Critical Care Environment Research Articles

Improving Patient Care Through Collaborative Re-envisioning of the Model of Critical Care.

Advanced medical therapies enable people to live longer with multiple comorbidities, increasing the acuity and complexity of care required upon admission into the intensive care unit. This, coupled with the shift toward a less experienced nursing workforce as skilled nurses retire or leave the critical care environment, prompted the need to re-envision how critical care is delivered. The purpose of this quality improvement project was to embed the values of staff and patient partners in a re-envisioned critical care model, which aligns the provision of high-quality care with staff skill mix and patient needs. Through a series of clinical nurse specialist-led engagement sessions with patients, families, and the members of the healthcare team who work in this environment every day, we talked about what is important in critical care. We used their words and thoughts to inform and shape a new sustainable model of critical care. The 4 components identified as essential to achieving this vision include an acuity-complexity-based approach to care, a transition from separate high-acuity and intensive care areas to integrated units, development of a career pathway to advance practice, and exploration of opportunities to optimize the scope of the interprofessional team. Embedding the values and experience of the people directly connected with providing and/or experiencing critical care increases the likelihood of success in developing, implementing, and sustaining a new model of care. This multifaceted approach resulted in 4 distinct components with achievable outcomes that support this re-envisioned patient-centered sustainable model of critical care.

Proton Pump Inhibitor Usage in Urban vs. Rural Intensive Care Units: A Narrative Review of Implications for Standardization of Care.

Intensive care unit (ICU) patients frequently require and benefit from stress ulcer prophylaxis (SUP) using proton pump inhibitors (PPIs). Despite recognized benefits, PPIs are overutilized in patients who do not have high-risk factors predisposing them to clinically significant gastrointestinal bleeding (CSGIB), including mechanical ventilation and coagulopathy. This overuse increases the risk of adverse effects associated with PPIs. Several urban healthcare systems have created educational initiatives aimed at reducing PPI usage in patients who do not meet recommendations or who are outside the period for serious risk of CSGIB. However, there was no available literature exploring PPI use or educational trends in rural hospitals. This situation presents an opportunity to investigate the disparities in PPI use between rural and urban healthcare settings. This narrative review aimed to assess current data on PPI usage in both urban and rural critical care environments, and to appraise existing practices, ultimately identifying gaps in current literature and informing future guidelines. With these evaluations, this review intended to provide a comprehensive overview of current PPI prescribing practices in the ICU and improve patient care across diverse healthcare settings.

Art therapy as a bridge to expand burn care beyond surgery: Providers’ perspectives in an inpatient burn center

Burn injuries necessitate resource-intensive multidisciplinary care and psychosocial support. Incorporating art therapy in burn centers could enhance patient and provider care. However, research on the impact and reception of art therapy within the context of burn care is scarce. A doctoral dissertation study introduced art therapy intervention for burn patients. As part of this research, we conducted a qualitative study to explore health-care providers’ experiences, with a focus on their perspectives on burn-care and art therapy to inform research and clinical practice. Using thematic analysis in qualitative research, we conducted semi-structured interviews with 10 health-care providers from varied disciplines and identified the following three themes: a) Burn care is a “multifaceted problem” as well as an impact-driven, rewarding experience for providers; b) The visuality of art therapy coupled with physical activity is perceived as a necessary “emotional outlet” for burn patients; and c) Future art therapy research/practice goals are linked to complex patient presentations, specific multidisciplinary team challenges, and the critical care environment. Positive perceptions reinforced that art therapy could contribute to inpatient care as part of multidisciplinary burn teams. More research is needed to address the identified psychosocial, functional, and interprofessional needs of patients and providers.

Single-use vs. reusable flexible bronchoscopes for airway management and in critical care: a narrative review.

