Progressive Care Unit Research Articles

9185 Pembrolizumab-Induced New-Onset Type 1 Diabetes Mellitus: A Case Report

Abstract Disclosure: D. Teng: None. T.L. Connelly: None. M. Ahmad: None. R. Saeed: None. Introduction: Immune checkpoint inhibitors are becoming essential in the treatment of various cancers. Pembrolizumab is a monoclonal antibody that binds PD-1 receptors, thereby enabling an anti-tumor response by preventing T-cell suppression. Common side effects associated with pembrolizumab include thyroid disorders, hepatitis, pneumonitis, and acute kidney injury, among others. We describe an interesting case of a woman presenting with diabetic ketoacidosis (DKA) in the setting of pembrolizumab-associated new-onset type 1 diabetes mellitus, which was reported at 0.1% during initial clinical trials but is now being increasingly recognized as a complication of immune checkpoint therapy. Case Description: The patient is a 70-year-old female with past medical history notable for stage IIIA vulvar squamous cell carcinoma initially diagnosed and treated in 2017, with recurrence in 2022 and in 2023, at which point pembrolizumab therapy was initiated. Approximately one month after her first dose, the patient presented to the emergency department with palpitations, nausea, non-bloody vomiting, polydipsia, and non-bloody diarrhea. On arrival, the patient’s vital signs were as follows: 97.2 °F, BP 128/74 mmHg, heart rate 80 bpm, respiratory rate 18 per minute, and SpO2 100% on room air. No acute findings were noted on physical exam. Initial blood work was notable for: pH 7.146, lactate 2.4 mmol/L, bicarbonate 8 mmol/L, anion gap 37 mmol/L, creatinine 1.59 mg/dL, glucose 563 mg/dL, C-peptide 0.16 ng/mL, HbA1c 6.9%, and WBC 18.8 B/L with neutrophilic predominance. Urinalysis was notable for 4+ glucose and 4+ ketones. The patient was admitted to the progressive care unit and DKA protocol was initiated including the administration of IV fluids, insulin infusion, and electrolyte replacement. Additional blood work was unrevealing, including insulin autoantibodies <0.4 U/mL, negative islet cell IgG cytoplasmic autoantibodies, and negative anti-GAD65 antibodies. The patient was eventually discharged with outpatient Endocrinology follow-up. Discussion: Immunotherapy is quickly redefining the standard of care in the treatment of several types of malignancies through the leveraging of the body’s immune defense apparatus. Pembrolizumab prevents the deactivation of T-cells via the PD-1/PD-L1 pathway. Unfortunately, this also predisposes non-cancerous cells to autoimmune destruction by these T-cells. It is proposed that such is the mechanism by which pancreatic beta islet cells are destroyed in the setting of pembrolizumab use, thereby resulting in a rapid reduction in insulin production capability. New-onset type 1 diabetes complicated by DKA is potentially life-threatening, and so we believe this case highlights the need for both pre-treatment counseling as well as follow-up screening following initiation of pembrolizumab therapy. Presentation: 6/2/2024

Analysis of ST segment alarms in children admitted to the paediatric and cardiac intensive care units and cardiac progressive care unit: a single-centre retrospective study.

ST segment monitoring in the adult population allows for the early detection of myocardial ischaemia. In children admitted to the paediatric intensive care unit (PICU), cardiac intensive care unit (CICU), and cardiac progressive care unit (CPCU), it is unclear if continuous ST segment alarm monitoring is necessary in all patients. All patients admitted to the PICU, CICU, and CPCU during the study period were included. Children with any ST segment alarms were compared with those without an alarm during their stay. The electrocardiogram confirmed true ST segment alarms were compared with all other ST segment alarms. Demographic and clinical data were extracted from the medical record. Medical interventions and procedures occurring around ST segment alarms were recorded for multivariable analysis assessing for the association of true ST segment. Logistic regression was used to evaluate the associations with ST segment alarms during hospital stays. ST segment alarms occurred in 36% of hospital stays, and only 3.4% were considered true. True alarms were significantly more common among patients with a cardiac-related diagnosis, located in both cardiac units, and having received an intervention with any vasoactive medication. In the multivariable logistic regression, patients 11 years or older, hypotension, supraventricular tachycardia, and initiation/escalation of any vasoactive were independently associated with a true ST segment alarm. True ST segment alarms were infrequent, occurring in 1.2% of stays during the study period. Alarm monitoring may be beneficial in those with an underlying cardiac diagnosis.

