Intensive Care Unit Staff Research Articles

An audit of perioperative end-of-life care practices and documentation relating to patients who died in a surgical unit in three Victorian hospitals.

The number of older, frail patients undergoing surgery is increasing, prompting consideration of the benefits of intensive treatment. Despite collaborative decision-making processes such as advance care planning being supported by recent Australian legislation, their role in perioperative care is yet to be defined. Furthermore, there has been little evaluation of the quality of end-of-life care in the surgical population. We investigated documentation of the premorbid functional status, severity of illness, intensity of treatment, operative management and quality of end-of-life care in patients who died in a surgical unit, with a retrospective study of surgical mortality which was performed across three hospitals over a 23-month period in Victoria, Australia. Among 99 deceased patients in the study cohort, 68 had a surgical operation. Preoperative functional risk assessment by medical staff was infrequently documented in the medical notes (5%) compared with activities of daily living (69%) documented by nursing staff. Documented preoperative discussions regarding the risk of death were rarely and inconsistently done, but when done were extensive. Documented end-of-life care discussions were identified in 71%, but were frequently brief, inconsistent, and in 60% did not occur until 48 hours from death. In 35.4% of instances, documented discussions involved junior staff (registrars or residents), and 43.4% involved intensive care unit staff. Palliative or terminal care referrals also occurred late (1-2 days prior to death). Not-for-resuscitation orders were frequently changed when approaching the end of life. Overall, 57% of deceased patients had a documented opportunity for farewell with family. We conclude that discussions and documentation of end-of-life care practices could be improved and recommend that all surgical units undertake similar audits to ensure that end-of-life care discussions occur for high-risk and palliative care surgical patients and are documented appropriately.

Ethical Lessons from an Intensivist's Perspective.

Intensive care units (ICUs) around the world have been hugely impacted by the SARS-CoV-2 pandemic and the vast numbers of patients admitted with COVID-19, requiring respiratory support and prolonged stays. This pressure, with resulting shortages of ICU beds, equipment, and staff has raised ethical dilemmas as physicians have had to determine how best to allocate the sparse resources. Here, we reflect on some of the major ethical aspects of the COVID-19 pandemic, including resource allocation and rationing, end-of-life decision-making, and communication and staff support. Importantly, these issues are regularly faced in non-pandemic ICU patient management and useful lessons can be learned from the discussions that have occurred as a result of the COVID-19 situation.

A Remote Patient-Monitoring System for Intensive Care Medicine: Mixed Methods Human-Centered Design and Usability Evaluation.

BackgroundContinuous monitoring of vital signs is critical for ensuring patient safety in intensive care units (ICUs) and is becoming increasingly relevant in general wards. The effectiveness of health information technologies such as patient-monitoring systems is highly determined by usability, the lack of which can ultimately compromise patient safety. Usability problems can be identified and prevented by involving users (ie, clinicians).ObjectiveIn this study, we aim to apply a human-centered design approach to evaluate the usability of a remote patient-monitoring system user interface (UI) in the ICU context and conceptualize and evaluate design changes.MethodsFollowing institutional review board approval (EA1/031/18), a formative evaluation of the monitoring UI was performed. Simulated use tests with think-aloud protocols were conducted with ICU staff (n=5), and the resulting qualitative data were analyzed using a deductive analytic approach. On the basis of the identified usability problems, we conceptualized informed design changes and applied them to develop an improved prototype of the monitoring UI. Comparing the UIs, we evaluated perceived usability using the System Usability Scale, performance efficiency with the normative path deviation, and effectiveness by measuring the task completion rate (n=5). Measures were tested for statistical significance using a 2-sample t test, Poisson regression with a generalized linear mixed-effects model, and the N-1 chi-square test. P<.05 were considered significant.ResultsWe found 37 individual usability problems specific to monitoring UI, which could be assigned to six subcodes: usefulness of the system, response time, responsiveness, meaning of labels, function of UI elements, and navigation. Among user ideas and requirements for the UI were high usability, customizability, and the provision of audible alarm notifications. Changes in graphics and design were proposed to allow for better navigation, information retrieval, and spatial orientation. The UI was revised by creating a prototype with a more responsive design and changes regarding labeling and UI elements. Statistical analysis showed that perceived usability improved significantly (System Usability Scale design A: mean 68.5, SD 11.26, n=5; design B: mean 89, SD 4.87, n=5; P=.003), as did performance efficiency (normative path deviation design A: mean 8.8, SD 5.26, n=5; design B: mean 3.2, SD 3.03, n=5; P=.001), and effectiveness (design A: 18 trials, failed 7, 39% times, passed 11, 61% times; design B: 20 trials, failed 0 times, passed 20 times; P=.002).ConclusionsUsability testing with think-aloud protocols led to a patient-monitoring UI with significantly improved usability, performance, and effectiveness. In the ICU work environment, difficult-to-use technology may result in detrimental outcomes for staff and patients. Technical devices should be designed to support efficient and effective work processes. Our results suggest that this can be achieved by applying basic human-centered design methods and principles.Trial RegistrationClinicalTrials.gov NCT03514173; https://clinicaltrials.gov/ct2/show/NCT03514173

