Iranian Intensive Care Units Research Articles

Investigating Criteria for Weaning from Ventilators in Iran: A Systematic Review

Objectives: This systematic review was conducted to evaluate optimal techniques for weaning patients in Iranian intensive care units from ventilator support. Methods: Following PRISMA 2020 guidelines, studies on Iran's latest ventilator weaning methods were examined. Two researchers independently assessed the studies after transferring the studies to EndNote software and eliminating duplicates. A third collaborator resolved any disagreements and made the final decision. The evaluation encompassed primary, secondary, qualitative assessment, and data extraction stages. Results: The initial database search identified 1103 potentially relevant articles and was managed using EndNote software. After excluding 235 duplicates, screening based on title and abstract led to the exclusion of 457 articles from the remaining 868. During eligibility evaluation, 402 articles were excluded from 411 studies after thoroughly examining the complete text, aligning with inclusion and exclusion criteria. The qualitative assessment, guided by STROBE and CONSORT checklists, found all nine remaining studies satisfactory methodological quality. Consequently, these nine studies were included in the final analysis. Conclusions: Prioritizing, identifying, and implementing strategies for successful mechanical ventilation weaning is crucial for research and quality improvement. This study systematically reviewed the evidence on diverse methods to enhance ventilator weaning success in Iran. Nevertheless, additional studies are warranted to further ascertain ventilator-weaning strategies' effectiveness.

Psychometric validation of the Persian version of the ethical awareness scale for nurses working in Iranian intensive care units.

The purpose of this study was to translate and validate the ethical awareness scale for nurses working in Iranian intensive care units. A cross-sectional psychometric study. The study was conducted in Oct 2020 to Sep 2021, involving the participation of 200 ICU nurses. The process included translation of the original version of the ethical awareness scale into Persian, following the World Health Organization guideline, for use in Iran. The translated version was then evaluated for reliability, face validity, content validity ratio, content validity index, convergent validity and construct validity. The initial reliability of the scale was established. In qualitative face validity, a few items changed slightly and all items were retained in the quantitative face validity assessment. Based on Lawshe's values, three items were removed from the scale during CVR assessment. All items exhibited acceptable CVI scores. Convergent validity was established with an average variance extracted greater than 0.5. The fit indices, such as CFI = 0.94, GFI = 0.94, RMSEA = 0.01, AGFI = 0.97 and CMIN/DF = 2.99, supported the structural model of the scale. The fit indices for the structural model of the scale were all within acceptable ranges, suggesting that the model fit the data well. Its reliability was confirmed through the test-retest method, with Cronbach's alpha = 0.84 and McDonald's omega coefficient >0.8. The findings of this study indicate the Persian version of the ethical awareness scale for Iran (EAS-IR) is comparable in content to the original version, demonstrating its validity and reliability for assessing ethical awareness among Iranian nurses in ICUs. The scale can be a valuable resource for measuring ethical awareness in the Iranian healthcare context and may contribute to improving ethical practices and decision-making in ICU settings. In this project, no patient or public contribution was necessary, because it was not applied to our work.

Oral status and affecting factors in Iranian ICU patients: a cross-sectional study

BackgroundOral care is crucial in intensive care units (ICUs). Meanwhile, this action is not well-performed, therefore, mouth cavity-associated disorders cause serious outcomes, e.g. ventilator-dependent pneumonia. Considering a lack of studies in Iran on this subject, this study aimed to determine the oral status and affected factors in ICU patients in Iran.MethodsIn a cross-sectional study in 2019, we assessed the oral status of 138 patients admitted to the ICUs in the Kermanshah and Ilam provinces by census method. The tools were a demographic and clinical characteristics checklist, and Beck's oral status assessment scale (BOAS). The researcher investigated the condition of the patient's mouth, and their records. Data were analyzed using descriptive and inferential statistics.ResultsIn this study, the prevalence of moderate and severe disorders of the lips, gums and oral mucosa, tongue, teeth, and saliva were 14.4, 26.1, 16.6, 49.3, and 34.8 percent, respectively. Six percent of patients had a normal oral condition. Oral status had a significant relationship with education level, age, marital status, brushing teeth, NG tube, and consciousness level.ConclusionCompared to other studies, the prevalence of oral cavity disorders in ICU patients of the Ilam and Kermanshah provinces was high. It mandates paying crucial attention to nurses' continued education, using standard guidelines, and applying new facilities. Moreover, it is mandated for periodical visits of patients by a dentist in ICUs.