Reducing Central Line-Associated Bloodstream Infections With a Multipronged Nurse-Driven Approach.

Despite implementation of central catheter bundles, central line [catheter]-associated bloodstream infections (CLABSIs) remain a preventable hospital-acquired infection. A new population of patients with pulmonary artery catheters was introduced to the cardiac progressive care unit, increasing central catheter days, device use, and CLABSI rate. A quality improvement project was conducted. Nursing staff implemented a standardized central catheter rounding process 3 days a week to critically assess all central catheter dressings, deter-mine the necessity of each central catheter, and educate patients on the importance of keeping central catheter dressings clean, dry, and intact. Data were collected during central catheter rounds for each patient, entered in an electronic survey tool via mobile devices, and analyzed. From July 2019 through June 2022, a total of 2692 rounds were conducted for 707 individual patients with 3064 central catheters. Main interventions were dressing management, monitoring insertion site bleeding that extended beyond edges of the chlorhexidine gluconate pad, treating patients' allergies to products, and maintaining sustainability within the unit. Central catheter rounds decreased the CLABSI rate from 1.86 to 0.0 despite the continued increase in central catheter days. Central catheter dressing assessment, intervention, and education help reduce CLABSIs. Central catheter rounds are an important adjunct to the CLABSI bundle. A central catheter dressing management algorithm helps nurses decide when to change a dressing and which type of dressing to use.

It Takes a Village: Leveraging a Multidisciplinary Team and Technology for Urine Culturing Stewardship

Background: Patients without urinary tract infection (UTI) symptoms but with a positive urine culture are considered to have asymptomatic bacteriuria (ASB). This often represents colonization and treatment is not recommended or clinically beneficial. Treatment of ASB can promote antimicrobial resistance and increased rates of Clostriodies difficile infections. Many cases of ASB are incorrectly assigned as CAUTIs due to over-culturing practices. We hypothesized that a urine culture algorithm, embedded within a best practice alert (BPA) in the electronic medical record (EMR), would reduce urine culturing practices for ASB. Methods: From Feb 2022 through May 2023, a multidisciplinary team implemented an Inpatient Urine Culturing Stewardship Guideline. A BPA fired when a provider placed a urinalysis with reflex to culture (UACC) or urine culture (UC) order for patients who met criteria (Image 1). The BPA directed providers to remove the order, select the appropriate pathway from the guideline, or provide a rationale for placing the order. The intervention was piloted on three intensive care units and two progressive care units, containing both medical and surgical patients. Monthly ordering practices, CAUTI rates, and gram-negative rod (GNR) bacteremia rates from a 13-month pre-intervention baseline period were compared to a 16-month intervention period. Over the same time periods, we also assessed changes in ordering practices for comparison units which did not implement the intervention. Pre-and-post intervention cohorts were analyzed using median two sample tests and Exact Poison Method, as appropriate. Results: On intervention units there was a 41.0% reduction in the median number of UACC and UC orders per 1000 patient days from 16.31 during the baseline period to 9.62 in the intervention period (p=0.0036). Pan cultures per 1000 patient days in which one of the orders was a UACC or UC fell by 42.2% from a median of 10.20 per 1000 patient days to 5.90 (p=0.0008). The comparison units saw no significant reductions in UACC and UC orders (p=0.21) or pan cultures (p=1.0). On the intervention units, the CAUTI rate for the baseline period was 1.31 per 1000 catheter days versus 0.79 in the intervention period (IRR = 1.65; p=0.44). GNR bacteremias remained stable on the intervention units between the baseline and intervention periods (p=0.82). Conclusion: This multidisciplinary intervention, leveraging EMR clinical decision support, reduced urine and pan culturing practices while demonstrating a trend towards a reduced CAUTI rate. The prevalence of GNR bacteremias remained consistent with baseline levels, suggesting the intervention did not cause harm.