Impact of the Organizational Model Adopted during the COVID-19 Pandemic on the Perceived Safety of Intensive Care Unit Staff.

Background: The SARS-CoV-2 pandemic had a devastating health, social, and economic effect on the population. Organizational, technical and structural operations aimed at protecting staff, outpatients and inpatients were implemented in an Italian hospital with a COVID-19 dedicated intensive care unit. The impact of the organizational model adopted on the perceived safety among staff was evaluated. Methods: Descriptive, structured and voluntary, anonymous, non-funded, self-administered cross-sectional surveys on the impact of the organizational model adopted during COVID-19 on the perceived safety among staff. Results: Response rate to the survey was 67.4% (153 completed surveys). A total of 91 (59%) of respondents had more than three years of ICU experience, while 16 (10%) were employed for less than one year. Group stratification according to profession: 74 nurses (48%); 12 medical-doctors (7%); 11 physiotherapists (7%); 35 nurses-aides (22%); 5 radiology-technicians (3%); 3 housekeeping (1%); 13 other (8%). The organizational model implemented at ISMETT made them feel safe during their workday. A total of 113 (84%) agreed or strongly agreed with the sense of security resulting from the implemented measures. A vast majority of respondents perceived COVID-19 as a dangerous and deadly disease (94%) not only for themselves but even more as vectors towards their families (79%). A total of 55% of staff took isolation measures and moved away from their home by changing personal habits. The organizational model was perceived overall as appropriate (91%) to guarantee their health. Conclusion: The vast majority of respondents perceived the overall model applied during an unexpected, emergency situation as appropriate.

Endotracheal Tube Cuff Pressure Management: An Observational Study Guided by the SEIPS Model.

The aim of the rigorous endotracheal tube cuff pressure (ETTCP) management is to maintain cuff pressures within the recommended values during the mechanical ventilation period. However, hyperinflation or hypoinflation of cuff has been reported because of inconsistent clinical practices in intensive care unit (ICU) settings. Furthermore, there is no available best evidence for clinical decision-making regarding the ETTCP management provided by international institutes. The aim of this study was to examine the ETTCP management work system in ICU settings in urban hospitals of Turkey and the United States using the Systems Engineering Initiative for Patient Safety model. This was a direct observational, prospective field study, in which the COREQ (Consolidated Criteria for Reporting Qualitative Research) tool was used. The direct observations and follow-up interviews were conducted, and the results were reported using the Systems Engineering Initiative for Patient Safety model. We identified important characteristics of the ETTCP management work system in each of the 4 ICU and differences across the settings. Common use of the evidence-based and internationally used protocols may standardize the management of ETTCP, improve communication among ICU staff, and promote desired patient outcomes. There is a need for developing strategies to provide standardized ETTCP management and to improve patient's quality of care. To improve the patient outcomes and quality of care, ICU managers should consider clear expectations for ETTCP management in each job description, structured and evidence-based protocols, and effective communication among disciplines and provide teaching opportunities to encourage physicians, nurses, and respiratory therapists to meet their educational needs.

Strategies to Improve Mother's Own Milk Expression in Black and Hispanic Mothers of Premature Infants.

