Critical Care Practitioners Research Articles

Norepinephrine Salt Formulations and Risk of Therapeutic Error: Results of a National Survey

Norepinephrine is available commercially in solution containing its salt (eg, tartrate), but only the base form (ie, norepinephrine base) is active pharmacologically. Unfortunately, the outer label of drug packages frequently reports the dosage of norepinephrine as a salt, which can lead potentially to therapeutic errors when prescribing norepinephrine. We performed a survey to assess the level of awareness of this issue. National survey. Acute care units of Italian hospitals. Acute care physicians and nurses. A 15-item online survey was emailed to 305 critical care practitioners in Italy. Questions included information on the participants' background, methods of diluting norepinephrine, interpretation of recommended doses from guidelines, and a sample case related to the preparation and administration of the drug. We collected 106 responses from 54 hospitals. All hospitals used norepinephrine bitartrate salt. Of the participants, 53% responded that the guidelines express norepinephrine dosages as a salt, 23% as the base form, and 24% were unsure or unaware about it. The simulated patient-dose calculation was resolved in 81% of cases with an incorrect calculation referring to the norepinephrine salt and only in 19% referring to the norepinephrine base. There is significant variability in dosage management of norepinephrine across different hospital units, as well as a lack of knowledge regarding the salt-to-base ratio. Scientific publications (eg, guidelines) should specify whether they are referring to the base or salt form of norepinephrine. The adoption of different labeling and national standards for dilution may decrease the risk of therapeutic errors.

Support from advanced practitioners in critical care for ankle fracture dislocation

Background: Analgesic imitations, under-recognition of injury severity and delayed restoration of neutral alignment are common problems around ankle fracture dislocation (AFD). Optimal prehospital management improves long-term outcomes. Aims: This study aimed to explore ambulance clinicians' experiences of AFD incidents when supported by advanced practitioners in critical care (APCCs). Methods: Semi-structured online interviews were conducted. Data sets were coded and grouped to identify themes via thematic content analysis. Findings: Six clinicians agreed to take part (response rate 42%). AFDs were encountered infrequently (once per year). Four themes were identified: clinicians' confidence in managing AFD; value-added role of APCCs; prehospital challenges; and reflections on the incident. Conclusions: Benefits of the APCC role include enhanced technical skills, including in ankle reduction and analgesia, and in non-technical skills, such as leadership and decision-making. Improvements in clinician recognition and management of AFD and better awareness of the APCC role are recommended, as is research on optimal prehospital AFD management.

Multimodal monitoring in patients with acute brain injury – A survey from critical care providers

BackgroundMultimodal neuromonitoring (MMM) aims to improve outcome after acute brain injury, and thus admission in specialized Neurocritical Care Units with potential access to MMM is necessary. Various invasive and noninvasive modalities have been developed, however there is no strong evidence to support monitor combinations nor is there a known standardized approach. The goal of this study is to identify the most used invasive and non-invasive neuromonitoring modalities in daily practice as well as ubiquitousness of MMM standardization. MethodsIn order to investigate current availability and protocolized implementation of MMM among neurocritical care units in US and non-US intensive care units, we designed a cross-sectional survey consisting of a self-administered online questionnaire of 20 closed-ended questions disseminated by the Neurocritical Care Society. ResultsTwenty-one critical care practitioners responded to our survey with a 76% completion rate. The most commonly utilized non-invasive neuromonitoring modalities were continuous electroencephalography followed by transcranial doppler. The most common invasive modalities were external ventricular drain followed by parenchymal intracranial pressure (ICP) monitoring. MMM is most utilized in patients with subarachnoid hemorrhage and there were no differences regarding established institutional protocol, 24-h cEEG availability and invasive monitor placement between teaching and non-teaching hospitals. MMM is considered standard of care in 28% of responders' hospitals, whereas in 26.7% it is deemed experimental and only done as part of clinical trials. Only 26.7% hospitals use a computerized data integration system. ConclusionOur survey revealed overall limited use of MMM with no established institutional protocols among institutions. Ongoing research and further standardization of MMM will clarify its benefit to patients suffering from severe brain injury.