Flexible bronchoscopes have become essential in the operating theatre environment and in critical care. This narrative review compared single-use and reusable flexible bronchoscopes with a focus on safety, efficacy, cost-effectiveness and environmental impact. We searched MEDLINE, Embase and PubMed databases for studies related to flexible bronchoscopes for airway management or use in critical care. Human or animal studies of any design assessing single-use and reusable flexible bronchoscopes were included and qualitatively synthesised. We also searched manufacturer websites for relevant data. We included 52 studies and data from six manufacturer websites. There was mixed evidence for safety, and data on usability also showed significant heterogeneity, with different parameters, manufacturers and models examined. Neither single-use nor reusable flexible bronchoscopes appeared convincingly superior to the other for safety or usability. Cost analyses showed that the rate of use of flexible bronchoscopes per year, along with several other factors, affects cost-effectiveness for each institution, though the risk of cross-contamination is an advantage of single-use devices. However, sufficient evidence on the rate of bronchoscopy-induced infection in the operating theatre and critical care environment is lacking. Due to the risk of cross-contamination, single-use flexible bronchoscopes must be sterilised or incinerated after use, and completely recyclable single-use models are not currently available. Further research is required on safety, usability and life cycle assessment in the operating theatre and critical care environment, as well as on the rate of bronchoscopy-induced infection. Future comparative studies, including new manufacturers and designs, may lend further insights.

Parental Perspectives From the Survey of Sleep Quality in the PICU Validation Study on Environmental Factors Causing Sleep Disruption in Critically Ill Children.

Sleep promotion bundles being tested in PICUs use elements adapted from adult bundles. As children may react differently than adults in ICU environments, this study investigated what parents report disrupted the sleep of their child in a PICU. Secondary analysis of a multicenter validation study of the Survey of Sleep quality in the PICU. Four Northeastern U.S. PICUs, one hospital-based pediatric sleep laboratory. Parents sleeping at the bedside of a child in the PICU or hospital-based sleep laboratory. Anonymous one-time survey eliciting parts of hospital or ICU environments that have been described as disruptive to sleep in validated adult ICU and pediatric inpatient questionnaires. Level of sleep disruption was scored by Likert scale, with higher scores indicating more disruption. Age, demographics, baseline sleep, and PICU exposures were used to describe causes of sleep disruption in a PICU. Of 152 PICU parents, 71% of their children's sleep was disrupted significantly by at least one aspect of being in the PICU. The most prevalent were "being in pain or uncomfortable because they are sick" (38%), "not sleeping at home" (30%), "alarms on machines" (28%), and "not sleeping on their home schedule" (26%). Only 5% were disrupted by excessive nocturnal light exposure. Overall sleep disruption was not different across four PICUs or in those receiving sedation. The validation study control group, healthy children undergoing polysomnography, had less sleep disruption than those in a PICU despite sleeping in a hospital-based sleep laboratory. There are multiple aspects of critical care environments that affect the sleep of children, which are different from that of adults, such as disruption to home schedules. Future interventional sleep promotion bundles should include sedated children and could be applicable in multicenter settings.

Enhancing Spiritual Care in Intensive Care Units: An Analysis of the Impact Nurses’ Knowledge, Motivation, and Competency

Spiritual care, a vital component of holistic nursing, is often overlooked in intensive care units (ICUs) because of the limited knowledge, motivation, and competency of healthcare providers. This study investigated ICU nurses' knowledge, motivation, and skill in providing spiritual care. This cross-sectional study included 38 ICU nurses. A systematic questionnaire was used to evaluate nurses' knowledge, motivation, and competency in spiritual care. The relationships between these parameters were analyzed using univariate and bivariate analyses. The findings indicated that ICU nurses moderately understood spiritual care (M = 7.2, SD = 1.9) and exhibited strong motivation (M = 4.0, SD = 0.8). Skills in spiritual care were positively correlated with knowledge (r = 0.41, p < 0.05) and motivation (r = 0.52, p < 0.01). Previous spiritual care training markedly enhanced nurses' competencies (p < 0.05) and served as a significant predictor (β = 0.28, p < 0.05). This study underscores the critical role of knowledge, motivation, and competency in enhancing spiritual care among ICU nurses. Targeted interventions such as educational programs and institutional support are essential for improving spiritual care practices. Future research should focus on developing comprehensive training models to address the individual and systemic barriers to spiritual care integration in critical care environments.