Mother's own milk (MOM) is the gold standard of nutrition for premature infants. Yet, Hispanic and Black preterm infants are less likely than their White counterparts to receive MOM feedings. Evidence is lacking concerning potential modifiable factors and evidence-based strategies that predict provision of MOM among minority mothers of premature infants. A review of the literature was conducted to answer the clinical question: "What evidence-based strategies encourage and improve mother's own milk expression in Black and Hispanic mothers of premature infants?" Multiple databases including PubMed, Cochrane, and CINAHL were searched for articles published in the past 10 years (2010 through May 2020), reporting original research and available in English. Initial search yielded zero articles specifically addressing the impact of lactation interventions on MOM provision in minority mothers. Additional studies were included and reviewed if addressed breastfeeding facilitators and barriers (n = 3) and neonatal intensive care unit breastfeeding support practices (n = 7). Current strategies used to encourage and improve MOM expression in minority mothers are based on or extrapolated from successful strategies developed and tested in predominantly White mothers. However, limited evidence suggests that variation in neonatal intensive care unit breastfeeding support practices may explain (in part) variation in disparities and supports further research in this area. Neonatal intensive care unit staff should consider implementing scaled up or bundled strategies showing promise in improving MOM milk expression among minorities while taking into consideration the cultural and racial norms influencing breastfeeding decisions and practice. Experimental studies are needed to evaluate the effectiveness of targeted and culturally sensitive lactation support interventions in Hispanic and Black mothers.

Well-being in the Intensive Care Unit: Looking Beyond COVID-19.

Burnout among critical care personnel has increased due to the additional psychological and physical demands of caring for critically ill patients with limited resources. Factors that increase the risk of burnout include compassion fatigue, lack of control over the work environment, difficult interpersonal relationships, and constant exposure to end-of-life issues. Organizational commitment to physician wellbeing depends on improving workplace efficiency, recognizing stressors in the critical care environment, and providing resources to help manage staffing shortages. Community building, training in communication, and team-building strategies are important steps in building collaboration and camaraderie in the workplace.

The effects of the Critical-Care Pain Observation Tool on pain assessment/management nursing practices in an intensive care unit with brain-injured critically ill patients

Accurate pain assessment and management in critically ill patients withcognitive alterations who are unable to communicate constitute a major challenge for themedical and nursing staff of Intensive Care Units (ICUs). This study want assess the impact of Critical Care Pain Observation Tool (CCPOT) scale in ICU practice and evaluate the effects on pain assessment and management in brain-injured critically ill adult patients. This before-and-after study was carried out in an Italian ICU, where data were collected before (T0) and after (T1) implementation of the CCPOT in brain-injured critically ill adults. The study population consisted of 81 patients (35 before and 46 after intervention). The use of propofol fell significantly and at the same time the use of morphine increase significantly (morphine: t(80) = 1.51, p =.02) after intervention.Analysis of the data with respect to pain relief and prevention during some nursing care activities revealed a significant increase in the use of fentanyl citrate and paracetamol. Pain management was in line with the protocol, which envisaged administration of pain medications to patients with CCPOT scores less than 3 in 76.8% of cases. The present findings strongly support the value of the CCPOT scale in managing ICU patient pain in conjunction with medical and nursing staff training. However, further studies of larger patient samples should be performed.

The Vicious and Virtuous Facets of ICU Structure

Background: In the provision of medical facilities, intensive care units are very critical and it seems almost difficult to use the new therapeutic strategies without Intensive Care Unit (ICU). There are two types of ICU structure, known as the open or closed model. The aim of this study was to assess the variables driving the selection of the appropriate ICU management structure and modeling of the appropriate ICU management structure.Methods: This descriptive-exploratory study was performed among all resident doctors, consultants, therapists and neurosurgeons, ICU specialists, internal medicine specialists, respiratory diseases specialists, heads of associated units and head nurses, neurosurgery ICU workers and staff, and doctors of the Loghman Hakim Hospital in Tehran, Iran in 2018. The influence of independent variables on dependent variables and the effect of observed variables on latent variables were tested using the Structural Equation Technique (SEM technique) and the data collected in the LISREL program was analyzed.Results: This research included one hundred persons, including 91 men and 9 women. The factors affecting the performance and structure of the ICU were structural context (including open, semi-closed, and closed structure), organizational context, strategic context, treatment economics context, processes, and quality improvement.Conclusion: There is a good association between quality management and the application of the closed system of the ICU and each of the organizational, strategic, care economics, and processes factors.