Clinical and Genomic Characteristics of Candida auris in Central Ohio: An Insight into Epidemiological Surveillance

Background: Candida auris is an emerging threat to hospitalized patients and invasive disease is associated with high mortality. This study describes clinical and microbiological characteristics of nine patients identified with C. auris at Ohio State Wexner Medical Center discovered through active surveillance or clinical investigation and uses whole genome sequencing (WGS) to compare isolates. Methods: In November 2022, an active C. auris surveillance program was implemented to screen patients admitted to high-risk units (intensive care units and progressive care units). Bilateral axilla and groin swabs were obtained upon unit admission and, if positive, were submitted for C. auris polymerase chain reaction (PCR) with culture and sensitivity testing. Patients with a positive screening or clinical isolate from November 2022 to November 2023 underwent chart review for clinical characteristics, microbiologic data, and index admission information. For each isolate, DNA was extracted and WGS was performed. Core single nucleotide polymorphism (SNP) variation identified from the sequence data was used to infer genetic relationships among the isolates. Results: Nine patients were identified between November 2022 and November 2023. The clinical and microbiologic characteristics are summarized in Table 1. All patients were hospitalized at various acute care facilities across the state at least once in the preceding 12 months. C. auris was determined to be present on admission for 6 patients. For 5 of these patients, it was their first interaction with our healthcare system. Three patients were not in contact isolation for >3 days before C. auris was identified. Unit wide point-prevalence screening was completed in these cases and no evidence of transmission was found. WGS showed eight of the nine isolates were related with 28 or less core SNP differences between isolates (Figure 1). One isolate (8) was genetically distinct with >45000 core SNP differences. Five isolates were highly related with a range of 4-15 SNP differences. No temporal or spatial overlap at our institution was identified among these five patients. Conclusions: The active surveillance program identified several patients colonized with C. auris in addition to those found through clinical testing. Multiple risk factors for C. auris were identified with high patient mortality (67%). Majority of the isolates were closely related without association with a known outbreak or epidemiologic link, suggesting a possible diffuse common reservoir. Next steps with surveillance in acute care and long-term care facilities will be critical for early detection to halt transmission of this organism.

Efficacy of a Standardized Process in Optimizing Appropriate Use of Progressive Care Unit Beds in a Tertiary Care Facility.

Poor patient progression from the progressive care unit (PCU) beds has been recognized as a bottleneck, limiting the hospital's ability to optimize capacity for the sickest patients. Improving nurse management on PCU admission and discharge criteria could avoid PCU bottlenecks. Our institution lacked a standard process to identify clinically appropriate patients ready for transfer out of the PCU, causing delays in vacating PCU beds. The aim of this study was to determine if creating a standard process to empower bedside nurses and unit nursing leaders to push readiness information to the provider team improves the appropriateness of PCU stay and transfers patients out of the PCU earlier. The most common causes of delayed transfer out of the PCU were discussed among stakeholders. A process was designed to empower the bedside nurses to partner with a physician leader to send information to the provider team requesting evaluation of the patient's readiness to leave the unit. The improvement of meeting the criteria for PCU was evaluated by comparing 60 patients prior to the intervention phase with 139 patients during the intervention. The primary outcome, percentage of patients meeting PCU criteria, was 53% during the audit phase and 68% during the intervention phase (P = .05). The PCU transfer time was pushed 1 hour earlier in the day. The standard process of empowering bedside nurses to partner with physician leaders to push readiness for transferring patients out of the PCU resulted in a significant improvement in the percentage of patients meeting PCU criteria and earlier discharge of appropriate patients.

Abstract TP65: Mastering the Art of Herding Cats: Unraveling the Methods of Effective Communication in a Growing Stroke Program