Non-invasive versus arterial pressure monitoring in the pre-hospital critical care environment: a paired comparison of concurrently recorded measurements

BackgroundBlood pressure monitoring is important in the pre-hospital management of critically ill patients. Non-invasive blood pressure (NIBP) measurements are commonly used but the accuracy of standard oscillometric cuff devices may be affected by extremes of physiology and adverse conditions (e.g. vibration) during transport. This study aimed to quantify the accuracy of NIBP measurements amongst patients requiring pre-hospital critical care.MethodsA retrospective cohort study was undertaken using data from patients treated by a pre-hospital critical team between 1st May 2020 and 30th April 2023 that had NIBP measured concurrently with invasive blood pressure (IBP) arterial manometry. An acceptable difference was determined a priori to be < 20mmHg for systolic blood pressure (SBP) and diastolic blood pressure (DBP), and < 10mmHg for mean arterial pressure (MAP). The primary outcome was “pairwise agreement”, i.e. the proportion of paired observations that fell within this range of acceptability. Bland-Altman plots were constructed together with 95% limits of agreement to visualise differences between pairs of data. Associations with patient age, reason for critical care, transport status, haemodynamic shock, severe hypertension, and arterial catheter position were explored in univariate analyses and by fitting multivariable logistic regression models.ResultsThere were 2,359 paired measurements from 221 individual patients with a median age of 57. The most frequent reason for transport was cardiac arrest (79, 35.7%). Bland-Altman analyses suggested unacceptably wide limits of agreement with NIBP overestimating both SBP and MAP during hypotension and underestimating these values during hypertension. Haemodynamic shock (SBP < 90mmHg) was independently associated with reduced pairwise agreement for SBP (adjusted odds ratio [aOR] 0.52, 95% CI 0.35 to 0.77), DBP (aOR 0.65, 95% CI 0.42 to 0.99) and MAP (aOR 0.53, 95% CI 0.36 to 0.78) and severe hypertension (SBP > 160mmHg) with reduced pairwise agreement for SBP (aOR 0.17, 95% CI 0.11 to 0.27). There was no association between patient transport and agreement between the methods for SBP, DBP, or MAP.ConclusionsNon-invasive blood pressure measurements are often inaccurate in the pre-hospital critical care setting, particularly in patients with haemodynamic instability. Clinicians should be cautious when interpreting NIBP measurements and consider direct arterial pressure monitoring when circumstances allow.

Augmenting intensive care unit nursing practice with generative AI: A formative study of diagnostic synergies using simulation-based clinical cases.

As generative artificial intelligence (GenAI) tools continue advancing, rigorous evaluations are needed to understand their capabilities relative to experienced clinicians and nurses. The aim of this study was to objectively compare the diagnostic accuracy and response formats of ICU nurses versus various GenAI models, with a qualitative interpretation of the quantitative results. This formative study utilized four written clinical scenarios representative of real ICU patient cases to simulate diagnostic challenges. The scenarios were developed by expert nurses and underwent validation against current literature. Seventy-four ICU nurses participated in a simulation-based assessment involving four written clinical scenarios. Simultaneously, we asked ChatGPT-4 and Claude-2.0 to provide initial assessments and treatment recommendations for the same scenarios. The responses from ChatGPT-4 and Claude-2.0 were then scored by certified ICU nurses for accuracy, completeness and response. Nurses consistently achieved higher diagnostic accuracy than AI across open-ended scenarios, though certain models matched or exceeded human performance on standardized cases. Reaction times also diverged substantially. Qualitative response format differences emerged such as concision versus verbosity. Variations in GenAI models system performance across cases highlighted generalizability challenges. While GenAI demonstrated valuable skills, experienced nurses outperformed in open-ended domains requiring holistic judgement. Continued development to strengthen generalized decision-making abilities is warranted before autonomous clinical integration. Response format interfaces should consider leveraging distinct strengths. Rigorous mixed methods research involving diverse stakeholders can help iteratively inform safe, beneficial human-GenAI partnerships centred on experience-guided care augmentation. This mixed-methods simulation study provides formative insights into optimizing collaborative models of GenAI and nursing knowledge to support patient assessment and decision-making in intensive care. The findings can help guide development of explainable GenAI decision support tailored for critical care environments. Patients or public were not involved in the design and implementation of the study or the analysis and interpretation of the data.

Patient Safety Culture in the Context of Critical Care: An Observational Study.

