Practice In Intensive Care Unit Research Articles

Ventilation practices in the neonatal intensive care units in Saudi Arabia, survey of the utilization of volume-targeted ventilation among practicing neonatologists.

To assess the current practice in using volume-targeted ventilation among neonatologists working at the Neonatal Intensive Care Units (NICU) of Saudi Arabia. The questionnaire was provided electronically to 153 practicing Neonatologists working in 39 NICUs. The survey's results were received and statistically analyzed. One hundred nineteen (119) responses were received with, a 78% response rate. Volume Targeted Ventilation (VTV) was used routinely by 67.2%, whereas 21.8% still use only pressure control (PC)/pressure limited (PL) mode. During the acute phase of ventilation support, Assist Control was the most popular synchronized mode, whereas Synchronized Intermittent Mandatory Ventilation (SIMV) with pressure support (PS) or PSV were the two most common modes during the weaning phase, 31.8%, and 31% respectively. The majority of the neonatologists used a tidal volume of 4 ml/kg as the lowest and 6 ml/kg as the highest. The major reasons for not implementing VTV were the limited availability of ventilator devices that have an option of VTV, followed by lack of experience. VTV is the predominant ventilation practice approach among neonatologists working in the KSA. Limited availability and lack of experience in using are the main challenges. Efforts to equip NICUs with the most advanced ventilation technology, enhance practitioners' experience and sufficient training in its use are warranted.

Extracorporeal organ support for critically ill patients: Overcoming the past, achieving the maximum at present, and redefining the future

Extracorporeal organ support (ECOS) has made remarkable progress over the last few years. Renal replacement therapy, introduced a few decades ago, was the first available application of ECOS. The subsequent evolution of ECOS enabled the enhanced support to many other organs, including the heart [veno-arterial extracorporeal membrane oxygenation (ECMO), slow continuous ultrafiltration], the lungs (veno-venous ECMO, extracorporeal carbon dioxide removal), and the liver (blood purification techniques for the detoxification of liver toxins). Moreover, additional indications of these methods, including the suppression of excessive inflammatory response occurring in severe disorders such as sepsis, coronavirus disease 2019, pancreatitis, and trauma (blood purification techniques for the removal of exotoxins, endotoxins, or cytokines), have arisen. Multiple organ support therapy is crucial since a vast majority of critically ill patients present not with a single but with multiple organ failure (MOF), whereas, traditional therapeutic approaches (mechanical ventilation for acute respiratory failure, antibiotics for sepsis, and inotropes for cardiac dysfunction) have reached the maximum efficacy and cannot be improved further. However, several issues remain to be clarified, such as the complexity and cost of ECOS systems, standardization of indications, therapeutic protocols and initiation time, choice of the patients who will benefit most from these interventions, while evidence from randomized controlled trials supporting their use is still limited. Nevertheless, these methods are currently a part of routine clinical practice in intensive care units. This editorial presents the past, present, and future considerations, as well as perspectives regarding these therapies. Our better understanding of these methods, the pathophysiology of MOF, the crosstalk between native organs resulting in MOF, and the crosstalk between native organs and artificial organ support systems when applied sequentially or simultaneously, will lead to the multiplication of their effects and the minimization of complications arising from their use.

Postextubation dysphagia management in Danish intensive care units: A national survey.

