Providing Bedside Care Research Articles

Point of care magnetic resonance neonatal neuroimaging applications and early imaging in infants under active therapeutic hypothermia: a perspective.

As care of the most vulnerable infants in the neonatal intensive care unit (NICU) evolves, improved and real-time understanding of brain health becomes key. The availability of an in-NICU magnetic resonance imaging (MRI) scanner provides unique options to bedside care providers and researchers. We present our perspective on the 1-Tesla MRI unit in our NICU and its utilities and applications both in the clinical and research fields. We also discuss our experience with early and serial MRI in a cohort of infants with hypoxic-ischemic encephalopathy while undergoing therapeutic hypothermia, using a compatible cooling blanket and monitoring apparatus with special insight into the planning and organization between providers, and parental perspectives around early, detailed imaging.

Opportunities for Managing Pain and Anxiety in the Intensive Care Unit Using Virtual Reality: Perspectives from Bedside Care Providers

Opportunities for Managing Pain and Anxiety in the Intensive Care Unit Using Virtual Reality: Perspectives from Bedside Care Providers

Nursing experiences in antimicrobial optimisation in the intensive care unit: A convergent analysis of a national survey

BackgroundRecent evidence highlights the need for an interdisciplinary approach to antimicrobial stewardship (AMS). Nursing involvement in optimising antimicrobials in the intensive care unit (ICU) remains understudied. ObjectiveThe objective of this study was to explore nurses' perceptions and experiences of antimicrobial optimisation or stewardship in ICUs in Australia. MethodsAn anonymous web-based survey was deployed nationally in early 2021 through two ICU nursing networks. Associations between survey responses were analysed descriptively and by using nonparametric tests (with statistical significance established at p ≤ 0.05). Free-text survey responses underwent qualitative thematic analysis. Interpretation and reporting of quantitative and qualitative data were integrated. ResultsA total of 226 ICU nurses completed the survey. The majority (197/226; 87%) responded that lack of education limits engagement in AMS. Only 13% (30/226) reported the presence of AMS education and training for nurses in their ICUs. Only about half (108/226; 48%) of the nurses were confident to question prescribers when they considered that the antimicrobial prescribed was unnecessary, with nurses in senior roles more likely to do so than nurses providing bedside care (p < 0.05). Gaps in education (including unfamiliarity with AMS roles), noninclusive antimicrobial discussions, moral distress, and potential workload burden were seen as potential barriers/challenges to engagement. ConclusionThe multifactorial barriers identified that inhibit nurses from performing AMS tasks could be addressed by strengthening interprofessional education at all levels and by applying practical AMS interventions that are inclusive for nursing participation. A purposeful culture change that fosters psychological safety and collaborative practice is paramount to supporting nurses in these roles.

Importance of Nursing Protocol in administering chemotherapy drugs

Introduction : Cancer is an ugly enemy and currently the second leading cause of death in the world. The oncology nurse while performing her duties, build a strong relationship with their patients. The roles and responsibilities of nurses of working in cancer units have changed rapidly over the past century from nurses providing bedside care to advanced practice oncology nurses taking responsibility for assisting and performing invasive procedures along with diagnostic interpretation and screening for cancer prevention. Nurses role and responsibilities in the Oncology unit is quickly transforming according to the qualifications of a diploma holder to a graduate and post graduate nurse. There is also advancement in the technology in the field of treatment to the cancer patients. The future demands that the nurses function to meet both the medial as well as nursing needs of cancer patients. Therefore, the nurses need to be trained and well equipped in the field of Oncology and chemotherapy administration. Methodology : The literature search was done on various database of PubMed, CINHAL, Medline, Cochrane Journal, google scholar, various website was search too for the related content of the topic. Articles related to the search were selected and the content of the topic was included in this document according to its relevance. Results : In the literature reviews different countries have stated their protocol to be followed in their hospital to improve the practices and provide quality care to their patients. The reviews of the protocols have clearly stated the importance of providing chemotherapy through standard protocol for good practices and better clinical outcomes in patients. Nurses play key role in administering chemotherapy, therefore they have to be updating their knowledge and implement these protocol in their practices. The nurse too should update their knowledge and the senior nurses and ward managers need to adopt theses protocol into their practices and teach their junior nurses. Conclusion : The treatment modalities for cancer are varied. Chemotherapy being the commonest treatment prescribed. Nurses have a chief role in administering chemotherapy. Therefore, the nurses need to adopt the protocols into their practice which will address the nurses and patient’s safety, deliver good practice and lead to quality care to cancer patients, better clinical outcome and compliance to treatment.