Saving ambulance resources: a service evaluation of the identification of non-viable out-of-hospital cardiac arrest in London by advanced paramedic practitioners in critical care.

Advanced paramedic practitioners in critical care (APPCCs) are advanced clinical practitioners focused on the delivery of pre-hospital critical care. While working in an ambulance control room setting, APPCCs seek to identify emergency calls appropriate for operational APPCCs to attend. These would include out-of-hospital cardiac arrest (OHCA). Through interrogation of incoming emergency calls they are also able to identify OHCA calls where resuscitation may be futile. In these cases, and within a governance framework, they stand down multiple ambulance responders, leaving only the closest responding resource to attend, thereby 'saving resources' that can be re-directed to other waiting emergency calls. It is believed that this is the first initiative of this nature in the United Kingdom. A three-year retrospective service evaluation of data was undertaken. The aim was to quantify the number of 'saved resources', including both double crewed ambulances (DCAs) and solo (single-person) responders, and furthermore to equate those savings into potential hours saved, using average known job cycle times (JCTs). Additionally, safety was assessed by searching all mandated incident reports for occasions where, despite cancellation of resources by an APPCC, resuscitation was commenced by the first response to scene. A total of 13,356 ambulance resources were saved. Of these, 6593 (49.4%) were DCAs and 6763 (50.6%) were solo responders. Using the average JCT for deceased patients of 104.8 minutes, the total time saving equated to 23,328.48 hours of work or 1944.04 12-hour shifts. When considering DCAs alone, the average JCT for obviously deceased patients was 110.9 minutes. This equates to 12,186.1 hours of work or 1015.5 12-hour shifts. A total of 15 incident reports were identified. All had been investigated, revealing appropriate decision making in cancelling ambulance resources. No patient harm was identified. APPCCs working within a governance framework safely saved a significant number of ambulance resources over a three-year period. Perceived benefits include 'freeing up' DCA and solo responders, allowing them to be redirected to other emergency calls, leading to potential improvement in response times for patients waiting for an ambulance resource.

In-Hospital Violence and Its Impact on Critical Care Practitioners.

To provide a narrative review of hospital violence (HV) and its impact on critical care clinicians. Detailed search strategy using PubMed and OVID Medline for English language articles describing HV, risk factors, precipitating events, consequences, and mitigation strategies. Studies that specifically addressed HV involving critical care medicine clinicians or their practice settings were selected. The time frame was limited to the last 15 years to enhance relevance to current practice. Relevant descriptions or studies were reviewed, and abstracted data were parsed by setting, clinician type, location, social media events, impact, outcomes, and responses (agency, facility, health system, individual). HV is globally prevalent, especially in complex care environments, and correlates with a variety of factors including ICU stay duration, conflict, and has recently expanded to out-of-hospital occurrences; online violence as well as stalking is increasingly prevalent. An overlap with violent extremism and terrorism that impacts healthcare facilities and clinicians is similarly relevant. A number of approaches can reduce HV occurrence including, most notably, conflict management training, communication initiatives, and visitor flow and access management practices. Rescue training for HV occurrences seems prudent. HV is a global problem that impacts clinicians and imperils patient care. Specific initiatives to reduce HV drivers include individual training and system-wide adaptations. Future methods to identify potential perpetrators may leverage machine learning/augmented intelligence approaches.

A Delphi Process to Identify Relevant Outcomes That May Be Associated With a Predictive Analytic Tool to Detect Hemodynamic Deterioration in the Intensive Care Unit.

