Critical Care Clinical Practice Research Articles

Synbiotics (prebiotics and probiotics) in the nutrition of critically ill patients

Background: It is well known, nowadays, that intestinal microbiota is considered to be a synbiotic partner that maintains the host’s health. Probiotics are live microorganisms and prebiotics are selectively fermentable non-digestible oligosaccharides or food ingredients that when adequately present, provide health benefit for the host. The mechanisms in which these microorganisms are involved are gastrointestinal barrier function improvement, gut flora modification by antimicrobial peptides inducted by host cells, antimicrobial factors released by probiotics, epithelial adherence competition, and immunomodulation that advantages the host. Synbiotics are a synergic combination of probiotic bacteria and prebiotic ingredients that promote the growth of the former. Methods: In the present study, the existing evidence regarding the beneficial role of probiotics, prebiotics, and synbiotics in critically ill patients was evaluated. Results: The results were rather encouraging about the early use of pro/pre/synbiotics in daily care of critically ill patients but still controversial due to the lack of specific supportive evidence and strain specificity. Conclusions: Despite the positive effect of pro/pre/synbiotics supplementation, they cannot be widely applied in critical care clinical practice until well-designed prospective and randomized controlled trials are performed.

Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians: A Survey to Members of the Society of Critical Care Anesthesiologists.

Despite the growing contributions of critical care anesthesiologists to clinical practice, research, and administrative leadership of intensive care units (ICUs), relatively little is known about the subspecialty-specific clinical practice environment. An understanding of contemporary clinical practice is essential to recognize the opportunities and challenges facing critical care anesthesia, optimize staffing patterns, assess sustainability and satisfaction, and strategically plan for future activity, scope, and training. This study surveyed intensivists who are members of the Society of Critical Care Anesthesiologists (SOCCA) to evaluate practice patterns of critical care anesthesiologists, including compensation, types of ICUs covered, models of overnight ICU coverage, and relationships between these factors. We hypothesized that variability in compensation and practice patterns would be observed between individuals. Board-certified critical care anesthesiologists practicing in the United States were identified using the SOCCA membership distribution list and invited to take a voluntary online survey between May and June 2021. Multiple-choice questions with both single- and multiple-select options were used for answers with categorical data, and adaptive questioning was used to clarify stem-based responses. Respondents were asked to describe practice patterns at their respective institutions and provide information about their demographics, salaries, effort in ICUs, as well as other activities. A total of 490 participants were invited to take this survey, and 157 (response rate 32%) surveys were completed and analyzed. The majority of respondents were White (73%), male (69%), and younger than 50 years of age (82%). The cardiothoracic/cardiovascular ICU was the most common practice setting, with 69.5% of respondents reporting time working in this unit. Significant variability was observed in ICU practice patterns. Respondents reported spending an equal proportion of their time in clinical practice in the operating rooms and ICUs (median, 40%; interquartile range [IQR], 20%-50%), whereas a smaller proportion-primarily those who completed their training before 2009-reported administrative or research activities. Female respondents reported salaries that were $36,739 less than male respondents; however, this difference was not statistically different, and after adjusting for age and practice type, these differences were less pronounced (-$27,479.79; 95% confidence interval [CI], -$57,232.61 to $2273.03; P = .07). These survey data provide a current snapshot of anesthesiology critical care clinical practice patterns in the United States. Our findings may inform decision-making around the initiation and expansion of critical care services and optimal staffing patterns, as well as provide a basis for further work that focuses on intensivist satisfaction and burnout.

Quality of critical care clinical practice guidelines involving pharmacotherapy recommendations.