A robust safety culture is essential for ensuring high-quality healthcare delivery. From a nursing perspective, especially among critical patients, it fosters ongoing improvement by highlighting areas that need attention. This study aimed to evaluate the perception of patient safety culture among nurses within the critical care environment. An observational study was conducted at a central hospital in Portugal employing the Hospital Survey on Patient Safety Culture (HSPSC) questionnaire. The study encompassed 57, nurses predominantly female (73.7%), aged 25-64. Most participants were general nurses (77.2%), with a significant proportion (61.4%) working in the emergency department and possessing an average tenure of 13 years at the facility. The perception of critical patient safety culture (CPSC) was predominantly positive (40.6%), varying by department, with intensive care nurses reporting the highest positivity rates. Teamwork was identified as a strong point, receiving 80.7% positivity, highlighting it as a well-established domain in the CPSC, whereas other domains were recognised as requiring enhancements. The study pinpointed both strengths and weaknesses within the CPSC, offering a foundation for developing targeted strategies to bolster patient safety culture in critical care settings.

Critical care nurses’ orientations to caring for patients and their families at a selected hospital in KwaZulu-Natal

Background. Caring in a critical care environment may be conceptualised differently compared with other nursing disciplines because of the patient’s critical condition and the specialised staffing categories and skills. However, critical care nurses who prioritise caring can meaningfully connect with critically ill patient and their families, resulting in positive healthcare outcomes. Objective. To assess critical care nurses’ orientations to caring for critically ill patient and their families. Methods. A quantitative, descriptive, cross-sectional study was conducted with 139 purposively sampled critical care nurses working in a tertiary referral hospital in KwaZulu-Natal, South Africa. Data were collected using the Caring Assessment for Caregivers questionnaire, and analysis included descriptive and comparative statistics. Results. The overall mean score of critical care nurses’ orientations to caring was 116.01 (range of 25 - 125). Of the five subscales (dimensions), the dimension of ‘Maintaining belief ’ had the highest mean score of 24.25 and the dimension of ‘Being with’ had the lowest mean score of 22.70 (range 5 - 25). Conclusion. While critical care nurses reported high overall orientations to caring, lower mean scores on the subscale ‘Being with’ suggest that there are areas for critical care nurses to grow in their role as carers. Further research using qualitative approaches may shed valuable insights into how the critical care environment impacts the caring orientations of critical care nurses.

The impact of AI-based decision support systems on nursing workflows in critical care units.

This research examines the effects of artificial intelligence (AI)-based decision support systems (DSS) on the operational processes of nurses in critical care units (CCU) located in Amman, Jordan. The deployment of AI technology within the healthcare sector presents substantial opportunities for transforming patient care, with a particular emphasis on the field of nursing. This paper examines how AI-based DSS affect CCU nursing workflows in Amman, Jordan, using a cross-sectional analysis. A study group of 112 registered nurses was enlisted throughout a research period spanning one month. Data were gathered using surveys that specifically examined several facets of nursing workflows, the employment of AI, encountered problems, and the sufficiency of training. The findings indicate a varied demographic composition among the participants, with notable instances of AI technology adoption being reported. Nurses have the perception that there are favorable effects on time management, patient monitoring, and clinical decision-making. However, they continue to face persistent hurdles, including insufficient training, concerns regarding data privacy, and technical difficulties. The study highlights the significance of thorough training programs and supportive mechanisms to improve nurses' involvement with AI technologies and maximize their use in critical care environments. Although there are differing degrees of contentment with existing AI systems, there is a general agreement on the necessity of ongoing enhancement and fine-tuning to optimize their efficacy in enhancing patient care results. This research provides essential knowledge about the intricacies of incorporating AI into nursing practice, highlighting the significance of tackling obstacles to guarantee the ethical and efficient use of AI technology in healthcare.

Analysis of 20 Years of Ethics Consultations at a U.S. Children's Hospital.