Low Risk of HCW to Patient Transmission of SARS-CoV-2 in a Tertiary Care Cancer Center June 1, 2020-November 20, 2021

BackgroundSince the beginning of the coronavirus disease 2019 (COVID-19) pandemic, several outbreaks have been reported among patients or staff in acute care settings. The highly contagious B.1.617.2 (Delta) variant became the dominant strain in the United States around July 2021, heightening concern for transmission within healthcare facilities. This report outlines the risk of secondary transmission of SARS-CoV-2 from an infected healthcare worker (HCW) to patient, stratified by profession and care setting.MethodsThis study was conducted at a tertiary care cancer center in New York City from June 1, 2020, until December 4, 2021. On March 17, 2020, the study institution offered testing for all staff. Contact tracing was done for patients exposed to a confirmed HCW case of SARS-CoV-2. The exposure period was defined as two days before symptom onset or two days before positive polymerase chain reaction specimen from asymptomatic HCW.ResultsFrom June 1, 2020, to November 20, 2021, 434 HCWs with direct patient contact tested positive for COVID-19. 57% were registered nurses (RN), 11% patient care technicians (PCT), 8% advanced practice providers, 9% physicians, 11% therapists, and 4% in other fields. Most exposures occurred in outpatient clinics (58%). A total of 3,634 patients were contact traced. Among these, 16 (0.44%) tested positive for COVID-19 within two weeks, 7 (0.66%) occurring in patients exposed during admission. 144 (33%) index cases occurred after July 1, 2021, when Delta became the dominant variant, resulting 1,313 patient exposures. 4 transmission events occurred (0.30%) from 4 separate HCWs, 3 of whom were fully vaccinated.ConclusionsThe overall risk of COVID-19 transmission from HCW to patient is low, though increased among RNs and PCTs providing bedside care. Vaccination and implementation of control measures, such as symptom screening and universal masking, mitigates the risk of COVID-19 infection even among immunocompromised patients.

Occupational fatigue, individualized nursing care, and quality of nursing care among hospital nurses.

This study aimed to evaluate the relationships among nurse fatigue, individualized nursing care, and nurse-reported quality of care. The study used a cross-sectional design. Data from 858 registered nurses providing bedside care in hospitals were collected between March and April 2021 in the United States. Participants completed a self-administered online survey, including the Occupational Fatigue Exhaustion Recovery scale, the Individualized Care Scale-Nurse version, and a single item assessing nursing care quality. Relationships among the study variables were examined using multiple linear and logistic regression models. Nurses' higher levels of acute fatigue were significantly associated with decreased perceptions of individualized nursing activities provided to patients on their last shifts, specifically related to personal life condition and decision-making control. Nurses' higher levels of chronic fatigue were significantly associated with decreased perception of individualized nursing activities provided to patients on their last shifts related to clinical condition, personal life condition, and decision-making control. Nurses with higher levels of acute or chronic fatigue, and who perceived their nursing care activities as less individualized were less likely to assess their quality of care as excellent. These findings suggest that addressing hospital nurses' acute and chronic fatigue may contribute to promoting the delivery of individualized nursing care and in improving patients' quality of care. Healthcare institutions are encouraged to regularly monitor and manage nurse fatigue to improve the delivery of individualized and quality nursing care to their patients.

Association of Inpatient Postpartum Opioid Use with Bedside Nurse.