To assess the quality of critical care clinical practice guidelines (CPGs) involving pharmacotherapy recommendations. A systematic electronic search was performed using PubMed, MEDLINE, and Embase for critical care CPGs published between 2012 and 2022 and involving pharmacotherapy recommendations. The Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument was employed to appraise CPG quality through independent assessment by 2 appraisers. Twenty-one CPGs were evaluated. The number of recommendations in each guideline ranged from 2 to 250, with a total of 1,604 recommendations. The number of strong (vs weak) recommendations in each guideline ranged from 0 to 31, with a total of 116 strong recommendations, or 7.23% of the total number of recommendations. There was at least 1 pharmacist author for 9 (43%) of the guidelines. The AGREE II domains for which mean quality scores of evaluated guidelines were highest were scope and purpose (0.88; 95% CI, 0.85-0.92), rigor of development (0.80; 95% CI, 0.77-0.83), clarity of presentation (0.84; 95% CI, 0.81-0.87), and editorial independence (0.86; 95% CI, 0.79-0.94), while those for which mean scores were lowest were stakeholder involvement (0.69; 95% CI, 0.63-0.75) and applicability (0.49; 95% CI, 0.43-0.55). Involvement of a pharmacist in CPG development was associated with significantly higher scoring for stakeholder involvement (P = 0.0356). Strong recommendations accounted for less than 10% of the recommendations in the evaluated CPGs. Moreover, there are concerns related to guideline applicability (ie, advice or tools for putting recommendations into practice) and stakeholder involvement (ie, inclusion of individuals from all relevant groups). It is important to involve pharmacists in CPGs with pharmacotherapy recommendations.

Development and Implementation of Ontario Critical Care Clinical Practice Rounds

Background The COVID-19 pandemic brought unprecedented challenges to health care systems across the world. Health care professionals were burdened with time constraints as they balanced care for a large number of patients while managing crippling resource shortages. In the pandemic’s early stages, it was challenging for health care providers to provide evidence-based therapies due to the novel nature of COVID-19. There were also pressures to adopt unproven, yet highly touted treatments based on media reports and social media postings. These challenges were identified by Critical Care Services Ontario (CCSO), a provincial health organization that ensures the integration of the critical care system in Ontario, Canada. Since traditional methods of knowledge translation were inaccessible during the pandemic, CCSO created a webinar series titled Ontario Critical Care Clinical Practice Rounds (OC3PR) to share evidence-based practices with critical care professionals. Objective We sought to develop and implement a webinar series to connect critical care professionals with the best available evidence and clinical expertise during the COVID-19 pandemic. We were also interested in gathering attendee perceptions of OC3PR as an educational tool. Methods CCSO collaborated with 5 regional critical care leaders in Ontario to develop and implement OC3PR. This committee identified presentation topics based on perceived urgency and demand and selected presenters with expertise on their respective discussion topic. To promote accessibility, OC3PR was facilitated on the Zoom platform, live simulcasted on Youtube, and subsequently posted on Youtube for asynchronous viewing. Attendees also had the opportunity to share inquiries in live questions-and-answers sessions facilitated by the presenters. Finally, to gather the perceptions of and experiences with OC3PR, we invited attendees to partake in a web-based questionnaire at the end of each session. Results In total, 19 webinars were presented from November 26, 2020, to December 2, 2021, with 1481 registered unique attendees from within Canada and internationally and 17,533 Youtube visits. OC3PR presentation topics centered on resource rationing, patient therapies, staffing challenges, infection control, and vaccination. In addition, 22 follow-up questionnaires yielded 408 responses from attendees, which were composed of physicians (32%), registered nurses (15%), and other health care professionals. Our survey results suggest that OC3PR is beneficial to professionals as the majority of the respondents strongly agreed that it was of acceptable quality, enhanced their knowledge, relevant to their practice, and allotted appropriate timing for interactive components. Most (98%) respondents also reported that they would attend another OC3PR session. Conclusions The success of OC3PR as an accessible educational tool made it evident to CCSO that it would continue this forum in a postpandemic context. Although the webinar series was created for critical care professionals, it can be adapted by other health organizations to improve the integration of their health networks and enhance the support they provide for their workers. Conflicts of Interest None declared.

Assessment of Nurses Knowledge Regarding Delirium in Adult Critical Care Units in Baqubah

Research Question: What is the knowledge of nurses in assessing patients with delirium in critical care units in Baqubah? Aim of this study: An evaluation of nursing knowledge regarding delirium assessment in adult Critical care units. Method: A quantitative descriptive survey was carried out among 36 staff nurses working in Critical care units in Baqubah teaching hospital. A self-reporting questionnaire was used to collect data to answer the research question. Sample: All qualified nursing staff meeting outlined criteria and working in the Critical care clinical areas in the selected hospital were invited to participate in the study. A response rate of 80% (n=36) was achieved. Findings: More than half of the nurses reported that they don’t using validated tools to assess for delirium during their practice. However, critical care clinical practice in Baqubah lacks established protocols to screen for delirium resulting in non-adherence to clinical practice guidelines. Barriers and poor perceptions were identified in this survey in relation to delirium screening. This information can inform future care planning and care to be used to improve standards and quality of care in intensive care units. Keywords; Nurse, Nurse Knowledge, Delirium, Critical care units, Adults.

