Critical Care Workers Research Articles

ICU Bridge Program: Working with staff towards no family members feeling like "the elephant in the room"

The intensive care unit (ICU) provides specialized care to critically ill patients. Given the traumatic nature of critical illness and its treatments, up to 75% of family members of ICU decedents and survivors experience long-term psychological consequences, termed post-intensive care syndrome family (PICS-F). Anxiety, PTSD, and depression are common manifestations that significantly impact families’ quality of life and the recovery of those dependent on their caregiving. Although PICS-F can be mitigated by engagement with ICU staff, critical care workers are at risk of burnout and requesting closer liaisons with families is unfeasible. Bridging visitors and the ICU health care team would ensure that family members never feel like “the elephant in the room”.The ICU Bridge Program (ICUBP) is a unique volunteering and shadowing initiative designed and run by university students. Bridge Program volunteers are assigned to hospital ICUs in Montreal to be the first point of contact for visitors. This program addresses PICS-F by humanizing the ICU experience through compassionate human contact, continuous support, and an open line of communication. The diverse applicants are carefully selected and trained to maximize soft skills, such as emotional intelligence and active listening, which ensures that families feel welcome and understood in this tense environment. Furthermore, the ICUBP’s self-sufficient structure off-loads administrative responsibilities from resource-constrained hospitals and makes its implementation feasible and cost-efficient. By continuously monitoring its effect on patients, families, and staff, the ICUBP aims to improve and expand its contribution to whole-person care in the ICU.

The impact of the coronavirus pandemic on the mental health of critical care workers

The coronavirus pandemic has focused attention on the importance of critical care and highlighted the shortage of critical care specialists. Due to increasing workloads and high mortality rates, healthcare professionals were exposed to higher levels of physical and psychological stress during the pandemic than before. Our study investigated the effects of the coronavirus outbreak on the emotional, mental and moral stress of intensive care professionals. Our workgroup performed paper-based surveys among caregivers in the Department of Anaesthesiology and Intensive Therapy at Semmelweis University. The first survey was conducted at the start of the pandemic in 2020, the second survey was conducted after the third wave in 2021. We applied validated questionnaires (Professional Quality of Life, Demoralization Scale, Perceived Stress Scale, Impact of Event Scale, and Posttraumatic Growth Inventory), collected demographic data and information on lifestyle, recreation, dietary habits, and accepting psychological support. The number and demographic characteristics of the participants in the two studies are different, reflecting the changes in the workforce during the pandemic. Our results revealed no differences between the working and socio-demographic groups before the outbreak, however, one year later, nurses scored significantly higher on all negative psychological scales compared to other groups. Only a minority of the respondents had sought psychological support (9.5-12.7%), although more than a third of respondents reported the need for psychological support. Employees in new work positions showed significantly increased posttraumatic growth (2.91 ± 0.82 vs. 2.20 ± 1.06, p = 0.016). These findings demonstrate that nurses are the most strained workgroup during an uncertain and stressful period. The available mental support alone is not enough to help caregivers. Further steps are needed to improve the mental health of critical care workers. Orv Hetil. 2023; 164(42): 1646-1655.

Short term effects of simulation training on stress, anxiety and burnout in critical care health professionals: before and after study

IntroductionAnesthesia and critical care professionals have been shown to be particularly affected by the problems of stress, anxiety, and burnout. Simulation training could be a sustainable solution to help health care workers to deal with this situation. There is however poor scientific evidence on the short-term effect of simulation training on stress, anxiety and burnout in anesthesia and critical care workers. Material and methodsThis prospective observational study was conducted over one year. All anesthesia and critical care professionals participating in simulation training for critical situations were considered for inclusion. Perceived Stress Score (PSS), State Trait Anxiety Inventory (STAI) and Maslach Burnout Inventory (MBI) were collected before and 1 week after the training. ResultsNinety-three participants fully completed the before and after study. PSS levels were significantly lower after the simulation sessions (p = .008), as were STAI levels (anxiety state (p < .001) and anxious personality trait (p = .002). The severity of burnout levels also decreased after simulation training (p < .001). ConclusionSimulation training based on critical situations exposure seems to have positive and rapid effects on stress, anxiety and burnout in anesthesia and critical care staff.

