CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / The Intensive Care Unit (ICU) is a local in the hospital for receiving patients with injuries to life, whether clinical or surgical. During the time of admission of patients, their relatives have exalted feelings of anxiety, fears and doubts arising from separation and imminent risk of loss of their relative. Own rules and routines of the ICU, the restricted access of family in the unity and the unknowledge of the environment can exacerbate fear about functioning, care and interventions provided. This study aimed to: Develop a waiting room group to welcome family members of ICU patients as a strategy for humanization of assistance; Describe the stages of group process in the family host; analyze the group approach as a tool in the host of family of ICU patients. Qualitative research, descriptive and exploratory methodological, based in the âGroup process for nursesâ proposed by Maxine Looms (1979). The study was performed in the waiting room of the Intensive Care Unit (ICU) in a public hospital located in Fortaleza-CearÃ, Brazil. During the period from June to September 2011, the study respondents were family members who had relatives admitted into Intensive Care Unit. The inclusion of family members was conditional on signing the consent form. In the first stage, we made 37 individual interviews to know family needs about having a family member in the ICU. In the intervention phase with waiting room groups we had on average 20 visitors per day. The individual evaluation phase of these groups was performed with 26 relatives. The results showed that the family members need information of health status and diagnosis of their patient and this information should be clear and with less technical language. Professionals should be respectful and truthful when the information is provided. The groups were conducted following systematic guidelines and explaining the ICU routines. In the end we held orientations of questions of the group itself. In the evaluation of the groups found that the family felt welcomed and attended carefully to the proposed activities. The guidelines regarding handwashing and the possibility to talk / touch the patient were identified in speeches as relevant topics covered in the group. The information received on these activities generated change in the behavior of the family at the time of visit. The host is a strategy referenced successfully in serving families. The study showed that the performance of an educational group in the waiting room of the ICU, coordinated by nurses, can reduce unknownledge and anxiety of family members during the visit, not only to the patient, the nature and causes of disease, but also risks related to therapy. As well as encourage and motivate families to cope with the pain of hospitalization of their relative, thus helping to reduce the distress and suffering of all involved. Health promotion in the tertiary level, with the participation of the family becomes effective and concrete the Humanization of the hospital, with the expansion of its care and scientific knowledge, in addition to inpatient and techniques implemented them. / A Unidade de Terapia Intensiva (UTI) à a unidade hospitalar destinada a receber pacientes com agravos à vida, sejam clÃnico ou cirÃrgico. Durante o tempo de internamento dos pacientes, tambÃm seus familiares tem exaltados sentimentos de angÃstia, medos e dÃvidas decorrentes da separaÃÃo e do risco iminente da perda deste ente. As regras e rotinas prÃprias da UTI, o acesso restrito dos familiares a unidade e o desconhecimento do ambiente podem vir exacerbar o medo quanto ao funcionamento, cuidados e intervenÃÃes prestadas. Este estudo teve como objetivos: Desenvolver um grupo sala de espera de acolhimento aos familiares de pacientes em UTI como estratÃgia da polÃtica de humanizaÃÃo da assistÃncia; Descrever as etapas do processo grupal no acolhimento aos familiares; Analisar a abordagem grupal como instrumento no acolhimento ao familiar de pacientes internados na UTI. Pesquisa qualitativa, tipo descritivo exploratÃrio e como fundamentaÃÃo metodolÃgica o Group process for nurses proposta por Maxine Looms (1979). O local do estudo foi a sala de espera do Centro de Terapia Intensiva (CTI) em hospital pÃblico de referÃncia no Estado, situado em Fortaleza-CE, Brasil. Durante o perÃodo de junho a setembro de 2011, os participantes do estudo foram os familiares que possuÃam parentes internados no Centro de Terapia Intensiva. Na primeira etapa participaram de entrevistas individuais 37 familiares para conhecermos as necessidades que estes possuÃam por ter um familiar internado em UTI. Na fase de intervenÃÃo com os grupos de sala de espera participaram em mÃdia 20 visitantes por dia. A fase de avaliaÃÃo individuais destes grupos foi realizada com 26 familiares. A inclusÃo dos familiares esteve condicionada a assinatura do Termo de Consentimento Livre e Esclarecido. Os resultados mostraram que os familiares tÃm necessidade de informaÃÃes do estado de saÃde e do diagnÃstico de seus familiares e que estas, devem ser claras e com menos linguagem tÃcnica. Os profissionais devem ter respeito e sinceros quando as informaÃÃes forem dadas. Os grupos foram realizados seguindo roteiro sistematizado com orientaÃÃes das rotinas na UTI e no final realizÃvamos orientaÃÃes de perguntas do prÃprio grupo. Na avaliaÃÃo dos grupos verificou-se que os familiares sentiram-se acolhidos e que participavam com atenÃÃo as atividades propostas. As orientaÃÃes quanto a lavagem das mÃos e poder conversar/tocar com paciente foram apontadas nos discursos como temas relevantes abordados no grupo. E que as informaÃÃes recebidas sobre estas atividades geraram mudanÃa no comportamento dos familiares no momento da visita. O acolhimento à uma estratÃgia referenciada com Ãxito no atendimento aos familiares. O estudo evidenciou que a realizaÃÃo de um grupo educativo na sala de espera da UTI, coordenado por enfermeiros poderà reduzir inseguranÃa e a ansiedade dos familiares durante a visita, nÃo sà quanto ao paciente, à natureza e Ãs causas da doenÃa, mas tambÃm, aos riscos relacionados à terapÃutica. Assim como, incentivar e motivar os familiares no enfrentamento da dor da hospitalizaÃÃo do parente, ajudando assim a diminuir a angÃstia e o sofrimento de todos os envolvidos. A promoÃÃo de saÃde, em nÃvel terciÃrio, com a participaÃÃo da famÃlia torna-se efetiva e concreta a HumanizaÃÃo no ambiente hospitalar, com a ampliaÃÃo de seus cuidados e conhecimentos cientÃficos, para alÃm dos pacientes internados e das tÃcnicas a eles implementadas.