Changes in PD-1- and CTLA-4-bearing blood lymphocytes in ICU COVID-19 patients treated with Favipiravir/Kaletra or Dexamethasone/Remdesivir: a pilot study.

COVID-19, caused by SARS-CoV-2, requires new approaches to control the disease. Programmed cell death protein (PD-1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) play important roles in T-cell exhaustion in severe COVID-19. This study evaluated the frequency of whole blood lymphocytes expressing PD-1 and CTLA-4 in COVID-19 patients upon admission to the intensive care unit (ICU) (i.e., severe) or infection ward (i.e., moderate) and after 7 days of antiviral therapy. COVID-19 patients were treated with either favipiravir or Kaletra (FK group, 11 severe and 11 moderate) or dexamethasone plus remdesivir (DR group, 7 severe and 10 moderate) for 7 days in a pilot study. Eight healthy control subjects were also enrolled. The frequency of PD-1+ and CTLA-4+ lymphocytes in whole blood was evaluated by flow cytometry. Patients on DR therapy had shorter hospital stays than those on FK therapy. The frequency of PD-1+ lymphocytes in the FK group at baseline differed between COVID-19 patients and healthy controls, while the frequency of both PD-1+ and CTLA-4+ cells increased significantly 7 days of FK therapy. The response was similar in both moderate and severe patients. In contrast,the frequency of PD-1+ and CTLA-4+ lymphocytes varied significantly between patients and healthy controls before DR treatment. DR therapy enhanced PD-1+ but not the CTLA-4+ frequency of these cells after 7 days. We show that the frequency of PD-1 and CTAL-4-bearing lymphocytes during hospitalization was increased in Iranian ICU COVID-19 patients who received FK treatment, but that the frequency of CTLA-4+ cells was higher at baseline and did not increase in patients who received DR. The effectiveness of DR treatment may reflect differences in T-cell activation or exhaustion status, particularly in CTLA-4-expressing cells.

Medication Errors among Iranian Intensive Care Nurses: A Systematic Review.

Medication Error (ME) is a major patient safety concern in Intensive Care Units (ICUs). Critical care nurses play a crucial role in the safe administration of medication. This study was conducted to comprehensively review the literature concerning the prevalence of ME and associated factors and outcomes in Iranian ICU nurses. An extensive search of the literature was carried in international databases including PubMed, Web of Science, Scopus, and Google Scholar, as well as Persian databases such as Magiran and Scientific Information Database (SID) using ME-related keywords and the Persian equivalent of these keywords, from the first article written in this field to artcles published on March 30, 2021. The appraisal tool (AXIS tool) was used to assess the quality of the included studies. Fifteen studies were included in this systematic review. The prevalence of MEs made by ICU nurses was 53.34%. The most common types of MEs were wrong infusion rate (14.12%), unauthorized medication (11.76%), and wrong time (8.49%) errors, respectively. MEs occurred more frequently in morning work shifts (44.44%). MEs happened more frequently for heparin, vancomycin, ranitidine, and amikacin. The most important influential factor in the occurrence of MEs in ICUs was management and human factors. The prevalence of MEs made by Iranian ICU nurses is high. Therefore, nurse managers and policymakers should develop appropriate strategies, including training programs, to reduce the occurrence of MEs made by nurses in ICUs.