Postextubation dysphagia (PED) is a common complication to endotracheal intubation in critically ill patients and may lead to pneumonia, prolonged ventilation, longer hospital stays, and increased mortality. Recognizing dysphagia is paramount to preventing adverse events. The aim of this study was to describe PED management by investigating practice in Danish intensive care units (ICUs) focusing on current practice in 2023 (screening, prevention, and treatment), perceived best practice (barriers and facilitators), and when possible, to compare practice in 2017 and 2023. Self-reported, cross-sectional survey of dysphagia practice in Danish ICUs administered from April to May 2023. In addition, data were compared with the 2017 Dysphagia in Intensive Care Evaluation study, when possible. Only half of Danish ICUs reported to have a PED protocol, and less than half routinely screen patients for dysphagia after extubation. Most common screening methods were the oral mechanism examination, water test, and Facio-oral tract therapy. Nurses and physicians often relied on an overall physical assessment of the patient. Best treatment methods were uniformly agreed to be patient positioning, modification of food and fluids, use of ergonomic utensils, and compensatory maneuvers. Key barriers to dysphagia management were lack of specialized staff, under-recognition of dysphagia as a health issue, and lack of standardized protocols. Awareness of PED is increasing and identification, prevention, and treatment is slowly improving, but systematic implementation of protocols for dysphagia screening and treatment could enhance dysphagia management in Danish ICUs.

Practice and Predictors of Do-Not-Resuscitate Orders in a Tertiary-Care Intensive Care Unit in Saudi Arabia.

The objective of this study was to describe Do-Not-Resuscitate (DNR) practices in a tertiary-care intensive care unit (ICU) in Saudi Arabia, and determine the predictors and outcomes of patients who had DNR orders. This retrospective cohort study was based on a prospectively collected database for a medical-surgicalIntensive CareDepartment in a tertiary-care center in Riyadh, Saudi Arabia (1999-2017). We compared patients who had DNR orders during the ICU stay with those with "full code." The primary outcome was hospital mortality. The secondary outcomes included ICU mortality, tracheostomy, duration of mechanical ventilation, and length of stay in the ICU and hospital. Among 24790 patients admitted to the ICU over the 19-year study period, 3217 (13%) had DNR orders during the ICU stay. Compared to patients with "full code," patients with DNR orders were older (median 67 years [Q1, Q3: 55, 76] versus 57 years [Q1, Q3: 33, 71], p < 0.0001), were more likely to be females (43% versus 38%, p < 0.0001), had worse premorbid functional status (WHO performance status scores 4-5: 606[18.9%] versus 1894[8.8%], p < 0.0001), higher prevalence of comorbid conditions, and higher APACHE II score (median 28 [Q1, Q3: 23, 34] versus 19 [Q1, Q3: 13, 25], p < 0.0001) and were more likely to be mechanically ventilated (83% versus 55%, p < 0.0001). Patients had DNR orders were more likely to die in the ICU (67.8% versus 8.5%, p < 0.0001) and hospital (82.4% versus 18.1%, p < 0.0001). On multivariable logistic regression analysis, the following were associated with an increased likelihood of DNR status: increasing age (odds ratio (OR) 1.01, 95% confidence interval (CI) 1.01-1.02), higher APACHE II score (OR 1.09, 95% CI 1.08-1.10), and worse WHO performance status score. Patients admitted in recent years (2012-2017 versus 2002-2005) were less likely to have DNR orders (OR 0.35, 95% CI 0.32-0.39, p < 0.0001). Patients with DNR orders had higher ICU mortality, more tracheostomies, longer duration of mechanical ventilation and length of ICU stay compared to patients with with "full code" but they had shorter length of hospital stay. In a tertiary-care hospital in Saudi Arabia, 13% of critically ill patients had DNR orders during ICU stay. This study identified several predictors of DNR orders, including the severity of illness and poor premorbid functional status.

The effect of developmental care on the length of hospital stay and family centered care practice for very low birth weight infants in neonatal intensive care units: A cluster randomized controlled trial