Background The critical care literature has seen an increase in the development and validation of tools using artificial intelligence for early detection of patient events or disease onset in the intensive care unit (ICU). The hemodynamic stability index (HSI) was found to have an AUC of 0.82 in predicting the need for hemodynamic intervention in the ICU. Future studies using this tool may benefit from targeting those outcomes that are more relevant to clinicians and most achievable. Methods A three-round Delphi study was conducted with a panel of 10 critical care physicians and three nurses in the United States to identify outcomes that may be most relevant and achievable with the HSI when evaluated for use in the ICU. To achieve criteria for relevance, at least 65% of panelists had to rate an outcome as a 4 or 5 on a 5-point scale. Results Nineteen of 24 outcomes that may be associated with the HSI achieved consensus for relevance. The Kemeny-Young approach was used to develop a matrix depicting the distribution of outcomes considering both relevance and achievability. "Reduces time spent in hemodynamic instability" and "reduces times to recognition of hemodynamic instability" were the highest-ranking outcomes considering both relevance and achievability. Conclusion This Delphi study was a feasible method toidentify relevant outcomes that may be associated with an appropriate predictive analytic tool in the ICU. These findings can provide insight to researchers looking to study such tools to impact outcomes relevant to critical care practitioners. Future studies should test these tools in the ICU that target the most clinically relevant and achievable outcomes, such as time spent hemodynamically unstable or time until actionable nursing assessment or treatment.

Female paramedics' attitudes towards career progression in the ambulance service

Background: Women's historic under-representation in paramedic roles in the London Ambulance Service (LAS) has recently improved, and women and men are equally represented in paramedic roles. However, the gender balance of advanced paramedic practitioners in critical care in the LAS remains unequal, with women constituting only 15.1% of this group. Aims: This study aimed to gather the views of female paramedics to gain some insight into potential reasons for this under-representation. Methods: A feminist pragmatic approach was taken. Qualitative, open-ended surveys were distributed via internal social media and bulletins. These surveys underwent primary thematic analysis to generate lines of enquiry that informed semi-structured interview questions. The questions were then posed to a maximum variation, purposeful sample of six women from the LAS. Interviews were audio-recorded, transcribed and thematically analysed. Findings: Ninety-four women responded to the survey; six were sampled for interviews. The women varied by experience, clinical grade, age, work location and societal factors, including whether they were mothers and the number of children they had. A main overarching theme was ‘social construction of women and career progression within the ambulance service’. This was informed by three interrelated subthemes of ‘caregiving lifestyle’, ‘perceptions of self’ and ‘gender stereotypes’. Conclusion: Women in the ambulance service have unique challenges that mirror those in wider society. Social constructs may impose unconscious bias and pressures that prevent women from advancing. Organisational structures and the cultural norms of the LAS may require adapting to improve the gender balance of the workforce and therefore the service it delivers.

Variance in management of extracorporeal membrane oxygenation-associated fibrin sheaths at a single institution.

Extracorporeal membrane oxygenation (ECMO) support for patients with cardiac or respiratory failure has been increasingly used by advanced critical care practitioners. The thromboembolic complications of ECMO have been extensively discussed and researched; however, research and discussion on the development, risks, and management of cannulae-associated fibrin sheaths are lacking. Institutional review board approval was not required. We have presented three cases detailing the identification and individualized management of ECMO-associated fibrin sheaths at our institution. The three patients provided written informed consent for the report of their case details and imaging studies. Of our three patients with ECMO-associated fibrin sheaths, two were managed successfully with anticoagulation alone. One could not receive anticoagulation therapy and underwent inferior vena cava filter placement. Fibrin sheath formation around indwelling ECMO cannulae is an unresearched complication of ECMO cannulation. We would recommend an individualized approach to the management of these fibrin sheaths and have provided three examples of successful management.

Delirium: The Next Vital Sign in the PICU?*

Delirium: The Next Vital Sign in the PICU?*

Assessment of Knowledge, Barrier in Implementation, and Compliance to Ventilator Bundle among Resident Doctors and Nurses Working in Intensive Care Units of a Tertiary Care Center of Western India: A Cross-sectional Survey.