Our objective was to assess the association between the nurse providing bedside care and women's postpartum opioid use. Retrospective study of all women who birthed at a single center (December 2015 to November 2016). Patient, prescriber, and clinical data were abstracted. The postpartum nurse and total opioid use during the first 12-hour postpartum shift after birth were determined. A high amount of opioid use was defined as morphine milligram equivalents greater than or equal to 90% for this population (stratified by vaginal and cesarean births). A logistic regression model was fit with covariates entered in a step-wise manner to identify the extent to which individual nurses were associated with a greater likelihood of high opioid use by establishing one model in which the only covariate was nurse (model 1) and assessing whether the addition of patient (model 2), birth (model 3), and prescriber factors (model 4) altered the association. Kendall rank correlation assessed rank changes between models. Of the 8376 and 2957 women who had vaginal and cesarean births, 17.9% and 10.2%, respectively, had high opioid use. In the vaginal cohort, women cared for by 46 of 200 nurses were significantly less likely to have high opioid use. Following adjustment, patients cared for by 53 of 200 bedside nurses (model 4) had significantly lower odds of having high opioid use. The rank order of nurses, with respect to the likelihood of opioid use, remained similar after adjustment for patient, birth, and prescriber factors (Τ = 0.84). Findings were similar for the cesarean cohort: 35 of 113 nurses were associated with a significantly lower likelihood of their patients having high opioid use, and the rank order remained similar after covariate adjustment (Τ = 0.78). There is significant variation in postpartum women's opioid use based on the nurse that is not explained by patient, birth, or prescriber factors.

Radiation Safety While Providing Bedside Care During Portable Radiog-

Respiratory Therapists (RTs) and Intensive Care Unit (ICU) nurses are at a potential risk of undesirable exposure to ionizing radiation when providing bedside care to patients requiring portable radiography.

Creating a Tool to Assess Interpretive Services Perceptions at a Hospital System Level.

The importance of using professional interpretive services (IS) when communicating with patients and families with limited English proficiency (LEP) is well described in the literature. There is no standardized tool to reliably evaluate IS from the point of view of bedside care providers. Collected local qualitative data and literature review informed an anonymous electronic survey that was distributed to physicians and nursing staff at a tertiary care children's hospital. Authors then used exploratory factor analysis to analyze results. Survey response rate was 27%. Seven key factors were identified; the original survey was revised using the two most impactful questions contributing to each factor. Re-analysis showed Pearson correlation coefficients at or above 0.9. Using this simplified 14 question questionnaire, hospital systems can assess the knowledge, attitudes, self-reported utilization and perceived barriers around IS, allowing for targeted interventions to improve the care of LEP patients.

Characterization of Ebola Virus Risk to Bedside Providers in an Intensive Care Environment.

Background: The 2014–2016 Ebola outbreak in West Africa recapitulated that nosocomial spread of Ebola virus could occur and that health care workers were at particular risk including notable cases in Europe and North America. These instances highlighted the need for centers to better prepare for potential Ebola virus cases; including understanding how the virus spreads and which interventions pose the greatest risk. Methods: We created a fully equipped intensive care unit (ICU), within a Biosafety Level 4 (BSL4) laboratory, and infected multiple sedated non-human primates (NHPs) with Ebola virus. While providing bedside care, we sampled blood, urine, and gastric residuals; as well as buccal, ocular, nasal, rectal, and skin swabs, to assess the risks associated with routine care. We also assessed the physical environment at end-point. Results: Although viral RNA was detectable in blood as early as three days post-infection, it was not detectable in the urine, gastric fluid, or swabs until late-stage disease. While droplet spread and fomite contamination were present on a few of the surfaces that were routinely touched while providing care in the ICU for the infected animal, these may have been abrogated through good routine hygiene practices. Conclusions: Overall this study has helped further our understanding of which procedures may pose the highest risk to healthcare providers and provides temporal evidence of this over the clinical course of disease.

Structure and Outcomes of Educational Programs for Training Non-electroencephalographers in Performing and Screening Adult EEG: A Systematic Review.