Identifying, describing, and assessing interventions that support new graduate nurse transition into critical care nursing practice: a systematic review protocol

BackgroundGiven a persistent nursing shortage in Canada and a decline in new nurses entering the profession, new graduate nurses (NGNs) are being hired into positions historically reserved for more experienced staff. Critical care settings, which are areas of specialty nursing practice, are now routinely hiring NGNs in many hospitals. While evidence on NGN transition into critical care is emerging, best practices around training and support for these nurses are limited internationally, and non-existent within the Canadian context. Therefore, the aim of this systematic review is to identify, describe, and assess the effectiveness of interventions that support NGN transition into critical care clinical practice settings.MethodsThis is a systematic review of interventions using the Joanna Briggs Institute Methodology. Data sources will include MEDLINE, CINAHL, PsychINFO, Education Source, and Nursing and Allied Health electronic databases. Two independent reviewers will screen titles and abstracts using predetermined inclusion criteria. A consensus meeting will be held with a third reviewer to resolve conflicts when necessary. Full texts will also be screened by two independent reviewers and with conflicts resolved by consensus. Data will be extracted using a standardized extraction form. We will assess the quality of all included studies using Joanna Briggs Institute quality assessment tools. Data describing interventions will be reported narratively and a meta-analysis will be conducted to determine effectiveness, if appropriate.DiscussionThis systematic review will identify interventions that support NGN transition into critical care nursing practice. The findings of this study will provide a foundation for developing strategies to support NGN transition into these areas of specialty nursing practice.Systematic review registrationPROSPERO CRD42020147962.

Journal club as a tool to facilitate evidence based practice in critical care

Background: A journal club is a forum to debate and review clinical practice using a number of models to gauge the strength of evidence associated with the clinical practice. A large body of evidence supports the importance of journal clubs as a method to improve patient outcome by enhancing the implementation of evidence-based practice and professional development in the clinical setting1–3. Journal club activities have been recommended by the Hamad Medical Corporation (HMC) Critical Care Nursing Network (CCNN), Qatar, and started in the critical care areas of Hamad General Hospital for different critical care specialties such as trauma, surgical, and medical ICUs since 2014. Methods: The journal club is a 1-hour monthly critical care educational activity for HMC critical care nurses. A flyer promoting the article to be discussed is shared with the critical care nurses one week prior to the scheduled date and each session is attended by 15–20 nurses. Participants gain continuing professional development (CPD) credits for each session they attend. The articles discussed cover patient safety and critical care clinical practices. A structured review of the selected articles is facilitated by an expert educator with a research background. The strength of the evidence to change current clinical practice will be evaluated in a group discussion format (Table 1). At the end of each journal club activity, the facilitator summarizes the learning points, recommendations, and the action plan if the group believes changes to current clinical practice are recommended3. Results: Around 50 journal clubs have been conducted in the critical care units of HMC with a total attendance of 1100 nurses. The journal club activity encouraged critical care nurses to establish the first nursing clinical research team in critical care areas of HMC (Table 2). Additionally, it had a positive impact on improving the professional development and competency level of the critical care nurses which were assessed and evaluated by HMC critical care competency assessors through applying the specialty critical care competency checklist. Finally, implementation of the journal club activity and reviewing best available evidence and research literature led to improvements in clinical practice (Table 3). Conclusion: Implementation of the journal club activity helped in developing critical care nurses’ awareness on current research studies and best available evidence, in addition to keeping them up-to-date with new findings, practices, and critical care trends. The journal club with its structured review questions has proven to be an effective way of evaluating the strengths of the evidence presented in the reviewed articles and sometimes led to changing our critical care clinical practice. It also contributes to improving nurses’ ability to critically appraise research articles. Furthermore, it promotes the implementation of new knowledge gained in clinical practice which is expected to improve patient safety and outcomes.