AbstractEmpirical studies of pediatric clinical ethics cases are scant in the biomedical and bioethics literature. In this study, more than 100 detailed records of clinical ethics consultations spanning from 2000 to 2020 at a moderately sized U.S. Mid-Atlantic children's hospital were abstracted and analyzed. Findings of the analysis were generally consistent with other studies in pediatric clinical ethics, with additional insight into aspects of moral distress associated with cases, family engagement with consultations, and other characteristics of interest also documented. Over the 20-year time frame, ethics consults were completed on average twice a year, with a detectable upward trend. Consultations were requested across the spectrum of services and units within the hospital, with critical care environments represented most frequently and genetic and neurological conditions being the most common primary diagnoses. Ethical analysis most commonly related to questions around the principles of autonomy and beneficence.

Comparative Analysis of Artificial Intelligence (AI) Languages in Predicting Sequential Organ Failure Assessment (SOFA) Scores.

The Sequential Organ Failure Assessment (SOFA) score plays a crucial role in intensive care units (ICUs) by providing a reliable measure of a patient's organ function or extent of failure. However, the precise assessment is time-consuming, and daily assessment in clinical practice in the ICU can be challenging. Realistic scenarios in an ICU setting were created, and the data mining precision of ChatGPT 4.0 Plus, Bard, and Perplexity AI were assessed using Spearman's as well as the intraclass correlation coefficients regarding the accuracy in determining the SOFA score. The strongest correlation was observed between the actual SOFA score and the score calculated by ChatGPT 4.0 Plus (r correlation coefficient 0.92) (p<0.001). In contrast, the correlation between the actual SOFA and that calculated by Bard was moderate(r=0.59, p=0.070), while the correlation with Perplexity AI was substantial, at 0.89, with a p<0.001. The interclass correlation coefficient analysis of SOFA with those of ChatGPT 4.0 Plus, Bard, and Perplexity AI was ICC=0.94. Artificial intelligence (AI) tools, particularly ChatGPT 4.0 Plus, show significant promise in assisting with automated SOFA score calculations via AI data mining in ICU settings. They offer a pathway to reduce the manual workload and increase the efficiency of continuous patient monitoring and assessment. However, further development and validation are necessary to ensure accuracy and reliability in a critical care environment.

The CLABSI Playbook: Design and Implementation of a Multipronged Approach to Decrease CLABSIs.

Central line-associated blood stream infections (CLABSIs) are a quality marker for the critical care environment. They have become an area of particular interest because they cost the healthcare system close to a billion dollars per year and have a significant impact on patient safety. Through a preliminary analysis of our system's CLABSI rates, we found significantly higher rates than the national average, prompting further investigation. We decreased our CLABSI rate by over 40% from 2021 (1.6 per 1,000 line days) to the fourth quarter of 2022 (0.91) and kept the rate below or around the national rate (0.86) for the last three quarters of 2022. Through looking at current outcome data, identifying key stakeholders, developing dedicated committees, conducting root cause analyses, monitoring progress, adjusting procedures, scaling to the system, and continuously monitoring and reporting results, we have shown the efficacy of this kind of quality improvement structure and strive to reduce our hospital system's impact on avoidable healthcare-associated patient harm.

Critical Care Nurses’ Perception of Medication Administration Errors in Kelantan, Malaysia: A Cross-Sectional Study

Background. The study investigates critical care nurses’ perceptions of medication administration errors (MAEs) in a tertiary hospital in Kelantan, Malaysia, within the unique sociocultural context of East-Coast Malaysia. The research aims to understand the causes and underreporting of MAEs and assess the proportion of reported incidents according to MAE types. Methods. A cross-sectional study involving 424 critical care nurses from Hospital Raja Perempuan Zainab II (HRPZII), Hospital Sultan Ismail Petra (HSIP), and Hospital Tanah Merah (HTM) was conducted. Nurses in administrative roles or unavailable during the survey period were excluded. The study utilized a validated Medication Administration Errors Survey questionnaire to gauge nurses’ perceptions on the causes of MAEs, reasons for underreporting, and the percentage of reported incidents based on MAE types. Results. Results indicate that illegible medication orders from doctors were identified as the primary cause of MAEs, while a lack of 24-hour pharmacist availability received the lowest score. The most common reason for not reporting MAEs was identified as the nursing administration’s focus on individuals rather than systemic issues when errors occur. The majority of MAEs were non-intravenous, with incorrect timing of administration being the leading cause. Conclusion. The study sheds light on critical care nurses’ perspectives on MAEs in a Malaysian hospital setting, highlighting key factors contributing to these errors and barriers to their reporting. Understanding these perceptions is crucial for developing strategies to mitigate MAEs and enhance patient safety in critical care environments.