Deception and Distress

AbstractIn the lead article in the January‐February 2023 issue of the Hastings Center Report, Abram Brummett and Erica Salter provide a conceptual framework to help physicians think through the ethics of deceiving a patient or someone closely connected to the patient. Brummett and Salter identify four main ethical features of any act of clinical deception and elaborate on how, in a given case, these features together influence the degree to which a deception could be justified. A second article in this issue presents an ethnographic study of the effect of the Covid‐19 pandemic on critical care workers in an intensive care unit. The authors describe a level and form of moral distress that, they argue, goes beyond what the term “moral distress” captures. The authors offer “distressed work” to better mark the broad consequences for care workers’ roles, occupations, and vocations.

How to handle occupational well-being of critical care workers. A lesson from the pandemic

Abstract Background The PSIC study (Prospective Study of Intensivists and COVID-19) monitored the intensivists working in one of the two COVID-19 hub hospitals in Central Italy over 2 years from April 2020. This study showed how mental health varies in relation to the stressors posed by the different pandemic phases. Methods In 4 surveys corresponding to the 4 pandemic waves, the intensivists were invited to indicate changes in work activity and measure their state of mental health using standardized questionnaires administered via SurveyMonkey. Results During the pandemic there was a change in occupational stressors that led to insomnia, anxiety, depression, burnout, job dissatisfaction, unhappiness and intention to quit. The predominant stressors in the first wave were fear of unprotected exposure, distrust of safety measures, and compassion fatigue from having to inform relatives of the adverse outcome of treatment. In the second and third waves the workload, the monotony due to always following only one type of patient, the isolation, and the lack of time to meditate were the more relevant factors. The fourth wave added the stress deriving from interacting with anti-vax patients Conclusions Specific prevention strategies have been developed and applied for each of the stress factors identified. Excessive workload and lack of time for meditation originated from lack of staff were remedied with extraordinary temporary hires. The management of compassion fatigue and relations with anti-vax people were addressed with specific policies and training. The monotony and isolation in COVID-19 wards can only be resolved through employee turnover in ordinary departments. Organizational and financial efforts are necessary to protect the health of intensivists during a pandemic. Key messages • Monitoring of critical care workers during the pandemic waves indicated the preventive measures necessary to ensure their mental health and quality of care. • Protecting healthcare workers is a priority.

Knowledge mobilization in critical care and the evolving communication role of nurses.

The importance of appropriate communication skills within a health care setting rests upon the need for effective information sharing. When successful, this provides a supportive working environment for staff and has a positive impact on patient care and outcomes. The purpose of this study was to explore how knowledge/evidence is acquired, shared, and applied in the Critical Care (CC) environment for staff and patients/family members. A qualitative approach was used, consisting of semi-structured interviews and focus groups. Data analysis was conducted using an iterative thematic approach. Data collected prior to the COVID-19 pandemic from United Kingdom (UK) critical care workers (N=46), patients, and family members (N=21) identified four communication roles performed by the nursing staff: team member; diplomat; translator and friend. It was evident that without suitable training and support, the stresses and demands placed upon the nurses could lead to disenfranchisement and burnout. These findings are relevant and timely given the impact of the pandemic, highlighting the need for accessible and alternate communication strategies to support nurses by reducing stress, moral distress and increasing psychological safety. Improved communication can provide tailored information for staff and patients/family improving the CC experience for all.