Safety culture in two metropolitan Australian tertiary hospital intensive care units: A cross-sectional survey

BackgroundSafety culture is significant in the complex intensive care environment, where the consequences of human error can be catastrophic. Research within Australian intensive care units has been limited and little is understood about the safety culture of intensive care units in Queensland. AimThe aim was to evaluate and compare safety culture in the intensive care units of two metropolitan tertiary hospitals in Queensland. MethodA cross-sectional survey, Safety Attitudes Questionnaire, was administered to all medical, nursing and allied health professionals in the research sites (A and B) during January and February 2016. Data were collated into six safety culture domains of teamwork climate, safety climate, job satisfaction, stress recognition, working conditions and perceptions of management. Comparison was made using t-tests and between demographic groups using generalising estimating equations. ResultsIn total, 206 surveys were returned from 522 staff (39.5% response rate). The majority of respondents were nurses (80.6%). Site B scored all domains of the safety attitudes questionnaire significantly higher than Site A (p < 0.001). The scores for both site A and B were significantly higher in all domains (p < 0.001) than a previous Australian study conducted in 2013. Both sites returned low scores in the stress recognition domain. Medical staff perceived the teamwork climate as more positive than nursing staff (mean difference 16.6 [Wald χ2 = 10383.8, p < 0.001]). Allied health professionals reported poorer perceptions of working conditions than medical staff (mean difference 7.8 [Wald χ2 = 775.4, p < 0.001]). ConclusionDespite similar governance and external structures, differences were found in safety culture between the two research sites. This finding emphasises the importance of local, unit-level assessment of safety culture and planning of improvement strategies. This study adds to the evidence and implications for critical care clinical practice that these interventions need to be unit focused, supported by management and multidisciplinary in approach.

Conflicts of interest disclosure forms and management in critical care clinical practice guidelines.

Trustworthy clinical practice guidelines (CPGs) require identification and careful management of conflicts of interest (COIs) among all participants in the guideline development. Furthermore, COIs are more common than anticipated. However, there are no universally accepted methods to identify and manage COIs. To describe and summarize the current COI disclosure forms and management policies in selected critical care professional societies that develop high-impact CPGs. In addition, we aim to provide suggestions to guideline developers on how to identify and manage different types of COIs. We searched PubMed and MEDLINE for CPGs published between 2013 and 2018 in English language and addressed general critical care topics. We then ranked the CPGs according to the numbers of citations and selected the first five critical care professional societies that sponsored the guidelines. We obtained the most recent COI declaration forms and management policies. Two reviewers abstracted data on different types of COI in each of the disclosure forms and management policies. All selected professional critical care societies require that members declare direct financial COIs; four societies inquire specifically about intellectual COIs (involvement in primary research). Three out of five societies require members to disclose indirect institutional financial COIs; however, none inquire about other forms of institutional COI. We developed, by consensus, a streamlined framework to classify and manage different types of COIs. The current COI disclosure forms of selected professional societies provide more attention to financial disclosures and COIs and less attention to detecting and managing intellectual COIs, while rarely addressing institutional COIs. We provide some suggestions for guideline developers on the classification and management of different COIs in the context of CPGs.

Methodologic Innovation in Creating Clinical Practice Guidelines: Insights From the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption Guideline Effort.

To describe novel guideline development strategies created and implemented as part of the Society of Critical Care Medicine's 2018 clinical practice guidelines for pain, agitation (sedation), delirium, immobility (rehabilitation/mobility), and sleep (disruption) in critically ill adults. We involved critical illness survivors from start to finish, used and expanded upon Grading of Recommendations, Assessment, Development and Evaluation methodology for making recommendations, identified evidence gaps, and developed communication strategies to mitigate challenges. Thirty-two experts from five countries, across five topic-specific sections; four methodologists, two medical librarians, four critical illness survivors, and two Society of Critical Care Medicine support staff. Unique approaches included the following: 1) critical illness survivor involvement to help ensure patient-centered questions and recommendations; 2) qualitative and semiquantitative approaches for developing descriptive statements; 3) operationalizing a three-step approach to generating final recommendations; and 4) systematic identification of evidence gaps. Critical illness survivors contributed to prioritizing topics, questions, and outcomes, evidence interpretation, recommendation formulation, and article review to ensure that their values and preferences were considered in the guidelines. Qualitative and semiquantitative approaches supported formulating descriptive statements using comprehensive literature reviews, summaries, and large-group discussion. Experts (including the methodologists and guideline chairs) developed and refined guideline recommendations through monthly topic-specific section conference calls. Recommendations were precirculated to all members, presented to, and vetted by, most members at a live meeting. Final electronic voting provided links to all forest plots, evidence summaries, and "evidence to decision" frameworks. Written comments during voting captured dissenting views and were integrated into evidence to decision frameworks and the guideline article. Evidence gaps, reflecting clinical uncertainty in the literature, were identified during the evidence to decision process, live meeting, and voting and formally incorporated into all written recommendation rationales. Frequent scheduled "check-ins" mitigated communication gaps. Our multifaceted, interdisciplinary approach and novel methodologic strategies can help inform the development of future critical care clinical practice guidelines.