Background: Since becoming a Comprehensive Stroke Center in 2008, our annual stroke patient volume doubled, and intervention volume grew nearly 6-fold. The program achieved multiple milestones over this time, transitioning from a combined ICU-progressive care unit to separate specialized units, and later relocating to a new facility with a dedicated Neuro ICU and two progressive care units. As the program expanded, innovative communication techniques and processes were adopted to accommodate the growing staff and infrastructure. Methods: The development and dissemination of intervention reports to stakeholders from each stroke case heightened awareness of time goals and fostered collaboration. Effective communication was further facilitated through the development of a SharePoint site, newsletter, and electronic handbook. Strategically designed dashboards provided crucial data on volumes, diversion, and treatment times. QR codes were introduced for convenient data and research request access. Moreover, detailed electronic follow-up reports facilitated external collaboration with referring facilities. Results: Embracing electronic communication enhanced information sharing, improving our team’s grasp of program data, outcomes, launches, and outreach initiatives. The monthly newsletter achieved a 60% open rate, contributing to nearly 5,000 SharePoint site visits. Monthly intervention reports to stroke team responders heightened time goal awareness, fostering collaboration, improving documentation, and reducing the need for case delay documentation clarification. Sending an average of 71 follow-up reports monthly to referring hospitals and EMS agencies strengthened external partnerships. Moreover, leveraging social media amplified community outreach for stroke education. Conclusion: We have found electronic communication to be successful for our growing program. To enhance engagement and accommodate diverse learners, we recommend utilizing a range of methods, including visuals, quizzes, and interactive content. Future plans involve expanding communication strategies with emerging techniques and conducting a formal analysis to assess stakeholders' comprehension of shared information in stroke care.

Phenobarbital Versus Benzodiazepines for the Treatment of Severe Alcohol Withdrawal.

Phenobarbital may offer advantages over benzodiazepines for severe alcohol withdrawal syndrome (SAWS), but its impact on clinical outcomes has not been fully elucidated. The purpose of this study was to determine the clinical impact of phenobarbital versus benzodiazepines for SAWS. This retrospective cohort study compared phenobarbital to benzodiazepines for the management of SAWS for patients admitted to progressive or intensive care units (ICUs) between July 2018 and July 2022. Patients included had a history of delirium tremens (DT) or seizures, Clinical Institute Withdrawal Assessment of Alcohol-Revised (CIWA-Ar) >15, or Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score ≥4. The primary outcome was hospital length of stay (LOS). Secondary outcomes included progressive or ICU LOS, incidence of adjunctive pharmacotherapy, and incidence/duration of mechanical ventilation. The final analysis included 126 phenobarbital and 98 benzodiazepine encounters. Patients treated with phenobarbital had shorter median hospital LOS versus those treated with benzodiazepines (2.8 vs 4.7 days; P < 0.0001); a finding corroborated by multivariable analysis. The phenobarbital group also had shorter median progressive/ICU LOS (0.7 vs 1.3 days; P < 0.0001), and lower incidence of dexmedetomidine (P < 0.0001) and antipsychotic initiation (P < 0.0001). Fewer patients in the phenobarbital group compared to the benzodiazepine group received new mechanical ventilation (P = 0.045), but median duration was similar (1.2 vs 1.6 days; P = 1.00). Scheduled phenobarbital was associated with decreased hospital LOS compared to benzodiazepines for SAWS. This was the first study to compare outcomes of fixed-dose, nonoverlapping phenobarbital to benzodiazepines in patients with clearly defined SAWS and details a readily implementable protocol.

Severe COVID-19 infection: An institutional review and literature overview.

Our study aimed to describe the group of severe COVID-19 patients at an institutional level, and determine factors associated with different outcomes. A retrospective chart review of patients admitted with severe acute hypoxic respiratory failure due to COVID-19 infection. Based on outcomes, we categorized 3 groups of severe COVID-19: (1) Favorable outcome: progressive care unit admission and discharge (2) Intermediate outcome: ICU care (3) Poor outcome: in-hospital mortality. Eighty-nine patients met our inclusion criteria; 42.7% were female. The average age was 59.7 (standard deviation (SD):13.7). Most of the population were Caucasian (95.5%) and non-Hispanic (91.0%). Age, sex, race, and ethnicity were similar between outcome groups. Medicare and Medicaid patients accounted for 62.9%. The average BMI was 33.5 (SD:8.2). Moderate comorbidity was observed, with an average Charlson Comorbidity index (CCI) of 3.8 (SD:2.6). There were no differences in the average CCI between groups(p = 0.291). Many patients (67.4%) had hypertension, diabetes (42.7%) and chronic lung disease (32.6%). A statistical difference was found when chronic lung disease was evaluated; p = 0.002. The prevalence of chronic lung disease was 19.6%, 27.8%, and 40% in the favorable, intermediate, and poor outcome groups, respectively. Smoking history was associated with poor outcomes (p = 0.04). Only 7.9% were fully vaccinated. Almost half (46.1%) were intubated and mechanically ventilated. Patients spent an average of 12.1 days ventilated (SD:8.5), with an average of 6.0 days from admission to ventilation (SD:5.1). The intermediate group had a shorter average interval from admission to ventilator (77.2 hours, SD:67.6), than the poor group (212.8 hours, SD:126.8); (p = 0.001). The presence of bacterial pneumonia was greatest in the intermediate group (72.2%), compared to the favorable group (17.4%), and the poor group (56%); this was significant (p<0.0001). In-hospital mortality was seen in 28.1%. Most patients were male, obese, had moderate-level comorbidity, a history of tobacco abuse, and government-funded insurance. Nearly 50% required mechanical ventilation, and about 28% died during hospitalization. Bacterial pneumonia was most prevalent in intubated groups. Patients who were intubated with a good outcome were intubated earlier during their hospital course, with an average difference of 135.6 hours. A history of cigarette smoking and chronic lung disease were associated with poor outcomes.