Improving Healthcare with a world perspective

The COVID-19 pandemic has caused severe issues, including loss of quality of life, negative economic impacts and, most of all, exposed weaknesses in health systems.&#x0D; A major weakness was the inability to respond to population needs during a pandemic, especially vulnerable groups, as well as supporting the impacts on mental health and increase in poverty,&#x0D; Research on how to redistribute high-quality healthcare to develop early diagnosis and treatment will be most welcome.&#x0D; Also, new evidence on how to strengthen primary healthcare for the elderly, especially those with chronic diseases and those at risk of severe complications.&#x0D; Efforts should be made to strengthen evidence on infection control and support and protect critical care workers and healthcare workers on the front lines of emergency, as well as on how to improve the training of human resources at the grassroots and the use of diagnostics technology at local level.&#x0D; Evidence on successful processes of upgrading health data systems and the usage of digital data, smartphone applications for quarantine monitoring, robotic devices, and artificial intelligence to track the origin and spread of infections. spread and spread of the virus, should also be welcome..&#x0D; Finally, we should appeal for further evidence on improving the effectiveness of vaccination and promote access to international cooperation, avoid barriers to the intellectual property transfer and intellectual property and approach multilateral licensing commitments,.&#x0D; The Covid - 19 pandemic has brought great lessons and it is a lever for a profound change in the way we develop healthcare learning from a shared world perspective. In short, we should support the process of generating evidence on innovation for global healthcare improvements.

Psychological Impact of the Very Early Beginning of the COVID-19 Outbreak in Healthcare Workers: A Bayesian Study on the Italian and Swiss Perspectives.

BackgroundWe investigated the COVID19-related psychological impact on healthcare workers in Italy and in Italian-speaking regions of Switzerland, three weeks after its outbreak. All professional groups of public hospitals in Italy and Switzerland were asked to complete a 38 questions online survey investigating demographic, marital and working status, presence of stress symptoms and need for psychological support.ResultsWithin 38 h a total of 3,038 responses were collected. The subgroup analysis identified specific categories at risk according to age, type of work and region of origin. Critical care workers, in particular females, reported an increased number of working hours, decline in confidence in the future, presence of stress symptoms and need for psychological support. Respondents reporting stress symptoms and those with children declared a higher need for psychological support.ConclusionsThe large number of participants in such a short time indicates for a high interest on topic among health-care workers. The COVID19 outbreak has been experienced as a repeated trauma for many health-care professionals, especially among female nurses' categories. Early evidence of the need of implementating short and long-term measures to mitigate impact of the emotional burden of COVID-19 pandemic are still relevant.

Investigating the psychological impact of COVID-19 on healthcare workers in the intensive care unit

Background/Aim: The disease caused by the SARS-CoV-2 virus, COVID-19, has become the first viral disease outbreak defined as a pandemic in the 21st century. Experience with previous endemics shows that critical care workers disproportionately suffer from depression and anxiety after facing such outbreaks; however, data are limited regarding the early phase of spread. Our aim was to investigate depression and anxiety in healthcare workers employed in ICUs during the initial phase of COVID-19 spread in Istanbul, Turkey, and possible relationships with various characteristics of healthcare workers. Methods: This cross-sectional study evaluated descriptive and demographic characteristics, professions, COVID-19-related perceptions, depression and anxiety in healthcare workers from the 12 ICUs of six hospitals located in Istanbul, Turkey. The Beck Depression (Beck-D) and Anxiety (Beck-A) Inventories and the State-Trait Anxiety Inventory (STAI) TX-I and TX-II were used to assess depression and anxiety. Employees that worked in ICUs were included, regardless of profession, ICU type (neonatal/pediatric or adult), age, education and working status. We compared recorded data among employees with regard groups based on ICU type, sex, education status, profession, marital status, children, cohabiting status, and whether they were residing at their home. Additionally, multivariable regression analyses were performed to identify factors that were independently associated with scores obtained from the depression and anxiety scales. Results: A third of the studied population were found to have moderate-to-severe levels of depression and anxiety according to the Beck-D and Beck-A scales. The STAI TX-I scores were similar in all comparison groups except for significantly higher scores in participants living with their family/friends (P=0.027). STAI TX-II scores were higher in pediatric/neonatal ICU workers (P=0.001), nurses (P=0.002), employees without children (P=0.046), and those residing in their home (P=0.031). Beck-D scores were higher in nurses (P=0.001), those with lower education (P=0.025), subjects without children (P=0.008) and individuals living with their family/friends (P=0.002). Beck-A scores were higher in participants with lower education (P=0.001), nurses (P<0.001), those without children (P=0.049), subjects living with their family/friends (P=0.001), and those not residing in their home (P=0.003). There were only weak correlations between COVID-19-related perceptions and scale scores. Multivariable regression showed that being a physician and living alone were independently associated with lower Beck-D and Beck-A scores. Conclusion: The psychological impact of COVID-19 seems to be unassociated with disease-related perceptions during the early spread of disease, but about a third of ICU employees were found to have clinically-relevant levels of depression and anxiety. Our results show that nurses should receive continuous mental assessment and support, and that ICU employees may benefit from being provided with accommodation when caring for patients with diseases such as COVID-19.