BackgroundDespite previous studies suggesting that developmental care can provide benign stimulation to promote neural development of newborns, more evidence is needed regarding the other clinical benefits of developmental care. ObjectiveTo evaluate the effect of implementing developmental care on the length of hospital stay, the improvement of care practice in neonatal intensive care units, as well as the short-term outcome of very low birth weight infants. DesignCluster-randomized controlled trial. Setting(s) and participantsFrom March 1, 2021 to March 1, 2022, 1400 very low birth weight infants were recruited from 14 tertiary neonatal intensive care units in China. MethodsWe assigned 14 neonatal intensive care units to either developmental care or standard care. The length of hospital stay of the infants was the primary outcome analyzed at the individual level. Secondary outcomes were family centered care practice including parental involvement, the skin to skin care, exclusive breast milk, oral immune therapy and breastfeeding. The environmental management (noise and light) and the short-term outcomes were also evaluated. ResultsThe length of hospital stay for the developmental care group was 65 % as long as that for the control group (HR: 0.65, 95 % CI, 0.451–0936, p = 0.021). After controlling the covariables, the adjusted HR = 0.755 (95 % CI, 0.515 to 1.107, p = 0.150). When compared to the control group, the developmental care group had greater access to SSC, with 22 infants (3.8 %) in the developmental care group compared to 13 infants (1.7 %) in the standard care group (p = 0.013). A greater proportion of infants in the developmental care group were fed at the breast, than those in the standard care group (136 [23.6 %] vs 9 [1.1 %]; p = 0.029). Compared to the control group, exclusively breast milk was significantly more favorable in the developmental care group (435 [75.6 %] vs 114 [15.0 %]; p = 0.001). The difference remained significant even after adjusting for covariates. However, the rate of oral immune therapy and parental involvement was similar in the two groups. The average noise and light levels in the developmental care group were significantly lower than those in the standard care group. After adjusting for confounders, the difference remained significant. There were no significant differences among groups in the mortality and major morbidity. ConclusionsDevelopmental care might have developed an accumulated effect over time on the length of hospital stay among very low birth weight infants. The implementation of developmental care can greatly improve family centered care practices and the neonatal intensive care unit environment. RegistrationClinicalTrials.govNCT05166720. Registration date: 1 March, 2021.

Reliability and validity assessment of the Chinese version of the Intrahospital Transport Safety Scale (IHTSS) in intensive care units

BackgroundIntrahospital transport of critically ill patients is a common practice in intensive care units (ICUs), where patients’ safety is constantly challenged in high-intensity and dynamic environments. While Intrahospital Transport Safety Scale (IHTSS) is widely used internationally to evaluate the intrahospital transport safety, it has not been introduced in China.ObjectivesThis study aimed to assess the reliability and validity of the Chinese version of the IHTSS scale among critical care nurses in China.MethodsA cross-sectional study was conducted using a cluster sampling method. A total of 544 critical care nurses from 25 ICUs in 10 tertiary hospitals were recruited. We employed exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to examine the questionnaire’s underlying factor structure, ensuring construct validity. Additionally, internal consistency was assessed using Cronbach’s alpha coefficient, test-retest reliability, and corrected item-total correlation.ResultsThe Chinese version of the scale displayed robust psychometric properties, with a Cronbach’s α coefficient of 0.976, a split-half reliability of 0.906, and a test-retest reliability of 0.856. EFA revealed a robust four-factor model that accounted for 75.970% of the variance, with the factor loadings of the items ranging from 0.433 to 0.951. CFA indicated a strong model fit, with a chi-square to degrees of freedom ratio (CMIN/DF) of 2.765, comparative fit index (CFI) of 0.943, incremental fit index (IFI) of 0.943, and goodness-of-fit index (GFI) of 0.845, supporting the efficacy of the four-factor model in assessing intrahospital transport safety for critically ill patients.ConclusionThe Chinese version of the IHTSS demonstrated favourable reliability and validity among critical care nurses in China, making it a suitable tool for measuring the level of intrahospital transport safety for critically ill patients.

Intensive care nurses' perceptions and awareness of delirium and delirium prevention guidelines.