Knowledge, attitude, and practice of Iranian critical care nurses related to prevention of pressure ulcers: A multicenter cross-sectional study

IntroductionPressure ulcers (PU) are a major, but preventable health problem in all health settings, but especially in intensive care units (ICUs). This study aimed to investigate the knowledge, attitude, and practice (KAP) of Iranian ICU nurses related to the prevention of PU. MethodsIn a cross-sectional study, data obtained from 183 ICU nurses working in four hospitals affiliated to Mazandaran University of Medical Sciences, Sari, Iran were evaluated. The study was conducted from July to October 2020. Data were collected using a four-part questionnaire including demographic characteristics, Pieker Pressure Ulcer Knowledge Test (PPUKT), Attitude toward Pressure Ulcer Prevention (APUP) tool, and the practice of nurses related to the prevention of PU. FindingsThe mean scores of KAP of ICU nurses toward PU prevention were 70.57 (SD = 13.51), 52.82 (SD = 6.16), and 22.44 (SD = 5.20), respectively. There was a positive correlation between nurses' attitude and practice (r = 0.232, P = 0.002), and a negative correlation between knowledge and attitude (r = −0.156, P = 0.035) of nurses regarding PU prevention. Additionally, a positive correlation was found between nurses' years of working experience in ICU and their knowledge regarding PU prevention (r = 0.159, P = 0.032). ConclusionAccording to the results of the present study, the level of KAP of Iranian ICU nurses related to PU prevention were desirable, positive, and relatively desirable. Therefore, nurse managers and policymakers should try to eliminate the main barriers such as heavy workload, inadequate nurse staffing, and lack of appropriate guidelines for PU prevention which consequently affect the practice of ICU nurses in the prevention of PU.

Translation and adaptation of the modified NUTRIC score for critically ill patients.

Some critically ill patients are at high nutritional risk, and early identification of these patients is needed to reduce morbidity and mortality related to underfeeding. The Modified NUTrition Risk in Critically ill (mNUTRIC) score is the first nutritional risk assessment tool developed and validated specifically for ICU patients. This study aims to translate and adapt the Modified NUTRIC (mNUTRIC) Score into Persian to facilitate use in Iranian Intensive Care Units and assess its efficiency in a pilot sample. The translation process followed standardized steps: initial translation, synthesis of translations, back -translation to the English language, revision and cultural adaptation of the tool by language specialist and expert committee. A pilot study was conducted on the application of the tool in 46 critically ill patients from three ICUs in Iran hospitals. The translation and adaptation process generated a feasible version of the mNUTRIC Score in the Persian language.The translated version was easily introduced into Iranian ICUs. The prevalence of patients with a mNUTRIC score of five or more was 43% (n=46). Translation of mNUTRIC Score from English into Persian, following internationally accepted methodology, has provided the ICU care in Iran with a comprehensive and useful instrument.

Comparison of Modified NUTRIC, NRS-2002, and MUST Scores in Iranian Critically Ill Patients Admitted to Intensive Care Units: A Prospective Cohort Study.

There are no data on the validity of the modified Nutrition Risk in the Critically Ill (m-NUTRIC)-score and Nutritional Risk Screening 2002 (NRS-2002)-score in Iranian intensive care unit (ICU) patients. The Malnutrition Universal Screening Tool (MUST) is still used in most Iranian ICUs. Our goal was to test the validity of these tools in the Iranian ICU population. The association between nutrition risk scores and outcomes (longer length of stay [LOS], prolonged mechanical ventilation [MV], and 28-day mortality) was assessed using the multivariable logistic regression. The performance of nutrition risk tools to predict 28-day mortality was assessed using the receiver operating characteristic curve. A logistic regression model was used to test the interaction between nutrition risk category, energy adequacy, and 28-day mortality. Four hundred forty patients were included. Both the m-NUTRIC and NRS-2002 scores were significantly associated with all 3 outcomes (all P < .001). However, no significant association was identified between the MUST and all 3 outcomes (P > .05). The area under the curve for predicting 28-day mortality was 0.806 (95% CI, 0.756-0.851), 0.695 (95% CI, 0.632-0.752), and 0.551 (95% CI, 0.483-0.612) for m-NUTRIC, NRS-2002, and MUST, respectively. Greater energy adequacy was associated with a lower 28-day mortality rate in patients with high m-NUTRIC but not in those with low m-NUTRIC score (P interaction = .015). In the Iranian ICU population, the m-NUTRIC score may be a valid tool for identifying patients who would benefit from more aggressive nutrition therapy.