Psychological crisis and emergency intervention for frontline critical care workers during the COVID-19 pandemic.

To explore the main feelings and coping strategies among frontline critical care workers during the first phase of the COVID-19 pandemic and to evaluate the level of satisfaction after a psychological crisis and emergency intervention. The health crisis brought about by the COVID-19 pandemic has exposed critical care workers to an intense physical and emotional burden. Scientific research recommends psychological crisis and emergency interventions during the acute phase to help cope with the situation and prevent emotional side effects. A multicentre descriptive study with mixed qualitative and quantitative data was developed. Healthcare and non-healthcare critical care workers from 16hospitals were included. Psychological crisis assistance was given (for individuals and groups), both face-to-face and online, with 18psychologists for two months. Content analysis from the psychologists' session reports after each intervention was performed (COREQ). Satisfaction with the intervention was assessed with an 'ad hoc' 21-item online survey. A total of 553 interventions were carried out (361 individually and 192 in groups). Four themes were identified: 1-Imbalance between occupational demands and resources; 2-Acute stress responses; 3-Personal and professional consequences; and 4-Protection factors. The main protection factor identified was group cohesion and perceived social support. The mean general satisfaction with the intervention was high and 96.2% (n=252) of the participants would recommend it in future. A psychological crisis and emergency intervention helped critical care workers during the COVID-19 pandemic to verbalise and integrate the situation, providing strategies to cope with the experience with a high level of satisfaction from the participants assisted. During the COVID-19 pandemic, support groups guided by psychologists fostered reflection on aspects related to work, interaction with patients and relatives and social support from workmates that help them for coping with stress, share emotions and experiences and feel understood.

Critical Care Workers Have Lower Seroprevalence of SARS-CoV-2 IgG Compared with Non-patient Facing Staff in First Wave of COVID19.

IntroductionIn early 2020, at first surge of the coronavirus disease 2019 (COVID-19) pandemic, many health care workers (HCW) were re-deployed to critical care environments to support intensive care teams looking after patients with severe COVID-19. There was considerable anxiety of increased risk of COVID-19 for these staff. To determine whether critical care HCW were at increased risk of hospital acquired infection, we explored the relationship between workplace, patient facing role and evidence of immune exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within a quaternary hospital providing a regional critical care response. Routine viral surveillance was not available at this time.MethodsWe screened over 500 HCW (25% of the total workforce) for history of clinical symptoms of possible COVID19, assigning a symptom severity score, and quantified SARS-CoV-2 serum antibodies as evidence of immune exposure to the virus.ResultsWhilst 45% of the cohort reported symptoms that they consider may have represented COVID-19, 14% had evidence of immune exposure. Staffs in patient facing critical care roles were least likely to be seropositive (9%) and staff working in non-patient facing roles most likely to be seropositive (22%). Anosmia and fever were the most discriminating symptoms for seropositive status. Older males presented with more severe symptoms. Of the 12 staff screened positive by nasal swab (10 symptomatic), 3 showed no evidence of seroconversion in convalescence.ConclusionsPatient facing staff working in critical care do not appear to be at increased risk of hospital acquired infection however the risk of nosocomial infection from non-patient facing staff may be more significant than previous recognised. Most symptoms ascribed to possible COVID-19 were found to have no evidence of immune exposure however seroprevalence may underrepresent infection frequency. Older male staff were at the greatest risk of more severe symptoms.