To qualitatively and quantitatively summarize curricula, teaching methods, and effectiveness of educational programs for training bedside care providers (non-experts) in the performance and screening of adult electroencephalography (EEG) for nonconvulsive seizures and other patterns. PRISMA methodological standards were followed. MEDLINE, EMBASE, Cochrane, CINAHL, WOS, Scopus, and MedEdPORTAL databases were searched from inception until February 26, 2020 with no restrictions. Abstract and full-text review was completed in duplicate. Studies were included if they were original research; involved non-experts performing, troubleshooting, or screening adult EEG; and provided qualitative descriptions of curricula and teaching methods and/or quantitative assessment of non-experts (vs gold standard EEG performance by neurodiagnostic technologists or interpretation by neurophysiologists). Data were extracted in duplicate. A content analysis and a meta-narrative review were performed. Of 2430 abstracts, 35 studies were included. Sensitivity and specificity of seizure identification varied from 38 to 100% and 65 to 100% for raw EEG; 40 to 93% and 38 to 95% for quantitative EEG, and 95 to 100% and 65 to 85% for sonified EEG, respectively. Non-expert performance of EEG resulted in statistically significant reduced delay (86min, p < 0.0001; 196min, p < 0.0001; 667min, p < 0.005) in EEG completion and changes in management in approximately 40% of patients. Non-experts who were trained included physicians, nurses, neurodiagnostic technicians, and medical students. Numerous teaching methods were utilized and often combined, with instructional and hands-on training being most common. Several different bedside providers can be educated to perform and screen adult EEG, particularly for the purpose of diagnosing nonconvulsive seizures. While further rigorous research is warranted, this review demonstrates several potential bridges by which EEG may be integrated into the care of critically ill patients.

857. Contact Precautions as a Barrier to Hand Hygiene: PDSA to Improve Compliance with Gloved Hand Hygiene

BackgroundFull compliance with personal protective equipment (PPE) is challenging, with multiple barriers noted: adherence to appropriate PPE, lack of knowledge of appropriate PPE, added time to workflow, and appropriate donning/doffing techniques of PPE to avoid self-contamination. Recent studies note that nurses tend to batch care to achieve more while in the room. A hand hygiene technology system alerted MRICU nurses to difficulties performing WHO’s Five Moments of hand hygiene (HH) when in contact precaution PPE.MethodsWe implemented the ‘Plan-Do-Study-Act’ (PDSA) framework to address the MRICU team concerns. Six nurses were directly observed while providing bedside care to understand nursing workflow and barriers to HH while in contact precautions.ResultsAll 6 nurses performed hand hygiene prior to entering the room and at the time of exiting the room. Once donning contact precautions, they had variable but low compliance with any additional HH opportunities. The average missed opportunities per encounter was 5.2 (range: 2-11). Moments that would require hand washing or sanitizer if nurse were not gloved were not met with changing gloves. An average of 9.8 tasks were achieved in each room (range: 3-18). On average, each visit was 16 (range: 4-30 minutes) minutes long.ConclusionThere is significant opportunity for improved HH while in PPE. Nurses may be more aware of the “Five moments” when not wearing gloves in contact precaution rooms, but lose the trigger once the gloves are on in the contact precaution rooms. An education campaign to improve hand sanitizer usage with gloves is the next step in this PDSA. More prominent placement of glove boxes in the rooms will also serve as a trigger to remind nurses to change gloves after certain tasks. Limitations of this PDSA cycle include Hawthorne effect of the nurses knowing they were observed and potentially changing their workflow. We also only observed morning workflow; nurses on different shifts may have different workflow.Disclosures All Authors: No reported disclosures

Work environment and nurse outcomes: a secondary analysis from the RN4CAST@IT study

Abstract Introduction Nursing care in cardiology requires advanced skills, continuity of care and global care of the chronic patient. The relationship with the patient requires a psychological and moral commitment which, combined with time-pressure and high workloads, increases the risk of negatively impacting nurses' well-being. Emotional exhaustion in nurses has negative consequences on care, therefore nursing leaders should monitor this outcome and ensure that its incidence is limited. Purpose To test the relationship between the nursing working environment and emotional exhaustion among nurses in cardiology wards. Methods The data are drawn from the database of the larger study, RN4CAST@IT. This was a multi-center and multi-level study. A convenience sample of nurses providing bedside care was included. For the analyses presented here, the data relating to nurses working in Cardiology wards were extracted. The data were collected through a web survey between September and December 2015. The questionnaire investigated several topics about nursing staff including nurse-patient ratios, skill mix, working environment measured with PES-NWI, and emotional exhaustion with the Maslach Burnout Inventory. Descriptive statistical analyses were conducted to describe the sample and variables taken into consideration; a binomial logistic regression model was built to test the relationships between the dependent variable “high Emotional Exhaustion;' and the independent variables “PES-NWI composite score”, “workload” and “skill mix”. Results Responses by 291 cardiology nurses were analysed. Binary logistic regression, adjusted for skill mix and staffing, showed that, better working environment conditions reduced the risk that nurses working in the cardiology develop high Emotional Exhaustion by 96% (OR 0.038; 95% CI 0.011–0.136). Conclusions Considering the relationship that these analyses have shown between a favourable working environment, capable of involving professionals, of providing adequate resources and leadership, and the risk that professionals may develop a high level of emotional exhaustion, we need to reflect how it impacts on patients. These results are the starting point for analysing the organization of clinical contexts, with their peculiarities, to make them more and more suitable for people, both patients and professionals. Funding Acknowledgement Type of funding source: None