The impact of preceptorship on the newly qualified nurse and preceptors working in a critical care environment: An integrative literature review.

Preceptorship has been found to be effective in supporting Newly Qualified Nurses (NQNs) during their transition into challenging environments, particularly in addressing issues related to confidence and anxiety. Effective preceptorship is an element of best practice and essential to support NQNs' transition into the critical care setting. However, the impact of preceptorship on NQNs and their preceptors in critical care units is yet to be completely understood. To review the impact of preceptorship on NQNs and preceptors working in a critical care environment. An integrative literature review of the literature. The review employed Whittemore and Knafl's (2005) five-stage integrative review approach. Three databases (MEDLINE, CINAHL and PsycINFO) were searched for papers published between January 2010 and May 2022. The PRISMA framework was used to guide the search and screening. Thematic analysis was used to extract, organize and analyse the data. Nine studies were included in this review. Reflective thematic analysis revealed three themes, with four related subthemes. Preceptorship has an impact on the development of the NQNs and preceptors' 'nurturing' relationship. NQNs develop their knowledge, competence and confidence when experiencing supportive preceptorship. Meanwhile, preceptors experience a combination of increased workload and opportunities for learning and professional development as a result of preceptorship. There is evidence of the impact of preceptorship on learning and professional development for both NQNs and preceptors, but this is a complex phenomenon and further research is required to understand this area more fully. In nursing practice, it is well-established that Newly Qualified Nurses (NQNs) often face heightened levels of anxiety and a lack of confidence when embarking on their careers, particularly in the demanding and stressful environment of critical care units. This review holds particular significance in the realm of clinical practice as it delves into the pivotal role of preceptorship in nurturing the professional growth and development of NQNs within the challenging domain of critical care. Effective preceptorship, as an essential component of best practice, plays a pivotal role in aiding NQNs' transition into critical care settings.

Experiences of family members when accompanying patients in intensive care units: A qualitative study.

Family members of Intensive Care Unit (ICU) patients encounter numerous challenges while providing companionship to their hospitalized loved ones. This study aims to explore the experiences of family members with loved ones hospitalized in ICUs. Qualitative research was conducted using a content analysis approach. Ten family members of ICU patients were recruited using purposive sampling. Data were collected through semi-structured, in-depth interviews and analysed following Graneheim and Lundman's suggested steps. Analysis of interviews with ten family members of ICU patients revealed a theme of "challenging companionship on an obscure path," encompassing four categories (1-4) and nine subcategories (a, b and c). These included (1) the interplay between the patient and the family: a. family affected by the patient's condition; b. patient affected by the family's condition; (2) mixed emotions of apprehension and anticipation regarding ICU admission: a. fear of ICU hospitalization; b. hope for ICU hospitalization; (3) unaddressed needs and concerns: a. pressure from the ICU's visiting limitations; b. lack of a resting room to settle; c. vague information about the patient's condition; (4) two-way care suffering for families a. direct suffering associated with companionship; b. indirect suffering while observing the patients' suffering. Families of ICU patients encounter various challenges, revealing the complex interplay of emotions, needs and challenges within the ICU. This highlights the intricate dynamics in this critical health care environment. A holistic and empathetic approach in clinical practice is crucial in ICU care, particularly during the challenging journey patients and their families undergo in this critical setting. Health care systems and providers should adapt ICU rules to address evolving needs, alleviate concerns and enhance the overall family experience during their loved one's hospitalization in the ICU.

Critical Care Nurses' Moral Resilience, Moral Injury, Institutional Betrayal, and Traumatic Stress After COVID-19.