Delirium is an acute and fluctuating disturbance of cognition and is a common occurrence in critically ill patients. It is a manifestation of an acute brain dysfunction often attributed to higher survival rates and a subsequently aging population. Intensive Care Unit (ICU) treatment and survival often contributes towards development of delirium, and lack of or inappropriate management can translate into the development of long-term psychological effects that last even after discharge. While a lot is already known about this topic, and several assessment tools exist, these are not being consistently used by ICU nurses and as a result delirium often goes unrecognized, with unwarranted consequences. The study aimed to explore the perception of delirium among ICU nurses, and the extent of their awareness about guidelines to assess and prevent delirium in ICU patients. It also sought to understand the application of delirium guidelines in ICU practice. A quantitative, exploratory, self-reporting survey was conducted among 145 ICU nurses from one critical care unit in the Republic of Ireland. The overall response rate was 71% (103/145). Most nurses (85%) who participated in this survey believed delirium was expected. However, only 45% acknowledged it is a complication. Only 31% of nurses monitored delirium using a validated scale and few observed this as a part of routine care. Most nurses had received education; however, this did not translate to their clinical practice. Guidelines on managing delirium may not be routinely implemented in the ICU settings of hospitals in the Republic of Ireland. As the findings suggest, a gap exists between theory and practice, necessary revision of policy or creating a new policy, supplemental educational sessions such as bedside sessions, e-learning module, study day or seminars need to be organized to improve nurses' awareness related to delirium and delirium prevention guidelines.

Use of nursing care bundles for the prevention of ventilator-associated pneumonia in low-middle income countries: A scoping review.

Ventilator-associated pneumonia (VAP) is a significant concern in low-middle-income countries (LMICs), where the burden of hospital-acquired infections is high, and resources are low. Evidence-based guidelines exist for preventing VAP; however, these guidelines may not be adequately utilized in intensive care units of LMICs. This scoping review examined the literature regarding the use of nursing care bundles for VAP prevention in LMICs, to understand the knowledge, practice and compliance of nurses to these guidelines, as well as the barriers preventing the implementation of these guidelines. The review was conducted using Arksey and O'Malley's (2005) five-stage framework and the PRISMA-ScR guidelines guided reporting. Searches were performed across six databases: CINAHL, Medline, Embase, Global Health, Scopus and Cochrane, resulting in 401 studies. After screening all studies against the eligibility criteria, 21 studies were included in the data extraction stage of the review. Across the studies, the knowledge and compliance of nurses regarding VAP prevention were reported as low to moderate. Several factors, ranging from insufficient knowledge to a lack of adequate guidelines for VAP management, served as contributing factors. Multiple barriers prevented nurses from adhering to VAP guidelines effectively, including a lack of audit/surveillance, absence of infection prevention and control (IPC) teams and inadequate training opportunities. This review highlights the need for adequate quality improvement procedures and more efforts to conduct and translate research into practice in intensive care units in LMIC. IPC practices are vital to protect vulnerable patients in intensive care units from developing infections and complications that worsen their prognosis. Critical care nurses should be trained and reinforced to practice effective bundle care to prevent VAP.

Analysis of clinical treatment of acute respiratory distress syndrome assisted by artificial intelligence