Class of 2014 Abstract / Specific Aims: To evaluate the association of weight-based insulin dose with hypoglycemia in critically ill patients receiving continuous intravenous insulin infuions. To determine whether higher weight-based doses of insulin were associated with a higher incidence of hypoglycemia Methods: This was a retrospective, case-control study conducted at a tertiary care, academic medical center. Adult (>18 years) patients admitted to the intensive care unit (ICU) receiving intravenous (IV) regular insulin infusions for the management of hyperglycemia between 1 January 2008 and 30 March 2013 were included. Medical records were retrospectively reviewed. Each patient with hypoglycemia was matched with a non-hypoglycemic control subject, based on age range and sex. Laboratory data, patient demographics, hypoglycemic events, insulin infusion data, SOFA scores, length of hospital and ICU stay, and patient outcomes were collected and evaluated. Main Results: Sixty-one patients experienced a hypoglycemic event and were matched with 61 non-hypoglycemic control subjects for statistical analysis. With the exception of ethnicity (p = 0.041) as a demographic predictor of hypoglycemia; age, sex, weight, height, and BMI were not significant. The starting insulin infusion rate and the total number of insulin units per day administered were not found to be associated with hypoglycemia, p=0.107 and p=0.357, respectively. Conclusion: This study failed to show significance in the total units per day of insulin and the incidence of hypoglycemia. There was no statistical significance in BMI between case and control groups, thus no clear conclusion can be made associating hypoglycemia with weight-based insulin dosing.

Patienterna på en intensivvårdsavdelning ligger i riskzonen för oavsiktlig hypotermi. De tidigare identifierade riskgrupperna är bland annat förekomst av kontinuerlig hemodialys, vissa sederande läkemedel, stor mängd intravenös vätska samt kirurgiska ingrepp i generell anestesi. Hypotermi har negativa konsekvenser för patienterna som ökad blödningsrisk, försämrad sårläkning samt kardiologisk påverkan. Syftet med studien var att undersöka förekomsten av hypotermi hos intensivvårdade patienter. En retrospektiv deskriptiv studie på 583 vuxna patienter som vårdades på en intensivvårdsavdelning någon gång under 2009 genomfördes. Resultatet visade att 17 procent av patienterna hade drabbats av oavsiktlig hypotermi. Patienterna med intagningsorsakerna blödning och sepsis hade en ökad förekomst av hypotermi. Patienter med låg kroppsvikt samt äldre patienter hade en ökad förekomst av hypotermi vilket stämmer väl överens med tidigare studier. Däremot att yngre patienter samt kvinnliga patienter hade en högre förekomst av hypotermi är nya fynd. Det förefaller viktigt för intensivvårdssjuksköterskan att tidigt identifiera patienter i riskgrupper för oavsiktlig hypotermi och aktivt förhindra dess uppkomst. / The patients on an intensive care unit are often at risk for inadvertent hypothermia. Previously identified groups at risk include patients receiving continuous renal replacement therapy, some sedative drugs, large amounts of intravenous fluids and surgical procedures during general anesthesia. Hypothermia has negative consequences for patients such as increased risk for hemorrhaging, impaired wound healing and cardiological effects. The purpose of the study was to determine the prevalence of inadvertent hypothermia in patients receiving intensive care. We performed a retrospective descriptive study on 583 adult patients who had been admitted to an intensive care unit. The results showed that 17 percent of the patients had inadvertent hypothermia. The patients admitted under the categories bleeding or septicemia had an increased occurrence of hypothermia. Patients with lower bodyweight and elderly patients had a higher occurrence which concurs with previous research. We also found that younger patients and female patients had a higher occurrence of hypothermia which is new findings. It appears that it is important for the intensive care unit nurse to early identify those patients at risk and to actively prevent its occurrence.

