständigt arbeta strukturerat och medvetet genom sina omvårdnadshandlingar. För att möjliggöra det behövs ett personcenterat förhållningssätt med utgångspunkt i patientens resurser. / Background: Intensive care unit delirium is a complex neuropsychiatric syndrome with a fluctuating nature that can impair the prognosis and increase suffering for the patient. In addition, the permit leads to increased societal costs. The genesis is considered multifactorial where risk and triggering factors may affect the occurrence. Common experiences among healthcare professionals is that the condition can be difficult to identify, manage and treat. Pharmacological interventions implemented have resulted in insufficient success, therefore nursing interventions are also recommended. Aim: To compile evidence about nursing interventions to prevent intensive care delirium. Method: The method consisted of an integrative literature study to map and compile current research involving delirium. A total of 15 articles from CINAHL and PubMed were included. Results: Based on the results of the included articles, preventive interventions could be identified into four main categories; Involve next of kind to the patient, Cognitively stimulate the patient, Physically stimulate the patient and Promoting patients normal sleep cycle. Conclusion: It appears that the intensive care nurse, with seemingly simple nursing measures, can prevent delirium in the patient. Most nursing measures can be seen as linked to the person's fundamental nursing needs that are already implemented in healthcare today. An important part of the intensive care nurse's preventive work is to be able to identify factors triggering delirium, and continuing structured work in a conscious way through their nursing actions. To enable this, a person-centered approach based on the patient's resources is needed.

Objectives: To describe the characteristics of children who died and their modes of dying in a South African Paediatric Intensive Care Unit (PICU). Design: Retrospective review of data extracted from the Child Healthcare Problem Identification Programme (Child PIP)and the PICU summary system (admission and death records) on children of any age who died in the PICU between 01 January 2013 and 31 December 2017. Setting: Single-centre tertiary institution. Patients: All children who died during PICU admission were included. Measurements and Main Results: Four-hundred and fifty-one (54% male; median (IQR) age 7 (1-30) months) patients died in PICU on median (IQR) 3 (1-7) days after PICU admission; 103 (22.8%) had a cardiac arrest prior to PICU admission. Mode of death in 23.7% (n=107) was withdrawal of life sustaining therapies; 36.1% (n=163) died after limitation of life sustaining therapies; 22.0% (n=99) died after failed resuscitation and 17.3% (n=78) were diagnosed brain dead. Ultimately, 270 (60%) children died after the decision to limit or withdraw life sustaining therapies. There was no difference in the number of deaths during office and after-hours periods (45.5% vs. 54%; p = 0.07). Severe sepsis (21.9%) was the most common condition associated with death, followed by cardiac disease (18.6%).Ninety-four (20.8%) patients were readmitted to the PICU within the same year; 278 (61.6%) had complex chronic disorders. During the last phase of life, 75.0% (n=342) were on inotropes, 95.9% (n=428) were ventilated, 12.0% (n=45) received inhaled nitric oxide and 10.8% (n=46) renal replacement therapy. Only 1.5% (n=7) of children became organ donors and postmortems were done in 47.2% (n=213) of the patients. Conclusions: Most PICU deaths occurred after a decision to limit or withdraw life-sustaining therapy. Severe sepsis was the most common condition associated with death. Referral for organ donation was extremely rare.

Family-centered care (FCC) is considered the gold standard for care delivery in the Neonatal Intensive Care Unit (NICU). However, there are challenges with the implementation of FCC in practice and there is limited literature about how to tailor this approach for specialized NICU populations. To explore FCC for surgical neonates in the NICU, the concept was explored using Roger’s evolutionary concept analysis. Results illustrate that FCC in the NICU is a philosophy or care, rather than a set of interventions. The subsequent cross-sectional descriptive exploratory study showed that the surgical infants in our sample (n=11) received a limited amount of skin-to-skin care (median 0 mins/day) and parents reported challenges to being involved in their infant’s care. This thesis supports the challenges with the implementation of FCC in practice and both the need to consider multiple perspectives and the need for broader systemic change in order to support a FCC philosophy.

Clinical social workers have roles in providing end-of-life care in the United States. Although clinical social workers are present in the intensive care unit (ICU) setting and have expertise to address end-of-life care dynamics, social workers are not consistently included in end-of-life discussions in the ICU setting. The purpose of this action research study was to explore the barriers that prevent clinical social workers from being included in end-of-life discussions in the ICU and how clinical social workers perceive their roles in end-of-life discussions in the adult ICU setting. Open-ended questions were used to gather data by facilitating 4 focus groups with 17 clinical social workers employed at a Florida hospital. This study was guided by complexity theory, which is concerned with complex systems and how systems can produce order while simultaneously creating unpredictable system behavior. A thematic analysis coding technique was used to analyze the data collected. Three themes emerged from data analysis: the ICU setting as chaotic, complex, and unpredictable; role ambiguity; and lack of confidence of social workers to perform expected roles in end-of-life discussions. The implications of this study for social work practice and social change relate to closing the gap between the patient, family members, social workers, and the medical team by developing protocols that consistently include social workers in end-of-life discussions, including education for the multidisciplinary team in the ICU on the skill set and role of clinical social workers in end-of-life discussions and formal training and education for clinical social workers regarding end-of-life care.

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

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

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

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

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