To evaluate the clinical practice of intensive care unit (ICU) physicians at Hebei General Hospital in identifying patients meeting the diagnostic criteria for acute respiratory distress syndrome (ARDS) and the current status of invasive mechanical ventilation management and adjunctive therapy in these patients, and to analyze the incidence and clinical outcomes of ARDS. A retrospective cohort study was conducted. The patients who were hospitalized in the ICU of Hebei General Hospital from April 10, 2017 to June 30, 2022 and met the Berlin definition diagnostic criteria for ARDS were enrolled as study subjects. Artificial intelligence (AI) technology was applied to search the basic information (age, gender, height, body weight, etc.), auxiliary examination, electronic medical record, non-drug doctor's advice, drug doctor's advice, critical report, scoring system, monitoring master table and other data of the above medical records in the electronic medical record system of the hospital. The first set of laboratory indicators sequentially retrieved from the system daily from 05:00 to 10:00 and vital signs and mechanical ventilation-related parameters recorded in the "critical care report" at 06:00 daily were extracted, and outcome indicators of the patients were collected. After screening and analysis, a total of 255 patients who met the ARDS diagnostic criteria were finally enrolled. The overall incidence of ARDS in the ICU accounted for 3.4% (255/7 434) of the total number of ICU patients, of which mild, moderate and severe ARDS accounted for 22.4% (57/255), 49.0% (125/255), and 28.6% (73/255), respectively, while the recognition rates of clinical doctors were 71.9% (41/57), 58.4% (73/125) and 71.2% (52/73), respectively. During the ICU stay, 250 patients (98.0%) received only invasive mechanical ventilation, while 5 patients (2.0%) received both non-invasive and invasive mechanical ventilation. The tidal volume/ideal body weight of ARDS patients was 7.64 (6.49, 9.01) mL/kg, and the positive end-expiratory pressure (PEEP) was 8.0 (5.0, 10.0) cmH2O (1 cmH2O ≈ 0.098 kPa). In addition, during the diagnosis and detection of ARDS, only 7 patients were recorded the platform pressure and 6 patients were recorded the drive pressure. Regarding adjunctive therapies, 137 patients (53.7%) received deep sedation, 26 patients (10.2%) underwent lung recruitment, 55 patients (21.6%) received prone ventilation, 42 patients (16.5%) were treated with high-dose steroids, 19 patients (7.5%) were treated with neuromuscular blockade, and 8 patients (3.1%) were treated with extracorporeal membrane oxygenation (ECMO). Finally, 70 patients (27.5%) were discharged automatically, while 50 patients (19.6%) died in the ICU, of which the ICU mortality of mild, moderate, and severe ARDS patients were 15.8% (9/57), 22.4% (28/125), and 17.8% (13/73), respectively. After follow-up, it was found that all 70 patients discharged automatically died within 28 days after discharge, and the overall ICU mortality adjusted accordingly was 47.1% (120/255). The overall incidence of ARDS in ICU patients at Hebei General Hospital is relatively low, with a high recognition rate by clinical physicians. Despite the high level of compliance and implementation of lung protective ventilation strategies and auxiliary treatment measures, it is still necessary to further improve the level of standardization in the implementation of small tidal volume and respiratory mechanics monitoring. For the implementation of auxiliary measures such as prone ventilation, it is necessary to further improve the enthusiasm of medical staff. The mortality in ICU is relatively low in ARDS patients, while the rate of spontaneous discharge is relatively high.

Retrospective assesment of continuous renal replacement therapy practice in medical intensive care unit

Retrospective assesment of continuous renal replacement therapy practice in medical intensive care unit

Nation-wide survey of oral care practice in Japanese intensive care units: A descriptive study.

Oral care for critically ill patients helps provide comfort and prevent ventilator-associated pneumonia. However, a standardized protocol for oral care in intensive care units is currently unavailable. Thus, this study aimed to determine the overall oral care practices, including those for intubated patients, in Japanese intensive care units. We also discuss the differences in oral care methods between Japanese ICUs and ICUs in other countries. This study included all Japanese intensive care units meeting the authorities' standard set criteria, with a minimum of 0.5 nurses per patient at all times and admission of adult patients requiring mechanical ventilation. An online survey was used to collect data. Survey responses were obtained from one representative nurse per intensive care unit. Frequency analysis was performed, and the percentage of each response was calculated. A total of 609 hospitals and 717 intensive care units nationwide participated; among these, responses were collected from 247 intensive care units (34.4%). Of these, 215 (87.0%) and 32 (13.0%) reported standardized and non-standardized oral care, respectively. Subsequently, the data from 215 intensive care units that provided standardized oral care were analyzed in detail. The most common frequency of practicing oral care was three times a day (68.8%). Moreover, many intensive care units provided care at unequal intervals (79.5%), mainly in the morning, daytime, and evening. Regarding oral care methods, 96 (44.7%) respondents used only a toothbrush, while 116 (54.0%) used both a toothbrush and a non-brushing method. The findings of our study reveal current oral care practices in ICUs in Japan. In particular, most ICUs provide oral care three times a day at unequal intervals, and almost all use toothbrushes as a common tool for oral care. The results suggest that some oral care practices in Japanese ICUs differ from those in ICUs in other countries.