Prevalence of pressure ulcer in Iran's intensive care units: A systematic review and meta-analysis

Background &amp; Aim: Pressure ulcer (PU) is a costly, painful, and often a preventable problem with varying prevalence in different health centers. PU is associated with prolonged length of stay and mortality. This systematic review and meta-analysis aimed to estimate the prevalence of PU in Iran’s intensive care units (ICUs). Methods &amp; Materials: In this research, 9 articles published in Persian and English were studied. National (Science Information Database (SID) and Magiran) and international databases (PubMed, Scopus, and Web of Science) were searched using the keywords of pressure ulcers, bedsore, pressure sore, decubitus ulcer, pressure injury, Iran, and all of the possible combinations without time limitations. Results: The total prevalence of PU in Iran’s ICUs was 19.59% (95% confidence interval [CI]: 13.15-25.97). The prevalence of PU in region 1 of the country (Alborz, Tehran, Qazvin, Mazandaran, Semnan, Golestan, and Gom) was 28.55% (95% CI: 12.27-44.84), and it was 10.31 (95% CI: 3.88-16.75) in other areas of the country. Meta-regression results showed a significant relationship between the prevalence of PU and the mean age of the patients (P=0.012) as well as the study sample size (P=0.043). Conclusion: We found that the overall prevalence of PU in Iran’s ICUs was relatively high. Considering the high prevalence of PU in Iranian ICUs, it seems necessary to investigate and implement effective interventions to control and reduce this problem.

Nutritional care and balance of energy in patients hospitalized in Iranian intensive care units

Abstract Objective Malnutrition is a concerning problem among hospitalized patients in intensive care units (ICU S ): it can lead to increase infection, hospital costs and mortality. Inadequate energy intake is one of the most important risk factors in the etiology of malnutrition during the hospital stay. The aim of this study was to assess nutritional care and energy balance in patients hospitalized in Iranian intensive care units. Methods This study was conducted on 124 patients in two general hospitals in Amol, a city in the north of Iran, from May 2015 to February 2016. Anthropometric indices such as mid-arm muscle circumference (MAMC), mid-upper-arm circumference (MUAC), triceps skinfold thickness (TSF) and calf circumference were measured at admission and discharge. Energy and protein needs and intake were measured daily during each patient's ICU stay. Two questionnaires — Subjective Global Assessment (SGA) and Sequential Organ Failure Assessment (SOFA) — were used to assess nutritional status. Results Formula made in-house was the main formula for tube feeding in Iran's hospitals. The energy and protein intake of patients in ICU S was significantly less than their requirements. The rate of malnutrition was 39.6% on admission and 83.1% on discharge, based on the SGA and mean SOFA score, which decreased significantly during patients’ ICU stay. All of the patients’ anthropometric measurements decreased significantly during their ICU stay. Conclusions The present study showed that nutrition support for Iranian ICUs patients was inappropriate. A consideration of nutritional care to prevent malnutrition and other complications is necessary in ICU S .

Development of a national core dataset for the Iranian ICU patients outcome prediction: a comprehensive approach

ObjectiveTo define a core dataset for intensive care unit (ICU) patients outcome prediction in Iran. This core data set will lead us to design ICU outcome prediction models with the...

Nutritional Care in Iranian Intensive Care Units.