Hospital Collaboration in Response to the COVID-19 Pandemic in Kansas City Metropolitan Region

IntroductionSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2, aka COVID-19) virus has evolved into a World Health Organization-declared pandemic which has strained our regional critical care and hospital resources.MethodsA Critical Care Task Force was established between Kansas City area intensive care units to allow for preparedness for potential surges by sharing of bed capacity both in the ICU and hospital, and ventilator capacity as well as weekly web-based meetings to share resource concerns and best practice. This Task Force also collected patient information to understand the dynamics of community impact and resource needs better. This effort allowed for compilation and dissemination of information regarding data that describe characteristics of patients with COVID-19 compared to a random sample of medical ICU patients with conditions other than COVID-19.Demographic and therapeutic factors affecting patients admitted to medical intensive care units in the Kansas City metro area are reported from May 5, 2020 until June 2, 2020 using a retrospective case-control study examining gender, race, and therapeutic options including modes of ventilation, vasopressor requirements, renal-replacement therapy, and disposition.ResultsDuring data collection, patients being treated for COVID-19 in intensive care units in the Kansas City metropolitan area were more likely to be older, less likely to be white, and less likely to be immunosuppressed as compared to those being treated for non-COVID illnesses. They were more likely to require non-invasive ventilation and undergo prone positioning but were equally likely to require invasive ventilation and other organ supportive therapy.ConclusionsHospitalized patients being treated for COVID-19 in the Kansas City metropolitan area have similar demographics to those being reported in the U.S. including age and race. Additionally, establishing a Critical Care Task Force in response to the pandemic allowed for preparation for a potential surge, establishing capacity, and disseminating timely information to policy makers and critical care workers on the front line.

Severe Acute Respiratory Syndrome Coronavirus-2 Infections in Critical Care Staff: Beware the Risks Beyond the Bedside.

Critical care workers were considered to be at high risk of severe acute respiratory syndrome coronavirus-2 infection from patients during the first wave of the pandemic. Staff symptoms, previous swab testing, and antibody prevalence were correlated with patient admissions to investigate this assumption. Cross-sectional study. A large critical care department in a tertiary-care teaching hospital in London, United Kingdom. Staff working in critical care. None. Participants completed a questionnaire and provided a serum sample for severe acute respiratory syndrome coronavirus-2 antibody testing over a 3-day period in April 2020. We compared the timing of symptoms in staff to the coronavirus disease 2019 patient admissions to critical care. We also identified factors associated with antibody detection. Of 625 staff 384 (61.4%) reported previous symptoms and 124 (19.8%) had sent a swab for testing. Severe acute respiratory syndrome coronavirus-2 infection had been confirmed in 37 of those swabbed (29.8%). Overall, 21% (131/625) had detectable severe acute respiratory syndrome coronavirus-2 antibody, of whom 9.9% (13/131) had been asymptomatic. The peak onset of symptoms among staff occurred 2 weeks before the peak in coronavirus disease 2019 patient admissions. Staff who worked in multiple departments across the hospital were more likely to be seropositive. Staff with a symptomatic household contact were also more likely to be seropositive at 31.3%, compared with 16.2% in those without (p < 0.0001). Staff who developed coronavirus disease 2019 were less likely to have caught it from their patients in critical care. Other staff, other areas of the hospital, and the wider community are more likely sources of infection. These findings indicate that personal protective equipment was effective at preventing transmission from patients. However, staff also need to maintain protective measures away from the bedside.

An in vitro visual study of fugitive aerosols released during aerosol therapy to an invasively ventilated simulated patient