Evaluation of the Impact of the Addition of Atypical Antipsychotics to Continuous Infusion Propofol Therapy.

Purpose: The administration of sedatives to critically ill patients is a common practice in intensive care units (ICU) and has been associated with negative outcomes. To mitigate this, atypical antipsychotics are utilized as adjunctive therapy. This study aims to review and quantify overall effectiveness of the atypical antipsychotics quetiapine, risperidone, and olanzapine on reduction in the amount of continuous infusion propofol utilized in the ICU. Methods: This was an observational study that took place from February 27, 2021 to December 31, 2022. The primary outcome of this study was the percentage change in average propofol infusion rate (mcg/kg/min) from baseline to the greater than 24 to 48 hours period after atypical antipsychotic initiation. Secondary outcomes included ICU length of stay, duration of mechanical ventilation, QTc interval monitoring, and continuation of the antipsychotic without a valid indication. Descriptive statistics were utilized for the statistical analysis. Results: A total of 47 patients were included in the study. The average baseline propofol rate was 31 mcg/kg/min, which reduced 8.6% to 28.35 mcg/kg/min over the 0 to 24 hours period, was reduced by 19.4% compared to baseline to a rate of 25 mcg/kg/min during the greater than 24 to 48 hours period, and finally a percent reduction of 54.2% seen during the greater than 48 to 72 hours period to a rate of 14 mcg/kg/min. Conclusions: Patients who received an adjunctive antipsychotic saw resulting propofol rate reductions of 8.6% at 24 hours, 19.4% at 48 hours, and 54.2% at 72 hours. However, research on this topic should not end here, as further investigation with higher-level study design is needed to determine the true impact of these agents for this indication.

Interventions to improve patient admission and discharge practices in adult intensive care units: A systematic review

ObjectivesTo identify and synthesise interventions and implementation strategies to optimise patient flow, addressing admission delays, discharge delays, and after-hours discharges in adult intensive care units. MethodsThis systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Five electronic databases, including CINAHL, PubMed, Emcare, Scopus, and the Cochrane Library, were searched from 2007 to 2023 to identify articles describing interventions to enhance patient flow practices in adult intensive care units. The Critical Appraisal Skills Program (CASP) tool assessed the methodological quality of the included studies. All data was synthesised using a narrative approach. Setting.Adult intensive care units. ResultsEight studies met the inclusion criteria, mainly comprising quality improvement projects (n = 3) or before-and-after studies (n = 4). Intervention types included changing workflow processes, introducing decision support tools, publishing quality indicator data, utilising outreach nursing services, and promoting multidisciplinary communication. Various implementation strategies were used, including one-on-one training, in-person knowledge transfer, digital communication, and digital data synthesis and display. Most studies (n = 6) reported a significant improvement in at least one intensive care process-related outcome, although fewer studies specifically reported improvements in admission delays (0/0), discharge delays (1/2), and after-hours discharge (2/4). Two out of six studies reported significant improvements in patient-related outcomes after implementing the intervention. ConclusionOrganisational-level strategies, such as protocols and alert systems, were frequently employed to improve patient flow within ICUs, while healthcare professional-level strategies to enhance communication were less commonly used. While most studies improved ICU processes, only half succeeded in significantly reducing discharge delays and/or after-hours discharges, and only a third reported improved patient outcomes, highlighting the need for more effective interventions. Implications for clinical practiceThe findings of this review can guide the development of evidence-based, targeted, and tailored interventions aimed at improving patient and organisational outcomes.