Intensive care units (ICUs) provides intensive treatment medicine to avoid complications such as malnutrition, infection and even death. As very little is currently known about the nutritional practices in Iranian ICUs, this study attempted to assess the various aspects of current nutrition support practices in Iranian ICUs. We conducted a cross-sectional study on 150 critically ill patients at 18 ICUs in 12 hospitals located in 2 provinces of Iran from February 2015 to March 2016. Data were collected through interview with supervisors of ICUs, medical record reviews and direct observation of patients during feeding. Our study showed that hospital-prepared enteral tube feeding formulas are the main formulas used in Iranian hospitals. None of the dietitians worked exclusively an ICU and only 30% of patients received diet counselling. Regular monitoring of nutritional status, daily energy and protein intake were not recorded in any of the participating ICUs. Patients were not monitored for anthropometric measurements such as mid-arm circumference (MAC) and electrolyte status. The nasogastric tube was not switched to percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEGJ) in approximately 85% of patients receiving long-term enteral nutrition (EN) support. Our findings demonstrated that the quality of nutritional care was inappropriate in Iranian ICUs and improvement of nutritional care services within Iranian ICUs is necessary.

The Meaning of Managerial Competency of ICU Head Nurses in Iran: A Phenomenological Study.

Background:The health system in Iran faces specific challenges as the managerial role of head nurses have changed. The importance of this role cannot be underestimated for the healthcare organizations' success. The present study was conducted to explore the meaning of managerial competence of head nurses in intensive care units (ICU) in Iran.Materials and Methods:This study used a qualitative approach. We extracted the lived experience of ten Iranian ICU head nurses. Data were collected through unstructured in-depth interviews from 2014 to 2015. Interviews were recorded and transcribed verbatim and were interpreted using Van Manen's six-step approach.Results:The expansion and clustering of 442 initial themes led to the emergence of 35 secondary themes, nine subthemes, and three main themes. Managerial competence – theme included “self-excellence,” “ward excellence,” and “intensive care excellence.”Conclusions:The “managerial competence of ICU head nurses” is a dynamic concept that reflects the psychological and functional capability of head nurses in contributing towards excellence in their own critical care practice as well as that of the ward. A competent head nurse has outstanding personal and nursing attributes and holistic knowledge, and is also committed to the ongoing professional improvement of him/herself. Using their ability to facilitate interpersonal and interprofessional communication effectively, a head nurse seeks the psychological, physical, and human optimization of the ward in which he/she works. Therefore, the goal of providing insightful critical care through smart organization and planning of nurses and other personnel can be achieved.

The Content of Plasma Selenium in Early Admitted Septic Patients.

Objective:Selenium depletion has been reported in critical illness correlates with an increase in mortality and morbidity. In this study, we aimed to access the selenium plasma levels of septic patients early at the Intensive Care Unit (ICU) admission in order to compare with reference range.Methods:We conducted a cross-sectional study in a university affiliated hospital aiming to assess the early plasma level of selenium in ICU admitted patients. eighty patients diagnoses with sepsis were included and considered for characteristic evaluation, monitoring criteria assessment and also blood sampling. All blood sampling was performed during 48 hours of the ICU admission in order to determined the plasma Selenium level by atomic absorption method.Findings:The mean plasma levels of selenium in male and female was 98.14 ± 23.52 and 78.1 ± 24.46 μ/L, respectively. Although selenium plasma levels was higher in the ICU male patients significantly, both had near normal range (80 μ/L).Conclusion:In this study we found that in early admitted Iranian ICU patients in Tehran, selenium deficiency has not routinely seen but probably will happen during ICU hospitalization.

A Survey of Adherence to Guidelines to Prevent Healthcare-Associated Infections in Iranian Intensive Care Units.