Appropriate implementation of a ventilator bundle (VB) is the key step in the prevention of ventilator-associated pneumonia (VAP). However, knowledge and compliance of critical care staff for VB are inconsistent in developing countries. This cross-sectional survey was planned to evaluate critical care practitioners' knowledge of, adherence to, and barriers toward implementation of VB in the ICUs of a tertiary care institute. All registered nurses and resident doctors who are direct care providers to patients of the ICU were included. Two sets of questionnaires were given to access knowledge and to identify potential barriers in the implementation of VB. To determine compliance with the VB, direct observation was done for three nonconsecutive days, and mean compliance per component of the bundle and overall compliance to VB was determined. Data were analyzed using descriptive and analytic statistics. Of these 75 participants, 43 (57.33%) were resident doctors and 32 (42.67%) were staff nurses. The median knowledge score of resident doctors and staff nurses for VB was 7 (range 3-10) and 6 (range 2-9), respectively, with an overall score of 7 (range 2-10). Self-reported adherence to individual components of VB ranged from 75% to 95%, among these, adherence to oral care protocol, including use of chlorhexidine oral rinse, was most, and adherence to DVT prophylaxis was least. The most common potential barriers identified were fear of potential adverse effects and unawareness of guidelines. Considerable gap is observed between knowledge and implementation of VB among critical care practitioners. Despite knowledge, fear of adverse events and lack of proper training are key barriers in implementation of VB. Paliwal N, Bihani P, Mohammed S, Rao S, Jaju R, Janweja S. Assessment of Knowledge, Barrier in Implementation, and Compliance to Ventilator Bundle among Resident Doctors and Nurses Working in Intensive Care Units of a Tertiary Care Center of Western India: A Cross-sectional Survey. Indian J Crit Care Med 2023;27(4):270-276.

Adults Are Not Just Large Kids: Caring for Adults in Pediatric Hospitals.

Adults Are Not Just Large Kids: Caring for Adults in Pediatric Hospitals.

A retrospective cohort study of pre-hospital agitation management by advanced paramedic practitioners in critical care.

Pre-hospital clinicians can expect to encounter patients with agitation, including acute behavioural disturbance (ABD). These situations carry significant risk for patients and emergency medical services. Advanced paramedics within the London Ambulance Service (LAS) are frequently tasked to these incidents. At present, little evidence exists regarding clinical decision-making and management of this patient group. We sought to explore the demographics of patients presenting with potential ABD and quantify the degree of agitation, physical restraint, effectiveness of chemical sedation and any associated complications. A retrospective analysis of pre-hospital clinical records for patients coded with ABD and attended by LAS advanced paramedics between 1 October 2019 and 30 September 2020. Sedation assessment tool (SAT) scores were used as the primary outcome measure. A total of 237 patient records were identified. Of the patients, 147 (62%) were physically restrained and 104 (44%) were chemically sedated. Sedation was more commonly administered where patients were exposed to physical restraint. High SAT scores were associated with the administration of sedative agents and at higher doses. Of patients undergoing sedation, 89 (85%) had a SAT score reduction of 2 points or a final score ≤ 0. The mean SAT score reduction was 2.72. Three cases of minor injury were reported following physical restraint. Advanced paramedics undertook sedation in less than half the cohort, suggesting that other strategies such as communication and positioning were utilised. Most patients were managed into a state between being restless and rousable, largely negating the need for ongoing physical restraint during hospital transfer. Appropriately trained advanced paramedics can utilise sedation safely and effectively in selected cases.