Noteworthy Professional News

Noteworthy Professional News

Building Moral Resilience.

Building Moral Resilience.

Evaluation of nurse accuracy in rating procedural pain among pediatric burn patients using the Face, Legs, Activity, Cry, Consolability (FLACC) Scale

BackgroundAccurate pain assessment is essential for proper analgesia during medical procedures in pediatric patients. The Faces, Legs, Activity, Cry, and Consolability (FLACC) scale has previously been shown to be a valid and reliable tool for assessing pediatric procedural pain in research labs. However, no study has investigated how rater factors (gender, number of dressing changes performed/week, burn history, having children, nursing experience, stress at home/work) and patient factors (pain intensity) affect the accuracy of FLACC ratings for procedural pain when implemented by bedside care providers. MethodTwenty-four nurses in an ABA verified Pediatric Burn Center watched four videos of dressing changes for pediatric burn patients in random order three times and rated the children's procedural pain using the FLACC scale. The four videos had standard FLACC scores established by an interdisciplinary panel. ResultsDescriptive and mixed modeling analysis was conducted to explore nurse rating accuracy and to evaluate the rater and patient factors that influenced the rating accuracy. The highest accuracy was reached when rating high procedural pain (with a FLACC of 6). Nurses underrated both mild and severe procedural pain. Nurses who had less nursing experience demonstrated significantly higher accuracy than those with more experience. ConclusionsThe present study is the first study in the literature to systematically examine the factors influencing the accuracy of FLACC rating for pediatric procedural pain among bedside care providers. The findings suggest that nurse clinical experience and patient pain intensity are two significant contributors to rating accuracy.

Research as a Standard of Care in the PICU*

Excellence in clinical care coupled with basic and applied research reflects the maturation of a medical subspecialty, advances that field, and provides objective data for identifying best practices. PICUs are uniquely suited for conducting translational and clinical research. In addition, multiple investigations have reported that a majority of parents are interested in their children's participation in clinical research, even when the research offers no direct benefit to their child. However, such activity may generate ethical conflict with bedside care providers trying to acutely identify the best approach for an individual critically ill child. Ultimately, this conflict may diminish enthusiasm for the generation of scientific evidence that supports the application of evidence-based medicine into PICU clinical standard work. Accordingly this review endeavors to provide an overview of current state PICU clinical research strengths, liabilities, opportunities, and barriers and contrast this with an established pediatric hematology-oncology iterative research model that constitutes a learning healthcare system. Narrative review of medical literature published in English. Currently, most PICU therapy is not evidence based. Developing a learning healthcare system in the PICU integrates clinical research into usual practice and fosters a culture of evidence-based learning and continual care improvement. As PICU mortality has significantly decreased, identification and validation of patient-centered, clinically relevant research outcome measures other than mortality is essential for future clinical trial design. Because most pediatric critical illness may be classified as rare diseases, participation in research networks will facilitate iterative, collaborative, multiinstitutional investigations that over time identify the best practices to improve PICU outcomes. Despite real ethical challenges, critically ill children and their families should have the opportunity to participate in translational/clinical research whenever feasible.