BackgroundHealthcare-associated infections (HAIs) are acquired by patients while receiving care. The highest incidence of HAIs has been documented in admissions to intensive care units. Adherence to evidence-based practices is the most important step for preventing HAIs.ObjectivesTo determine the rate of adherence to evidence-based post-insertion recommended care practices after admission into the intensive care unit for the following devices: central line catheter, indwelling urinary catheter, and mechanical ventilator.Patients and MethodsA structured observational cross-sectional research design was used. Data were collected using a checklist and a self-report questionnaire. The minimum sample size required for this study was 276 post-insertion care episodes, and 332 episodes were observed. The ANOVA test was used to identify any significant differences among the mean scores of the three devices.ResultsOverall observed adherence rates were 18.3%, 59.1%, and 43.1% for central line catheters, indwelling urinary catheter, and mechanical ventilator, respectively. Of the observed episodes of device care, only in 9.4% of the episodes was regular oral care performed for patients on mechanical ventilators and only in 19.3% of the episodes were indwelling urinary catheters properly secure after insertion. More so, in none (0.0%) of the episodes was the central line catheter hub disinfected before being accessed.ConclusionsEvidence-based post-insertion recommended care practices were not consistently and uniformly implemented in the intensive care units. Establishment of a program for the surveillance of adherence to recommended guidelines is required for improving compliance by health professionals and the quality of preventive care.

Rationales of restricted visiting hour in Iranian intensive care units: a qualitative study.

Today, critical care visitation is considered an important aspect of patient-centred care and its positive effects on patients and their relatives have been demonstrated. However, restricted visiting hours in the intensive care units (ICUs) is often an adopted norm. The reasons for such restricted policies in Iran still remain unknown. The purpose of this study was to identify the rationales for restricted visiting hours in adult ICUs in Iran. A qualitative design using a thematic analysis approach was used for data gathering and analysis. Participants in this study were six nurses, three head nurses, two patients and four visitors. They were chosen through purposive sampling method. Data were gathered through semi-structured individual interviews. The data analysis resulted in three themes: 'health protection', 'safety promotion' and 'privacy preservation'. The result showed that through restricted visiting hours, nurses try to protect vulnerable ICU patients from physical, psychological and legal risk. Although the ICU nurses' concerns seem reasonable in some cases, a review of visiting policies in order to meet the needs of patients and their families is essential. Effective supervision by charge nurses and regulation of environmental activities with visiting hours can resolve many concerns. Health care professionals, especially nurses, are required to create the conditions in which patients' family members are informed about the patients' health status and patients can be visited in suitable ward conditions.

Validity of Integrative Weaning Index of Discontinuation From Mechanical Ventilation in Iranian ICUs

Background: Today, usage of weaning index is a controversial issue. Proper use of these indexes is beneficial for prevention of the losses caused by weaning failure, rapid and reliable identification of patients who are potentially ready for spontaneous breathing and accelerating the weaning of mechanical ventilation. Objectives: This study is to determine the validity of integrative weaning index as a mechanical ventilation discontinuation predictor in patients hospitalized in the Iranian intensive care units. Patients and Methods: This scale was evaluated on 124 adult patients who were on mechanical ventilation for more than 24 hours, in two 24-hour phases, in six ICUs (Surgery-Trauma-Medical-Poisoning) of selected hospitals in Tehran, totaling 60 beds, by the researcher as a single blind test. Inclusion criteria were: Patient 18 to 80 years old, none of them suffering from neurological and neuromuscular diseases, none or a minimal dose of sedative drugs being used (15 - 18 points based on Palma and Cook criteria), non-addict or heavy smokers, not admitted in ICU-OH. The study was conducted from November 2011 to December 2012. The ventilators used were from Rafael brand. Results: There were 80 successful and 44 unsuccessful as well as 72 successful and 8 unsuccessful weaning cases in the first and second phase of the study, respectively. The area under the ROC curves for IWI was 0.967, with standard error of 0.020, 95% Confidence interval of 0.899 to 0.993 and Significance level of P = 0.001, SE = 94.59, SP = 66.67, PPV = 97.22, NPV = 50, DA = 92.5 and likelihood ratio of positive test being 2.84 besides the lowest likelihood ratio of negative test equal to 0.08), with Diagnostic odds ratio being 97% and Confidence interval of 0.82 to 0.97. Conclusions: Integrative weaning index has appropriate predictive validity for weaning patients from mechanical ventilation in Iranian intensive care units.