Impact of dexamethasone in severe COVID-19-induced acute kidney injury: a multicenter cohort study

BackgroundAcute kidney injury (AKI) in intensive care unit (ICU) patients with severe COVID-19 is common (> 50%). A specific inflammatory process has been suggested in the pathogenesis of AKI, which could be improved by dexamethasone (DXM). In a small monocenter study (n = 100 patients), we reported a potential protective effect of DXM on the risk of AKI. This study aimed to investigate the preventive impact of DXM on AKI in a multicenter study of patients with severe COVID-19.MethodsWe conducted a multicenter study in three French ICUs from March 2020 to August 2021. All patients admitted to ICU for severe COVID-19 were included. Individuals with preexistent AKI or DXM administration before admission to ICU were excluded. While never used during the first wave, DXM was used subsequently at ICU entry, providing two treatment groups. Multivariate Cause-specific Cox models taking into account changes in ICU practices over time, were utilized to determine the association between DXM and occurrence of AKI.ResultsSeven hundred and ninety-eight patients were included. Mean age was 62.6 ± 12.1 years, 402/798 (50%) patients had hypertension, and 46/798 (6%) had previous chronic kidney disease. Median SOFA was 4 [3–6] and 420/798 (53%) required invasive mechanical ventilation. ICU mortality was 208/798 (26%). AKI was present in 598/798 (75%) patients: 266/598 (38%), 163/598 (27%), and 210/598 (35%) had, respectively, AKI KDIGO 1, 2, 3, and 61/598 (10%) patients required renal replacement therapy. Patients receiving DXM had a significantly decreased hazard of AKI occurrence compared to patients without DXM (HR 0.67; 95CI 0.55–0.81). These results were consistent in analyses that (1) excluded patients with DXM administration to AKI onset delay of less than 12 h, (2) incorporating the different ‘waves’ of the COVID-19 pandemic.ConclusionsDXM was associated with a decrease in the risk of AKI in severe COVID-19 patients admitted to ICU. This supports the hypothesis that the inflammatory injury of AKI may be preventable.

Evaluating the use of casuistry during moral case deliberation in the ICU: A multiple qualitative case study

Intensive care unit (ICU) professionals engage in ethical decision making under conditions of high stakes, great uncertainty, time-sensitivity and frequent irreversibility of action. Casuistry is a way by which actionable knowledge is obtained through comparing a patient case to previous cases from experience in clinical practice. However, within the field of study as well as in practice, evidence-based medicine is the dominant epistemic framework. This multiple case study evaluated the use of casuistic reasoning by intensive care unit (ICU) professionals during moral case deliberation. It took place in two Dutch hospitals between June 2020 and June 2022. Twentyfive moral case deliberations from ICU practice were recorded and analyzed using discourse analysis. Additionally, 47 interviews were held with ICU professionals who participated in these deliberations, analyzed using thematic analysis. We found that ICU professionals made considerable use of case comparisons when discussing continuation, withdrawal or limitation. Analogies played a role in justifying or complicating moral judgements, and also played a role in addressing moral distress. The language of case-based arguments is most often not overtly normative. Rather, the data shows that casuistic reasoning deals with the medical, ethical and contextual elements of decisions in an integrated manner. Facilitators of MCD have an essential role in (supporting ICU professionals in) scrutinizing casuistic arguments. The data shows that during MCD, actual reasoning often deviated from principle- and rule-based reasoning which ICU professionals preferred themselves. Evidence-based arguments often gained the character of analogical arguments, especially when a patient-at-hand was seen as highly unique from the average patients in the literature. Casuistic arguments disguised as evidence-based arguments may therefore provide ICU professionals with a false sense of certainty. Within education, we should strive to train clinicians and ethics facilitators so that they can recognize and evaluate casuistic arguments.

Motivational drivers for health professionals in a large quality improvement collaborative project in Brazil: a qualitative study