Geriatric trauma: An opportunity for proactive palliative care

Mrs. Harrison is an 89 year old widow living independently in the community. In early 2015, she experienced a series of falls over a two month period, with the last resulting in hospitalization for a clavicle fracture and a small subdural hematoma. Her recovery was slow and her functional status was significantly diminished. When Mrs. Harrison expressed her fear and anxiety of the future to Judy, her primary nurse, Judy informed Mrs. Harrison of the geriatric palliative care service. Judy explained that the service could address physical and emotional concerns in a way that could facilitate Mrs. Harrison’s health care decisions. During her hospitalization, Mrs. Harrison and her family received a geriatric palliative care consultation. Based on the consultation, Mrs. Harrison elected to move to an assisted living facility where she had friends and where her family could visit on a regular basis. The facility that she chose allows her to ‘age in place’ by providing levels of service and assistance based on her individual needs. At age 89, Mrs. Harrison has no cognitive impairment, but notes that she has lost weight, is unable eat as much as she used to, cannot walk without her walker, and sleeps more during the day. Mrs. Harrison’s story of advancing frailty is one among hundreds that occur every day across the U.S. Her frailty is an indicator that she is in the final phase of her life, yet public understanding about aging and frailty is sorely lacking. As frontline clinicians providing bedside care, nurses are often best equipped to identify elders who are at risk of functional decline and death. Hospitalization presents an opportunity for advocacy in which nurses can trigger processes that can optimize future trajectories for frail elders. In the bestselling book, Being Mortal,1 Atul Gawande provides vivid insight into the struggles and challenges associated with

“Tele-rounding” with a remotely controlled mobile robot in the neonatal intensive care unit

Objective: To investigate the feasibility of ‘tele-rounding’ in the neonatal intensive care. Methods: In this prospective study utilizing telemedicine technology in the NICU for daily patient bedside rounds (‘tele-rounds’), twenty pairs of neonates were matched according to gestational age, diagnoses, and disease severity. One patient was cared for by the on-site NICU team lead by an on-site neonatologist. The other patient was cared for by the on-site team but led by an off-site neonatologist using a remote-controlled robot. Patient rounding data, clinical outcomes, length of stay, and hospital costs were compared between the two groups. Parents and staff were also surveyed about their satisfaction with telemedicine. Results: Except for one parameter, no significant differences in care or outcomes were found between patients cared for by either neonatologist. The exception was the time the off-site neonatologist spent on the patient encounter compared to the on-site neonatologist (median [interquartile range]), (5 minutes [5, 6] vs. 8 minutes [7, 10.5], p = 0.002). This difference was due primarily to time needed to operate and maneuver the robot or occasionally to slower or dropped connection to the Internet. There were positive perceptions of telemedicine among both parents and NICU staff. Conclusion: As long as direct bedside care providers are available, remote-controlled, robotic telemedicine technology can be utilized by neonatologists to perform daily patient rounds in the neonatal intensive care unit.

Production, Implementation, and Utilization of a Multidisciplinary Assessment for Those Undergoing Hematopoietic Cell Transplantation

Hematopoietic cell transplantation (HCT) is a demanding process, posing physical, psychosocial, and spiritual challenges for patients and families. To ensure patients and their families are supported and to help with potential stressors during this treatment, a comprehensive, multidisciplinary approach is critical. At this institution, a multidisciplinary team meets with patients and families prior to HCT admission to develop a supportive care assessment and plan. A tool was developed to provide communication of the assessment and plan to the bedside nurses. The purpose of this study was to identify a) how to improve teamwork and effectiveness of producing and implementing an individualized comprehensive multidisciplinary assessment and b) how to improve communication and utilization of the plan to bedside nurses. Upon approval from IRB, a validated team behavior survey, TeamSTEPPS 2.0, was distributed to each member of the multidisciplinary team. A separate, nurse-specific survey, assessing the application and utilization of the new tool at the bedside was distributed to staff nurses. Response rate for the nurse-specific survey was 43% and 63% for the multidisciplinary team survey. Although 100% of team members agreed they had a clear vision and vital role, only 35% believed the department had clear expectations of the team. Respondents recognized the following areas as necessary to the production and implementation of an effective assessment and plan: a) participation by all disciplines, b) recognition and constructive feedback among team members, and c) short- and long-term planning. Most nurses found the plan helpful in identifying issues relevant to providing bedside care. A comprehensive multidisciplinary team is essential when caring for patients and families undergoing HCT. Developing an easily accessible communication tool is important to bedside nurses caring for this population. To produce and implement such a tool effectively, teamwork is fundamental.