Designing learning simulations for cognitive absorption

‘The future of learning is immersive. In the future, learning will take the shape of a story, a play, a game; involving multiple platforms and players; driven by dialogue and augmented with technology, an interplay of immersive experiences, data, and highly social virtual worlds’ [1]. Our simulation was designed to raise aspirations as to what is ‘possible’ for our wider faculty as we expand our simulation-based education (SBE). The ‘Godzilla’ multi-casualty exercise offered a fun and engaging theme to the serious focus on student development and assessment. Facilitated at a music venue enabling creative visual and audio backdrops, to a dynamic and immersive learning space. This exploited sensory boundaries in the form of challenging environments, whilst focusing expectations for our student cohorts to demonstrate clinical praxis. The directing staff (DS) included academics, Critical Care Practitioners, Nurses, and Paramedics who ensured a multidisciplinary overview of students’ safety and feedback discussions, appraising decision making, treatment, and management of multiple patient scenarios. Drawing upon the multimedia and interdisciplinary expertise from the faculty, a holistic set of skills brought together the creation of an authentic educational experience, with the evaluation of the students against clinical expectations of a modern healthcare response. The main points of contact were at ‘handover’ post patient extraction and assessment, to senior clinicians. This exercise modelled inclusive approaches, reflected in the seminal Delphi study that identified requirements and opportunities in Immersive Learning namely: Facilitating Authentic Learning Experiences and Developing the Capabilities of the Future Workforce [1]. This approach aligns with the NHS Simulation Strategy [2] but also with the psychological concept of flow and deep absorption in learning proposed by the Open University Innovating Pedagogy report [3]. Premised on the innovation of best learning moments, our student tasks were designed to engender deep involvement through memorable learning activities. 36 level 4 Paramedic students and 24 level 6 Paramedic students undertook the simulated challenges. Facilitators and learners reported high levels of satisfaction and attainment of praxis. Comparisons were recognised between cohorts that informed future adaptations and design, evaluating tasks for future ambitions, fusing interdisciplinary endeavours. This successful exercise met the key learning objectives and students identified this as a ‘memorable’ point in their learning. Inclusion of our allied health professions had handover scenarios filmed with 360° and conventional cameras, and videos were edited for future curricular inclusion. The learning from this inaugural event will inform the diversity and complexity of future tasks set for students. Further feedback capture methods will be used to quantify further investment into future simulation-based educational endeavours. 1. Lee MJ, Georgieva M, Alexander B, Craig E, Richter J. State of XR & Immersive Learning Outlook Report 2021. Immersive Learning Research Network, Walnut, CA. 2021. 2. Health Education England (HEE) A national vision for the role of simulation and immersive technologies in health and care. NHS: 2020 3. Kukulska-Hulme A, Bossu C, Coughlan T, Ferguson R, FitzGerald E, Gaved M, Herodotou C, Rienties B, Sargent J, Scanlon E, Tang J, Wang Q, Whitelock D, Zhang S. Innovating Pedagogy 2021: Open University. Innovation Report 9: 2021

Mental health assessment – a 360° student experience

We have been developing 360° simulated practice videos for healthcare science students. The students who have taken part in the filming and watched the videos provided feedback on whether this would benefit their learning. We are doing this to continue to strive forward with innovations in virtual learning in line with Health Education England [1]. The simulation-based videos have been created to add to the healthcare sciences units to aid in ‘real-life’ teaching styles, to help build confidence and resilience in healthcare students, and to provide multidisciplinary, patient-focused scenarios that can be included in assessments [2]. First and third-year paramedic students took part in mass casualty scenarios filmed at our student’s union building. They worked with Critical Care Practitioners, Academics, Nurses in practice, and the National Ambulance Resilience Unit to create handover videos involving assessing casualties to create videos for other healthcare professionals. Follow-up videos were then filmed on the 360° cameras in the simulation suites to represent an accident and emergency environment as this is where mental health crisis assessments can take place. The adult psychosis presentation was filmed and shows ‘psychiatric liaison nurses’ played by second-year MSc and BSc mental health students assessing the person with suspected psychosis and making clinical decisions. The scenario mental state examination and the case study were scripted. Students could view the 360° videos using virtual reality headsets such as the Oculus Rift [3]. The student feedback evaluation data was collected via an online survey and focus group discussions (FGDs). A survey was completed with n=30 students across all fields of nursing students and paramedic students. The student FGD evaluations were very positive about alternative simulated learning styles with one student quoting ‘It will make an assessment of mental health patients a lot easier for students using appropriate tools and models’. Students found that simulation-based learning experience is an excellent addition to traditional learning approaches as it met the requirements for different learning styles. This research project brought together academics and practitioners from across practice and university. Future work should build on these resources based on feedback from students and service users. 1. National Health Service/Health Education England. 2020. A national vision for the role of simulation and immersive technologies in health and care. 2. ASPiH/HEE. 2016. Simulation-based Education in Healthcare Simulation-Based Education in Healthcare (aspih.org.uk) [Accessed on 17/06/2022] 3. Topal review: NHS. 2019. Preparing the healthcare workforce to deliver the digital future.