COVID-19 can cause serious respiratory complications resulting in the need for invasive ventilatory support and concurrent aerosol therapy. Aerosol therapy is considered a high risk procedure for the transmission of patient derived infectious aerosol droplets. Critical-care workers are considered to be at a high risk of inhaling such infectious droplets. The objective of this work was to use noninvasive optical methods to visualize the potential release of aerosol droplets during aerosol therapy in a model of an invasively ventilated adult patient. The noninvasive Schlieren imaging technique was used to visualize the movement of air and aerosol. Three different aerosol delivery devices: (i) a pressurized metered dose inhaler (pMDI), (ii) a compressed air driven jet nebulizer (JN), and (iii) a vibrating mesh nebulizer (VMN), were used to deliver an aerosolized therapeutic at two different positions: (i) on the inspiratory limb at the wye and (ii) on the patient side of the wye, between the wye and endotracheal tube, to a simulated intubated adult patient. Irrespective of position, there was a significant release of air and aerosol from the ventilator circuit during aerosol delivery with the pMDI and the compressed air driven JN. There was no such release when aerosol therapy was delivered with a closed-circuit VMN. Selection of aerosol delivery device is a major determining factor in the release of infectious patient derived bioaerosol from an invasively mechanically ventilated patient receiving aerosol therapy.

Investigation of Burnout, its Associated Factors and its Effect on the Quality of Life of Critical Care Nurses Working in Buraydah Central Hospital at Qassim Region, Saudi Arabia

Background:Burnout is a grave problem for critical care workers because they are exposed to prolonged psychosocial stressors, including advanced technology, high responsibilities and great patient acuity. The aim of this study was to investigate burnout, its associated factors and its effect on self-care among critical care nurses.Methods:A descriptive correlational research design was carried out with 170 critical care nurses at Buraydah Central Hospital at Qassim Region in Saudi Arabia. A self-administered questionnaire including socio-demographic and work-related characteristics was used, as well as the Short Form SF12 to assess the quality of life, and the Maslach Burnout Inventory (MBI) to assess the level of burnout.Results:The three Maslach Burnout Inventory subscales, high emotional exhaustion and depersonalization, low personal accomplishment and moderate total burnout score were used. The quality of life measure (sF12) showed moderate levels of physical, mental component score and total score of quality for the critical care nurses. Factors associated with burnout include age, nationality, and years of experience and the wish to change department showed statistical significance. Burnout and quality of life score had a significant negative correlation.Conclusion:Age, nationality, years of experience and wish to change department are all significantly associated with burnout. Finally, burnout and quality of life score of these critical care nurses had a negative significant correlation.

How do critical care staff respond to organisational challenge? A qualitative exploration into personality types and cognitive processing in critical care.

Critical care staff are frequently required to respond to stressful scenarios. The way staff counter organisational challenge may be influenced by their underlying personality type, preferred style of cognitive processing and previous clinical experience. Our objective was to explore the personality types of a sample of critical care workers, and the potential relationship of this with cognitive processing. This was achieved through a qualitative interview study in which participants were presented with difficult but realistic scenarios pertaining to staffing. Data on individual’s personality were captured using the ‘16 Personality Factor’ assessment, a tool that produces scores for 16 different elements of an individual’s personality. The existence of perfectionist and pragmatic cognitive processing styles were identified as one theme emerging from a prior analysis of these interview transcripts. We aimed to validate this, explore our ability to categorise individuals into groups based upon their cognitive processing. We identified that some individuals strongly tended to either a perfectionist or pragmatic style of cognitive processing for the majority of their decisions; however most adapted their style of processing according to the nature of the decision. Overall participants generally demonstrated average scores for all 16 personality factors tested. However, we observed that some factors tended to higher scores than others, indicating a pattern within the personalities of our sample cohort. Whilst a small sample size, our data suggests that individuals working within the same critical care environment may have clear differences in their approach to problem solving as a consequence of both their personality type and preferred style of cognitive processing. Thus there may be individuals within this environment who would benefit from increased support to minimise their risk of cognitive dissonance and stress in times of challenge.

Severe burnout among critical care workers in Turkey.