Safety and Feasibility of a Fast-Track Pathway for Neurosurgical Craniotomy Patients: Bypassing the Intensive Care Unit

To describe the safety and feasibility of a fast-track pathway for neurosurgical craniotomy patients receiving care in a neurosciences progressive care unit (NPCU). Traditionally, most craniotomy patients are admitted to the neurosciences intensive care unit (NSICU) for postoperative follow-up. Decreased availability of NSICU beds during the coronavirus disease-2019 delta surge led our team to establish a de-novo NPCU to preserve capacity for patients requiring high level of care and would bypass routine NSICU admissions. Patients were selected a priori by treating neurosurgeons on the basis of the potential need for high-level ICU services. After operation, selected patients were transferred to the postoperative care unit, where suitability for NPCU transfer was reassessed with checklist-criteria. This process was continued after the delta surge. From July 1, 2021 to September 30, 2022, 57 patients followed the NPCU protocol. Thirty-four (59.6%) were women, and the mean age was 56 years. Fifty-seven craniotomies for 34 intra-axial and 23 extra-axial lesions were performed. After assessment and application of the checklist-criteria, 55 (96.5%) were transferred to NPCU, and only 2 (3.5%) were transferred to ICU. All 55 patients followed in NPCU had good safety outcomes without requiring NSICU transfer. This saved $143,000 and led to 55 additional ICU beds for emergent admissions. This fast-track craniotomy protocol provides early experience that a surgeon-selected group of patients may be suitably monitored outside the traditional NSICU. This system has the potential to reduce overall health care expenses, increase capacity for NSICU bed availability, and change the paradigm of NSICU admission.

Feasibility, acceptability, and usability of implementing a medical device-related pressure injury algorithm for critically ill patients using non-invasive ventilation

ObjectivesDescribe the feasibility, acceptability, and usability of implementing a nurse-led intervention to prevent medical device-related pressure injury in critical care patients using non-invasive ventilation during hospitalization. Study designA quality improvement project, using a descriptive single-arm study design with convenience sampling. Setting and participantsThis study was conducted at a Midwestern medical center with 640 beds (two hospital campuses). After an educational session, the nurse-led algorithm for non-invasive ventilation medical device-related pressure injury prevention was implemented in two critical care nursing units (cardiac medical progressive care and neurotrauma intensive care unit). Nursing staff were full or part-time critical care nurses. Main outcome measuresFeasibility, acceptability, and usability of the non-invasive ventilation medical device-related pressure injury algorithm were measured (bedside rounding and pre/post System Usability Scale). ResultsThirty-five nurses (52.2 %) completed a pre-educational survey; 8 (11.2 %) completed a post-survey. The total mean pre-survey score was 70.7 (SD ± 13.6) and the post-survey mean score was 71.3(SD ± 19.6). There was a statistically significant increase in the post-survey mean score {Χ2 (1, N = 43) = 43.5, p <.05}, however, the 0.06 increase was not clinically meaningful. Bedside rounding interviews (n = 22) indicated 82 % (n = 18) of the nurses used the algorithm. The SUS tool mean score was 83.3 (10.73) pre-implementation (n = 21); and 85.63 (8.26) post-implementation (n = 5), indicating clinical usability of the algorithm pre- and post-implementation. ConclusionThe feasibility, acceptability, and usability of implementing a medical device-related pressure injury algorithm for critically ill patients using non-invasive ventilation were demonstrated during this study. More nursing research is needed to develop scalable interdisciplinary clinical algorithms to reduce medical device-related pressure injuries in patients using non-invasive ventilation. Implications for clinical practiceThis study focused on the bedside usability of the algorithm in a clinical setting. Implementing this nursing-developed algorithm created an interdisciplinary framework in which nursing assessment may guide clinical care.