Ketamine in Critically Ill Patients: Use, Perceptions, and Potential Barriers

Objective: To evaluate practitioner use of ketamine and identify potential barriers to use in acutely and critically ill patients. To compare characteristics, beliefs, and practices of ketamine frequent users and non-users. Methods: An online survey developed by members of the Society of Critical Care Medicine (SCCM) Clinical Pharmacy and Pharmacology Section was distributed to physician, pharmacist, nurse practitioner, physician assistant and nurse members of SCCM. The online survey queried SCCM members on self-reported practices regarding ketamine use and potential barriers in acute and critically ill patients. Results: Respondents, 341 analyzed, were mostly adult physicians, practicing in the United States at academic medical centers. Clinicians were comfortable or very comfortable using ketamine to facilitate intubation (80.0%), for analgesia (77.9%), procedural sedation (79.4%), continuous ICU sedation (65.8%), dressing changes (62.4%), or for asthma exacerbation and status epilepticus (58.8% and 40.4%). Clinicians were least comfortable with ketamine use for alcohol withdrawal and opioid detoxification (24.7% and 23.2%). Most respondents reported “never” or “infrequently” using ketamine preferentially for continuous IV analgesia (55.6%) or sedation (61%). Responses were mixed across dosing ranges and duration. The most common barriers to ketamine use were adverse effects (42.6%), other practitioners not routinely using the medication (41.5%), lack of evidence (33.5%), lack of familiarity (33.1%), and hospital/institutional policy guiding the indication for use (32.3%). Conclusion: Although most critical care practitioners report feeling comfortable using ketamine, there are many inconsistencies in practice regarding dose, duration, and reasons to avoid or limit ketamine use. Further educational tools may be targeted at practitioners to improve appropriate ketamine use.

End-Of-Life Care in the Potential Donor after Circulatory Death: A Systematic Review.

Donation after circulatory death (DCD) is becoming increasingly common, yet little is known about the way potential donors receive end-of-life care. The aims of this systematic review are to describe the current practice in end-of-life care for potential donors and identify metrics that are being used to assess discomfort among these patients. This review encompasses published literature between June 1, 2000 and June 31, 2020 of end-of-life care received by potential DCD patients. The population of interest was defined as patients eligible for Maastracht classification III donation after circulatory death for a solid organ transplantation. Outcomes examined included: analgesic or palliative protocols, and surrogates of discomfort (eg dyspnea, agitation). Among 141 unique articles, 27 studies were included for full review. The primary reason for exclusion was lack of protocol description, or lack of reporting on analgesic medications. No primary research studies specifically examined distress in the DCD eligible population. Numerous professional guidelines were identified. Surveys of critical care practitioners identified concerns regarding the impact of symptom management on hastening the dying process in the DCD population as a potential barrier to end-of-life palliative treatment. There is a paucity of empirical evidence for end-of-life symptom assessment and management for DCD patients. Key evidence gaps identified for DCD include the need for: i) a multidisciplinary structure of treatment teams and preferred environment for DCD, ii) objective tools for monitoring of distress in this patient population, and iii) evidence guiding the administration of analgesic medications following withdrawal of life sustaining therapy.

Eight years of CRASH: A bi-national initiative helping critical care doctors return to work.

Returning to work in critical care after a break in clinical practice can be a daunting process. This article describes development and evolution of the Critical Care, Resuscitation, Airway Skills: Helping you return to work (CRASH) course, including the supporting literature. CRASH is the first bi-national course assisting return to work (RTW) for critical care practitioners. It evolved as a collaborative effort across Australia and New Zealand, involving anaesthetists, emergency physicians and intensivists. The course is based around tailored sessions practising skills and clinical decision-making using simulation and case discussions, incorporating practical tips on returning to work. Participants receive resources to assist RTW including questionnaires and checklists developed by the faculty, which have been used to aid RTW in more than 30 hospitals in Australia and New Zealand. Attendance is open to all critical care practitioners who are registered with the relevant medical board and returning to work, who have taken leave from work for any reason. Since 2014, 197 participants have attended CRASH in-person or virtually, one of the largest RTW groups described in the literature. The aim of this article is to outline the literature around inactivity and RTW, and describe the development and adaptation of the CRASH course.