The pediatric intensive care unit (PICU) has been described as a stressful place for parents of critically ill children. Research to date has examined parents’ needs and stressors with a child in PICU. There is a paucity of research examining the experience for parents of a child who is transferred from the PICU to the hospital ward. Open-ended interviews were conducted with 10 parents within 24-48 hours after transfer from a PICU to a hospital ward at a children’s hospital in Canada to understand this experience. Parents revealed that the experience involved a search for comfort through transitions as expressed through the themes of: ‘being a parent with a critically ill child is exhausting’, ‘being kept in the know’, ‘feeling supported by others’, and ‘being transferred’. The findings from this study can help nurses and other health professionals working with parents to support them through the transition from PICU. Recommendations are made for the inclusion of family-centered care practices to assist parents through transitions.

Background: Based on survey data from both Canada and abroad, most people would prefer to be cared for and to die in their own homes. Although 70% of elderly patients state a preference for comfort care over high technology life prolonging treatment in an inpatient setting, 54% are still admitted to intensive care units (ICUs). Understanding their wishes regarding end-of-life care, and being able to engage in evidence informed end-of-life discussions has never been so important, in order to empower patients, and to optimize scarce resource management. For the purpose of this thesis, “very old” patients will be defined as those eighty years of age and older. All three manuscripts will be based on data from the Realistic 80 study, a prospective cohort trial of 1671 critically ill very old patients admitted to 22 Canadian ICUs. Objectives: Manuscript 1: To describe the hospital outcomes of the entire cohort of Realistic 80 patients, including their ICU mortality and length of stay, their hospital mortality and length of stay, and their ultimate dispositions. Manuscript 2: To derive a clinical prediction rule for hospital mortality in the medical patient cohort. Manuscript 3: To derive a clinical prediction rule for hospital mortality in the emergency surgical patient cohort. Data Source: A prospective, multicenter cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Methods: Clinical decision rule methodology was used to analyze the data set and to create two separate clinical prediction tools, one for critically ill elderly medical patients, and one for critically ill surgical emergency patients. A third manuscript describing general clinical outcomes was also produced. Results of Manuscript 1: A total of 1671 patients were included in this section of the “Realities, Expectations and Attitudes to Life Support Technologies in Intensive Care for Octogenarians: The Realistic 80 Study (a prospective cohort of nearly 2000 critically ill Canadian patients over eighty years old enrolled from 22 ICUs across Canada) that will provide the data for this thesis. The Realistic 80 cohort had a mean age of 84.5, a baseline Apache II score of 22.4, a baseline SOFA score of 5.3, an overall ICU mortality of 21.8%, and an overall hospital mortality of 35%. The cohort had a median ICU length of stay of 3.7 days, and an overall median hospital length of stay of 16.6 days. Only 46.4% of the survivors were able to return home to live. Results of Manuscript 2: Age, renal function, level of consciousness, and serum pH were the important predictors of hospital mortality in critically ill elderly medical patients. Our clinical prediction tool is very good, particularly at the all-important extremes of prognosis, and ready for external validation. Results of Manuscript 3: Renal function and serum pH were the important predictors of hospital mortality in critically ill elderly surgical patients. Our model’s performance is very good, and will serve to inform clinical practice once validated. Conclusions: Very old medical patients have longer ICU stays and higher mortality than their surgical counterparts. Premorbid health status and severity of illness are associated with mortality. Our medical patient clinical prediction tool is very good and ready for external validation. Our surgical emergency clinical prediction tool shows promise, but will require the incorporation of more patients and a repeat derivation phase prior to external validation or clinical implementation.

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: 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.

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.