Nurse Practitioner/Physician Assistant Leader Rounds Can Improve Patient Satisfaction Scores

Leaders of the Cardiac Surgery Progressive Care Unit at an urban medical center in the mid-Atlantic United States were seeking to improve the patient satisfaction scores related to physician/provider communication on Hospital Consumer Assessment of Healthcare Providers and Systems scores. They noted that nurse practitioners and physician assistants could have a wider impact on patient care and satisfaction by having formalized nurse practitioners/physician assistants leader rounds—rounds not only based on the patient’s medical care but rather for assessing the patient’s satisfaction with communication and their collective medical care. Results of this new initiative were taken directly from the Cardiac Surgery Progressive Care Unit Hospital Consumer Assessment of Healthcare Providers and Systems scores and demonstrated a significant overall increase.

Management of multiple frostbite casualties at a burn center: San Antonio, Texas, 12–20 February 2021

BackgroundFrostbite is an insidious disease that normally affects people of cold climates. Winter Storm Uri, which occurred from February 12–20, 2021, created unique metrological conditions for Texas. It caused prolonged sub-freezing temperatures and led to rolling blackouts, affecting 2.8 million Texans including 300,000 people in San Antonio. We report 13 frostbite patients admitted to one burn center during this event. ObjectiveWe aimed to determine the at-risk population for frostbite, to categorize their injury severity, and to describe their treatment. A secondary aim was to describe the rehabilitation management of these patients. MethodsThis is a single-center retrospective study. Each patient’s injuries were assessed by a topographical grading system. Comparisons were made among those who were admitted to the intensive care unit (ICU), admitted to the progressive care unit (PCU), and treated as outpatients. ResultsThirteen patients were identified. Ten (76.9 %) considered themselves homeless, and 9 (69.2 %) were directly exposed to the elements. The median delay between time of injury and presentation to a medical facility was 3 days (IQR 1–6). Only 3 patients presented to a medical facility within 24 h. Six (46 %) sustained grade 2 injuries, 2 (15 %) sustained grade 3 injuries, and 5 (38%) sustained grade 4 injuries. Only one patient met criteria to receive tissue plasminogen activator (tPA), which was discontinued due to hematochezia. Patients admitted to the ICU, when compared to patients admitted to the ward, had a longer length of stay (median 73 days v. 12 days, p = 0.0215), and required more amputations at below-the-knee or higher levels (3 v. 0, p-value 0.0442). ConclusionIn a region unaccustomed and perhaps unprepared to deal with winter storms, the population is particularly vulnerable to frostbite. Lack of awareness of frostbite injuries likely led to the delay in the presentation of patients, which prevented the timely use of tPA. Increasing public awareness may increase readiness.

A Qualitative Study of Hospital Interior Environments during the COVID-19 Pandemic.

Human beings have encountered different infectious diseases. However, there is not much validated data available on the physical environments of hospitals when responding to highly contagious viruses, such as COVID-19. This study was conducted to assess the physical environments of hospitals during the COVID-19 pandemic. There exists a need to analyze whether the physical environments of hospitals were conducive or obstructive to medical practice during the pandemic. A total of forty-six staff working in intensive care units, progressive care units, and emergency rooms were invited to participate in a semi-structured interview. Out of this group, fifteen staff members participated in the interview. They were asked to list the changes made to the hospital's physical environment during the pandemic, which included equipping the hospital environment for medical practice and protecting staff from becoming infected. They were also asked about desirable improvements that they believe could increase their productivity and ensure safety. The results indicated the difficulty in isolating COVID-19 patients and converting a single occupancy room into a double occupancy room. Isolating COVID-19 patients made it easier for staff to care for the patients, but it made them feel isolated and at the same time increased the walking distance. Signs indicating a COVID area helped them to prepare for medical practices ahead of time. Glass doors provided greater visibility and enabled them to monitor the patients. However, the dividers installed at nursing stations were obstructive. This study suggests that further research should be conducted once the pandemic is over.