Factors associated with venous thromboembolism in the paediatric intensive care unit: A systematic review and meta‐analysis

AbstractBackgroundPaediatric critical care practitioners have become increasingly concerned about venous thromboembolism (VTE). Although a wide range of factors associated with VTE in paediatric intensive care units (PICUs) have been identified, the strength and consistency of effect sizes are uncertain.Study DesignSystematic review and meta‐analysis of case–control and cohort studies.We searched six electronic databases from inception to 20 June 2021. The study population consisted of hospitalized children aged 0–21 years. Our primary outcome was factors associated with VTE in the PICU. We pooled effect sizes as odds ratios (ORs) using random‐effects models for each factor that was examined in at least three distinct samples. We assessed study quality using the Newcastle–Ottawa Scale and examined between‐study heterogeneity.ResultsThe meta‐analysis showed that age <1 year (OR = 1.80, 95% confidence interval [CI]: 1.08–3.01), sepsis (OR = 3.14, 95% CI: 1.55–6.38), central venous catheterization (CVC; OR = 7.76, 95% CI: 3.63–16.61), and mechanical ventilation (OR = 2.80, 95% CI: 1.90–4.13) was associated with an increased VTE risk.ConclusionWe identified that infancy, sepsis, and the use of CVC and mechanical ventilation therapies are more likely to cause VTE in critically ill children. It is still necessary to identify the association between VTE and important clinical variables (e.g., postpubertal age, postoperative status).Relevance to Clinical PracticeThis review provides evidence that supports the factors associated with VTE in specific clinical settings and suggests that nurses should focus on the precise identification of the factors associated with VTE.

Advanced airway management and drug-assisted intubation skills in an advanced critical care practitioner team.

Airway management, including endotracheal intubation, is one of the cornerstones of care of critically ill patients. Internationally, health professionals from varying backgrounds deliver endotracheal intubation as part of their critical care role. This article considers the development of airway management skills within a single advanced critical care practitioner (ACCP) team and uses case series data to analyse the safety profile in performing this aspect of critical care. Skills were acquired during and after the ACCP training pathway. A combination of theoretical teaching, theatre experience, simulation and work-based practice was used. Case series data of all critical care intubations by ACCPs were collected. Audit results: Data collection identified 675 intubations carried out by ACCPs, 589 of those being supervised, non-cardiac arrest intubations requiring drugs. First pass success was achieved in 89.6% of cases. A second intubator was required in 4.3% of cases. Some form of complication was experienced by 42.3% of patients; however, the threshold for complications was set at a low level. This ACCP service developed a process to acquire advanced airway management skills including endotracheal intubation. Under medical supervision, ACCPs delivered advanced airway management achieving a first pass success rate of 89.6%, which compares favourably with both international and national success rates. Although complications were experienced in 48.3% of patients, when similar complication cut-offs are compared with published data, ACCPs also matched favourably.

A Way Forward in the COVID-19 Pandemic: Making the Case for Narrative Competence in Pulmonary and Critical Care Medicine

Each surge of the coronavirus disease (COVID-19) pandemic presented new challenges to pulmonary and critical care practitioners. Although some of the initial challenges were somewhat less acute, clinicians now are left to face the physical, emotional, and mental toll of the past 2 years. The pandemic revealed a need for a more varied skillset, including space for reflection, tolerance of uncertainty, and humanism. These skills can assist clinicians who are left to heal from the difficulty of caring for patients in the absence of families who were excluded from the intensive care unit, public distrust of vaccines, and morgues overtaken by our patients. As pulmonary and critical care medicine practitioners and educators, we believe that cultivating practices, pedagogies, and institutional structures that foster narrative competence, “the ability to acknowledge, absorb, interpret, and act on the stories and plights of others,” in our ourselves, our trainees, and our colleagues, may provide a productive way forward. In addition to fostering needed skills, this practice can promote necessary healing as well. This perspective introduces the practice of narrative competence, provides evidence of support for its implementation, and suggests opportunities for curricular integration.