Objectives:To determine the prevalence and risk factors for burnout in the intensive care units (ICU) staff in Turkey. Burnout is prevelant in physicians and nurses in the ICU worldwide. Most ICU workers with burnout plan to leave their professions. Frequent replacement of ICU staff increases cost and decreases the quality of care. Prevalence and risk factors of burnout in ICU staff in Turkey are largely unknown.Methods:This is a cross-sectional study. Data were gathered using the Maslach Burnout Inventory (MBI) which was distributed during August 2018, among all 1161 ICU workers in Turkey.Results:Burnout was detected in at least one subscale in 99% of participants and in all 3 subscales in 15% of the participants. Risk factors for emotional exhaustion included female gender (odds ratio [OR]=1.87 [95% CI: 1.26-2.78]; p<0.01), alternate-day shift (OR=3.93 [95% CI: 1.66-9.30]; p<0.01), and incidence of end of life care (OR=1.01 [95% CI: 1.00-1.03]; p<0.01). For depersonalization it included alternate-day shift (OR=2.22 [95% CI: 1.15-4.26]; p<0.05), incidence of end of life care (OR=1.02 [95% CI: 1.01-1.03]; p<0.01), and for reduced personal accomplishment it included incidence of end of life care (OR=0.97 [95% CI: 0.96-0.98]; p<0.01).Conclusion:The results indicated that ICU staff in Turkey had a high rate of burnout.

Virtuous laughter: we should teach medical learners the art of humor.

There is increasing recognition of the stress and burnout suffered by critical care workers. Physicians have a responsibility to teach learners the skills required not only to treat patients, but to cope with the demands of a stressful profession. Humor has been neglected as a strategy to help learners develop into virtuous and resilient physicians. Humor can be used to reduce stress, address fears, and to create effective health care teams. However, there are forms of humor which can be hurtful or discriminatory. In order to maximize the benefits of humor and to reduce its harms, we need to teach and model the effective and virtuous use of humor in the intensive care unit.

Perceived barriers to therapeutic hypothermia for patients resuscitated from cardiac arrest: A qualitative study of emergency department and critical care workers*

To identify the barriers to implementation of mild therapeutic hypothermia for adult survivors of cardiac arrest. Despite scientific evidence to support therapeutic hypothermia for resuscitated cardiac arrest patients, it is inconsistently and at times inadequately used. Qualitative study, using semistructured interviews. A stratified random sample of 14 sites from an established network of 43 hospitals, including both community and tertiary care centers in Southern Ontario, Canada. Twenty-one intensive care unit and emergency department physicians and nurses. None. Purposive sampling was used to interview individuals who were most likely to be involved in the implementation and evaluation of the hypothermia protocol. All interviews were conducted by telephone by a clinician and a qualitative researcher. Interviews were recorded electronically and transcribed unless the participant declined to have the interview recorded. Untranscribed interviews were recorded as field notes and as direct quotations. New interviews were conducted until thematic saturation occurred. The analysis was completed through three phases of coding. Respondents identified lack of familiarity and availability of concrete therapeutic hypothermia protocols and process issues as the most frequent barriers. Process concerns included availability of equipment, equipment costs, and high workload demands for emergency nurses. Other barriers identified were variable nursing awareness, variable staff uptake, lack of agreement with supporting evidence, lack of interdisciplinary collaboration between the intensive care unit and emergency department, lack of interprofessional education between nurses and physicians, and challenges inherent in applying an intervention infrequently. This study demonstrated that the systematic adoption of a new intervention, therapeutic hypothermia, is met with interdependent generic, local, and individual barriers. A working awareness of the types of barriers that exist at multiple sites will assist in targeting specific knowledge translation strategies to improve adherence to evidence-based practice.

Critical Decisions in Emergency and Acute Care Electrocardiography. By William J. Brady and Jonathon D. Truwit

Critical Decisions in Emergency and Acute Care Electrocardiography. By William J. Brady, and Jonathon D. Truwit. . Wiley-Blackwell Publishing Ltd. 2009. ISBN: 978-1-4051-5906-7 This ECG manual is a collection of cases and clinical reviews, based around a number of relevant questions about ECG in a variety of acute situations. It is primarily aimed at critical care workers but has also value as a reference work for cardiologists, internists, and fellows. The book is divided into several parts, dealing with central themes: the value of ECG in clinical practice, cardinal clinical presentations, the acute coronary syndromes, dysrhythmias, critical … E-mail: y.vanbelle{at}erasmusmc.nl