BackgroundThe success of collaborative quality improvement (QI) projects in healthcare depends on the context and engagement of health teams; however, the factors that modulate teams’ motivation to participate in these projects are still unclear. The objective of the current study was to explore the barriers to and facilitators of motivation; the perspective was health professionals in a large project aiming to implement evidence-based infection prevention practices in intensive care units of Brazilian hospitals.MethodsThis qualitative study was based on content analysis of semistructured in-depth interviews held with health professionals who participated in a collaborative QI project named “Improving patient safety on a large scale in Brazil”. In accordance with the principle of saturation, we selected a final sample of 12 hospitals located throughout the five regions of Brazil that have implemented QI; then, we conducted videoconference interviews with 28 health professionals from those hospitals. We encoded the interview data with NVivo software, and the interrelations among the data were assessed with the COM-B model.ResultsThe key barriers identified were belief that improvement increases workload, lack of knowledge about quality improvement, resistance to change, minimal involvement of physicians, lack of supplies, lack support from senior managers and work overload. The primary driver of motivation was tangible outcomes, as evidenced by a decrease in infections. Additionally, factors such as the active participation of senior managers, teamwork, learning in practice and understanding the reason for changes played significant roles in fostering motivation.ConclusionThe motivation of health professionals to participate in collaborative QI projects is driven by a variety of barriers and facilitators. The interactions between the senior manager, quality improvement teams, and healthcare professionals generate attitudes that modulate motivation. Thus, these aspects should be considered during the implementation of such projects. Future research could explore the cost-effectiveness of motivational approaches.

Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.

What factors in the workplace enable success in antimicrobial stewardship in paediatric intensive care? An exploration of antimicrobial stewardship excellence through thematic analysis of appreciative inquiry interviews with healthcare staff

ObjectivesAntimicrobial resistance (AMR) is a major global health problem. Efforts to mitigate AMR prioritise antimicrobial stewardship (AMS) interventions. These interventions typically focus on deficiencies in practice and providing negative or...

Standard practices in cardiac monitoring: training needs of intensive care unit nurses

BackgroundEnforcing practice standards for cardiac monitoring in intensive care units (ICUs) has been shown to reduce misdiagnoses and inappropriate interventions. Continuous professional development (CPD) programs are committed to aligning clinical practices with recommended standards. The crucial initial phase in CPD development involves assessing the training needs of the targeted population.ObjectiveTo assess the training needs of ICU nurses in cardiac monitoring. The overarching goal was to formulate a focused Continuous Professional Development (CPD) program geared towards implementing standard practices in cardiac monitoring.MethodsThis study employed a generic qualitative approach with a descriptive design, utilizing interviews and focus groups from July to September 2018. Involving 16 ICU nurses. Content analysis was employed, encompassing transcription, fluctuant and iterative reading, unitization, categorization, coding, description, and interpretation.ResultsAll nurses recognized cardiac monitoring’s importance in the ICU but reported barriers to its effective implementation which were related to factors that could addressed by a CPD as insufficient knowledge and skills. Training needs were identified in both clinical and technical aspects, with recommendations for practical and theoretical activities and e-learning strategies. Barriers related to organizational aspects (equipment and communication within the healthcare team) were also mentioned.ConclusionICU nurses presented clear and specific training needs related to cardiac monitoring as knowledge, skills, and competencies. Other organizational aspects were also reported as barriers. Addressing these learning needs through targeted CPD aligned with organizational initiatives can contribute to enhancing the quality of cardiac monitoring practices in ICUs.

Early and consistent safe sleep practices in the neonatal intensive care unit: a sustained regional quality improvement initiative.

To increase compliance with standardized safe sleep recommendations for patients in a cohort of regional level III/IV neonatal intensive care units (NICUs) in accordance with recently revised guidelines issued by the American Academy of Pediatrics (AAP). A regional quality improvement (QI) initiative led by a multidisciplinary task force standardized safe sleep criteria across participating NICU sites. Universal and unit-specific interventions were implemented via Plan-Do-Study-Act (PDSA) cycles with evaluation of compliance through routine crib audits, run chart completion, and Pareto chart analysis. Following QI implementation, compliance with safe sleep guidelines for eligible NICU infants improved from 34% to 90% from October 2019 through September 2022. Compliance with early, consistent modeling of safe sleep practices nearly tripled in this cohort of regional NICUs. A standardized, timely approach to safe sleep transition demonstrated dramatic and sustained improvement in the practice and modeling of safe sleep behaviors in the NICU.