The culture of patient safety in an Iranian intensive care unit

To explore nurses' and physicians' attitudes and perceptions relevant to safety culture and to elicit strategies to promote safety culture in an intensive care unit. A strong safety culture is essential to ensure patient safety in the intensive care unit. This case study adopted a mixed method design. The Safety Attitude Questionnaire (SAQ-ICU version), assessing the safety climate through six domains, was completed by nurses and physicians (n = 42) in an academic intensive care unit. Twenty semi-structured interviews and document analyses were conducted as well. Interviews were analysed using a framework analysis method. Mean scores across the six domains ranged from 52.3 to 72.4 on a 100-point scale. Further analysis indicated that there were statistically significant differences between physicians' and nurses' attitudes toward teamwork (mean scores: 64.5/100 vs. 52.6/100, d = 1.15, t = 3.69, P < 0.001) and job satisfaction (mean scores: 78.2/100 vs. 57.7/100, d = 1.5, t = 4.8, P < 0.001). Interviews revealed several safety challenges including underreporting, failure to learn from errors, lack of speaking up, low job satisfaction among nurses and ineffective nurse-physician communication. The results indicate that all the domains need improvements. However, further attention should be devoted to error reporting and analysis, communication and teamwork among professional groups, and nurses' job satisfaction. Nurse managers can contribute to promoting a safety culture by encouraging staff to report errors, fostering learning from errors and addressing inter-professional communication problems.

Iranian intensive care unit nurses’ moral distress

Researchers have identified the phenomena of moral distress through many studies in Western countries. This research reports the first study of moral distress in Iran. Because of the differences in cultural values and nursing education, nurses working in intensive care units may experience moral distress differently than reported in previous studies. This research used a qualitative method involving semistructured and in-depth interviews of a purposive sample of 31 (28 clinical nurses and 3 nurse educators) individuals to identify the types of moral distress among clinical nurses and nurse educators working in 12 cities in Iran. A content analysis of the data produced four themes to describe the nurses' moral distress. The four themes were as follows: (a) institutional barriers and constraints; (b) communication problems; (c) futile actions, malpractice, and medical/care errors; (d) inappropriate responsibilities, resources, and competencies. The results demonstrate that moral distress for intensive care unit nurses is different and that the nursing leaders must reduce moral distress among nursing in intensive care.

Ventilator-associated pneumonia in Iranian intensive care units

Nosocomial pneumonia (NP) and ventilator associated pneumonia (VAP) occur most frequently in intensive care units (ICU). This study seeks to determine the etiological agents of NP and VAP along with their antibacterial susceptibility patterns, and to evaluate the factors contributing to patient mortality. The impact of appropriate therapy in terms of three parameters (body temperature, PaO2/FiO2 ratio and leukocyte count) was also assessed. This study involved 836 adult patients admitted to ICUs at the Nemazee Hospital, Shiraz, Iran, over nine months during 2008 and 2009. The inclusion criterion was the commencement of infection at least 48 hours following hospital admission. Clinical parameters including core temperature, leukocyte count. and PaO2/FiO2 ratio were evaluated. Antibiotic sensitivities of the isolated bacteria to a panel of antibiotics were determined using E-test. Of 836 cases, only 58 (6.9 %) cases of NP were diagnosed, of which 42 (72 %) were VAP. A. baumannii, MRSA, P. aeruginosa and MSSA were the most prevalent bacteria. Significant correlations between previous antibiotic therapy (p = 0.04), use of corticosteroids (p = 0.02) and attributable mortality were found. A strong correlation between fever abatement and the ratio of PaO2/FiO2 with responses to treatment and outcomes was also evident. Combined treatment with meropenem/imipenem, ciprofloxacin and vancomycin seems to be appropriate and could cover all possible infective agents. To reduce mortality rate, reasonable prescription of antibiotics and corticosteroids could be effective. Furthermore, adopting a strategy to reduce body temperature and PaO2/FiO2 ratio could be beneficial in patients' outcomes.