Traumatic stress and moral injury may contribute to burnout, but their relationship to institutional betrayal and moral resilience is poorly understood, leaving risk and protective factors understudied. To examine traumatic stress symptoms, moral injury symptoms, moral resilience, and institutional betrayal experienced by critical care nurses and examine how moral injury and traumatic stress symptoms relate to moral resilience, institutional betrayal, and patient-related burnout. This cross-sectional study included 121 critical care nurses and used an online survey. Validated instruments were used to measure key variables. Descriptive statistics, regression analyses, and group t tests were used to examine relationships among variables. Of participating nurses, 71.5% reported significant moral injury symptoms and/or traumatic stress. Both moral injury symptoms and traumatic stress were associated with burnout. Regression models showed that institutional betrayal was associated with increased likelihood of traumatic stress and moral injury. Increases in scores on Response to Moral Adversity subscale of moral resilience were associated with a lower likelihood of traumatic stress and moral injury symptoms. Moral resilience, especially response to difficult circumstances, may be protective in critical care environments, but system factors (eg, institutional betrayal) must also be addressed systemically rather than relying on individual-level interventions to address nurses' needs.

The effectiveness of prehospital rapid sequence intubation in critically ill patients

Background Tracheal intubation in critically sick patients presents a significant risk of complications attributable to variables such as respiratory failure, hemodynamic instability, and drug sensitivity. Present recommendations mostly depend on expert opinion and data from elective intubations, lacking substantial evidence from randomized controlled trials (RCTs) in critical care environments (ICU, ED, general wards). This systematic review sought to assess high-quality evidence-based methods for intubation in critically sick patients, concentrating on pharmacological agents, techniques, and equipment. Methods A thorough search of PubMed, BioMed Central, Embase, and the Cochrane Central Register of Clinical Trials found pertinent randomized controlled trials examining treatments aimed at enhancing the success rate and safety of tracheal intubation in critically sick patients. A meta-analysis was conducted when applicable. Results Intubation problems in critically sick patients vary from 4.2% to 39%. Pre-oxygenation by non-invasive ventilation (NIV) has shown enhanced effectiveness over conventional techniques in extending safe apnea duration and minimizing desaturation. Although high-flow nasal cannula (HFNC) enhanced comfort, its advantages for apneic oxygenation were restricted in this demographic. Etomidate and ketamine had equivalent safety and effectiveness as sedatives, whilst succinylcholine and rocuronium showed similar success rates as neuromuscular blocking drugs. The sniffing position outperformed the ramping position for laryngoscopy.

Sleep in the intensive and intermediate care units: Exploring related factors of delirium, benzodiazepine use and mortality

Aim of the studyThe primary purpose was to examine sleep difficulties and delirium in the Intensive and Intermediate Care Unit. Secondarily, factors impacting night-time sleep duration and quality, mortality, and the impact of benzodiazepine use on sleep outcomes were investigated. Materials and methodsThis retrospective study encompassed data from 323 intensive and intermediate care unit admissions collected in the Netherlands, spanning from November 2018 to May 2020. Sleep quality was measured using the Richards-Campbell Sleep Questionnaire. Night-time sleep duration was nurse-reported. We investigated associations of these sleep outcomes with age, sex, length-of-stay, natural daylight, disease severity, mechanical ventilation, benzodiazepine use, and delirium using Generalized Estimating Equations models. Associations with one-year post-discharge mortality were analyzed using Cox regression. ResultsNight-time sleep duration was short (median 4.5 hours) and sleep quality poor (mean score 4.9/10). Benzodiazepine use was common (24 % of included nights) and was negatively associated with night-time sleep duration and quality (B = -0.558 and -0.533, p <.001). Delirium and overnight transfers were negatively associated with sleep quality (B = -0.716 and −1.831, p <.05). The day-to-night sleep ratio was higher in the three days before delirium onset than in non-delirious individuals (p <.05). Age, disease severity and female sex were associated with increased one-year mortality. Sleep quality was negatively, but not-significantly, associated with mortality (p =.070). ConclusionsNight-time sleep in the critical care environment has a short duration and poor quality. Benzodiazepine use was not associated with improved sleep. Sleep patterns change ahead of delirium onset. Implications for clinical practiceConsistent sleep monitoring should be part of routine nursing practice, using a validated instrument like the Richards-Campbell Sleep Questionnaire. Given the lack of proven efficacy of benzodiazepines in promoting sleep in critical care settings, it is vital to develop more effective sleep treatments that include non-benzodiazepine medication and sleep hygiene strategies.