Quality of critical care clinical practice guidelines: Assessment with AGREE II instrument

Study objectiveClinical practice guidelines (CPGs) are cornerstones for the management of critically ill patients. Numerous CPGs have been generated in critical care medicine, but their qualities have never been systematically appraised. The aim of the present study was to systematically assess the quality of critical care CPGs. DesignA systematic electronic search was performed in PubMed and Scopus. All critical care CPGs were included for analysis. SettingNot applicable. PatientsNot applicable. InterventionNone. MeasurementsThe Appraisal of guidelines for research & evaluation II (AGREE II) instrument was employed to appraise the quality. CPGs were assessed independently by three raters and intraclass correlation coefficient to represent the agreement among raters. Main resultsA total of 89 CPGs were included for quantitative analysis. The results showed that domain 1 (scope and purpose) had the highest scores (0.93, IQR: 0.89–0.98) and domain 2 (stakeholder involvement) had the lowest scores (0.37, IQR: 0.30–0.46). The overall score was 0.83 (IQR: 0.67–0.83). Publication year was not associated with scaled scores in each domain. Domain 2 (stakeholder involvement) was significantly associated with the number of societies (coefficient: 0.702, p = 0.033). Also, greater number of societies were associated with higher scaled scores of domain 3 (coefficient: 0.768, p = 0.027), 4 (coefficient: 0.730, p = 0.029) and 5 (coefficient: 0.995, p = 0.023). ConclusionsThe study showed that the reporting quality of critical care CPGs were suboptimal. The reporting quality varied across the six domains, with the highest quality in domain 1 and lowest quality in domain 2. Strenuous efforts need to be made to improve the reporting of critical care CPGs.

An Interprofessional Approach to Undergraduate Critical Care Education

Published research suggests that the best outcomes in critical care clinical practice require an interprofessional (IP) collaborative approach to patient care. The Institute of Medicine has called for increased IP education. This article describes the development of an elective undergraduate IP critical care course. The course was developed to educate nursing and respiratory care students on the importance of IP practice, current evidence, and essentials of critical care. Several challenges were met in the development and implementation of the course. Various IP teaching strategies were used, including simulation, clinical observations, and student patient case presentations. An IP course provides a unique learning environment in which fundamental principles of critical care clinical practice and IP practice can be learned in an IP educational environment. There is a critical need to increase IP education and to conduct research related to IP education and its outcomes in preprofessional educational programs.

The lived experience of survivors of prolonged mechanical ventilation: a phenomenological study

Background Successful liberation from prolonged mechanical ventilation (PMV) is a challenging phenomenon. Whereas many physiological factors have been linked to successful PMV liberation, the psychosocial components are not well delineated. Objectives This article serves to describe the experience of patients who survived PMV and to identify salient factors that contributed to successful liberation. Methods A phenomenological approach was used to explore the lived experience of seven PMV survivors. Results Six mutually exclusive themes emerged from the participants’ descriptions to create a structural description of the lived experience. Conclusions Survivors credited their own self-determination and the expertise and care of health care professionals with their ability to be successfully liberated from prolonged mechanical ventilation. Although surviving PMV was described as frightening and traumatic, comfort and resolve were derived from family members, religion, prayer, and angelic encounters. These findings are useful in providing direction for critical care clinical practice and future research.