Partnering With Patients: Fall Prevention Agreement.

A fall prevention agreement was developed in a cardiac progressive care unit to engage patients and families on admission as partners in fall prevention. The postimplementation of the fall prevention agreement showed significant decreases in falls on this unit.

Pathway to Becoming a Progressive Care Certified Nurse.

Nurses working on progressive care units (PCUs) use specialized knowledge and skills to provide care to acutely ill patients. The literature suggests that specialty certification may have a positive impact on patient and nurse outcomes alike, although results are mixed. A project team set out to create a culture that encouraged nurses to pursue progressive care certified nurse (PCCN) certification on three cardiac medical PCUs at a large academic health center by implementing a Pathway to PCCN program, which is a structured, cohort-based approach to certification preparation.The primary aim of the intervention was to achieve a 10% PCCN certification rate within one year. Additionally, the project team evaluated whether participating in the Pathway to PCCN program affected staff nurses' self-reported confidence in their clinical judgment in 10 patient care domains: cardiac, pulmonary, behavioral, neurological, musculoskeletal, hematological, endocrine, gastrointestinal, renal, and multisystem.Project methods included structured strategies within a "4R" framework developed by the project team: recruitment, obtaining resources, providing reassurance, and celebrating certification through recognition. Project methods were evaluated using anonymous electronic surveys and staff interviews.The percentage of staff with PCCN certification increased from 0% to 15.2%. The average confidence levels reported by nurses who participated in the project (N = 64) increased in eight out of nine (89%) of the clinical judgment domains tested on the PCCN examination in Cohort 2, and in nine of the clinical judgment domains in Cohorts 1 and 3. Implementing a structured cohort pathway for specialty certification using the 4R framework is a strategy that can increase rates of specialty certification among eligible nurses.

Ethical Challenges and Implications of Deactivating Mechanical Circulatory Support for Patients With Preserved Cognitive Function.

Ethical Challenges and Implications of Deactivating Mechanical Circulatory Support for Patients With Preserved Cognitive Function.

Pulmonary Artery Catheter Education for Cardiac Progressive Care Unit Registered Nurses

Purpose: Pulmonary artery catheters (PAC) are utilized for diagnosis and management of pulmonary hypertension and heart failure in the CPCU at an academic medical center. Care of PAC was identified as an educational priority on the unit due to high staff turnover and the potential for complications secondary to PAC. Prior to the pandemic, Registered Nurses (RNs) on the unit received annual PAC education and new hires received training during orientation. However, pandemic meeting restrictions and de-prioritization of training precluded ongoing education, creating a knowledge gap.

Evidence Into Practice: Journal Clubs as an Implementation Strategy

Evidence Into Practice: Journal Clubs as an Implementation Strategy

Improving critical care patients' sleep quality in a surgical high-dependency unit: An evidence-based practice project.

Sleep is an essential basic need. However, patients in critical care often experience poor and fragmented sleep. As such, there is a need to examine strategies to promote sleep in critical care patients. This project aimed to promote sleep in surgical high-dependency patients through the implementation of evidence-based best practice. An evidence-based practice (EBP) project was implemented in May 2015 in a 24-bed surgical high-dependency (progressive care) unit in a public tertiary hospital in Singapore in three phases using the JBI framework. Outcomes measured were sleep quality, using the Richards-Campbell Sleep Questionnaire, and nurses' adherence to sleep promotion activities, using an audit tool adapted from the JBI-Practical Application of Clinical Education System. Data were collected at baseline, 1, 3, 6, and 12months. Getting Research into Practice analysis was done at each time point. A total of 120 patients were surveyed, and 150 observation audits were conducted over 1year. Sleep quality was similar between pre-audit (mean 53, SD 19.89) and month 1 (mean 54, SD 24.40), improved at month 3 (mean 64, SD 19.34), and sustained at month 6 (mean 64, SD 24.13) and 12 (mean 64, SD 19.4). The effect size between pre-audit and month 3 was a medium effect size of 0.49, which continued to improve at month 12, with a medium effect size of 0.56. Nurses' adherence to the EBP generally improved, and the thresholds of 80% were exceeded by month 12. Sleep is an essential basic need and can be improved through simple evidence-based interventions. Best practice for promoting sleep includes grouping nursing activities and reducing light and noise at night.