Moral distress, emotional impact and coping in intensive care unit staff during the outbreak of COVID-19

BackgroundFrom the beginning, the COVID-19 pandemic increased ICU workloads and created exceptionally difficult ethical dilemmas. ICU staff around the world have been subject to high levels of moral stress, potentially leading to mental health problems. There is only limited evidence on moral distress levels and coping styles among Spanish ICU staff, and how they influenced health professionals’ mental health during the pandemic. ObjectivesTo assess moral distress, related mental health problems (anxiety and depression), and coping styles among ICU staff during the first wave of the COVID-19 pandemic in Spain. DesignCross-sectional. Settings and participantsThe study setting consisted of intensive care unit and areas converted into intensive care units in public and private hospitals. A total of 434 permanent and temporary intensive care staff (reassigned due to the pandemic from other departments to units) answered an online questionnaire between March and June 2020. MethodsSociodemographic and job variables, moral distress, anxiety, depression, and coping mechanisms were anonymously evaluated through a self-reported questionnaire. Descriptive and correlation analyses were conducted and multivariate linear regression models were developed to explore the predictive ability of moral distress and coping on anxiety and depression. ResultsMoral distress during the pandemic is determined by situations related to the patient and family, the intensive care unit, and resource management of the organisations themselves. intensive care unit staff already reached moderate levels of moral distress, anxiety, and depression during the first wave of the pandemic. Temporary staff (redeployed from other units) obtained higher scores in these variables (p = 0.04, p = 0.038, and p = 0.009, respectively) than permanent staff, as well as in greater intention to leave their current position (p = 0.03). This intention was also stronger in health staff working in areas converted into intensive care units (45.2%) than in normal intensive care units (40.2%) (p = 0.02). Moral distress, coupled with primarily avoidance-oriented coping styles, explains 37% (AdR2) of the variance in anxiety and 38% (AdR2) of the variance in depression. ConclusionsOur study reveals that the emotional well-being of intensive care unit staff was already at risk during the first wave of the pandemic. The moral distress they experienced was related to anxiety and depression issues, as well as the desire to leave the profession, and should be addressed, not only in permanent staff, but also in temporary staff, redeployed to these units as reinforcement workers.

Experiences of Conscious Patients Undergoing Tracheal Intubation; A Qualitative Study

Background: Tracheal intubation is a life-saving action in situations such as respiratory failure. However, this therapeutic approach may produce a series of side effects and physiological stress, such as pain, insomnia, anxiety, fear, etc. Methods: The present study is a qualitative research with a content analysis method conducted for a period of two years. This study's required information has been collected using non-structured face-to-face interviews with 22 patients hospitalized in emergency and intensive care units. The data were analyzed using open coding and MAXQDA 12. Results: Findings from the interviews' were divided into two main categories of mental and physical experiences. Mental experiences are divided into 12 sub-categories and physical experiences into 7 sub-categories, each of them is also divided into further categories. Inability to speak is the most frequent complaint of patients in this study. The pain was the most common physical complaint of patients, mostly due to pain in the organs and pain due to blood sampling. Conclusion: Despite special training of medical staff in emergency and intensive care units to take care of patients and to obviate their special needs, it is observing that some patients under certain conditions such as intubation still face many unmet needs.

Psychiatric management of Patients in intensive care units.

Psychiatric management of Patients in intensive care units.

Sources of noise and their effects on nurses in intensive care units: A cross sectional study

BackgroundNoise is a serious threat to the health of people. In Intensive Care Units (ICU), the higher level of noise may negatively affect the health of the patients and health care staff. ObjectivesTo determine the sources of noise and the related adverse effects from the ICU nurses’ viewpoints. MethodsThe study sample included all nurses (148) working in ICUs. The data collection tool was a three-section questionnaire. The first section was related to personal- occupational characteristics. The second part evaluated internal and external noise sources from the nurses' viewpoints. The third section assessed the effect of noise on four domains: physiology, emotions, subjective perception, and performance. The data were analyzed by SPSS version 22, using descriptive and inferential statistics. ResultsThe results showed that the major internal sources of noise were monitoring alarms and ventilators (61.5%).The highest and lowest mean ± SD of the scores about the effect of noise on the study domains were related to physiology (16.1 ± 4.8) and performance (14.9 ± 5.25). The three domains' scores (subjective perception, emotions, physiology) had significant relationship with the bed occupancy rate, the type of ICU, and the number of beds (P < 0.05). Also, the performance domain's scores had a significant relationship with work experience, bed occupancy rate, and shift type (P < 0.05). ConclusionsSince ambient noise is a threat to health and disturbs the patients and ICU staff, we believe that proper strategies should be designed to reduce its levels.

Comparison of Hand Hygiene Adherence Rate before and after Training in a Multispecialty Hospital, Gujarat, India

Introduction: The most effective way to break the chain of transmission of infection in healthcare facility is Hand Hygiene (HH). However, the HH adherence rate/compliance is varying worldwide. Healthcare facilities should follow comprehensive, systematic approach for assessment of HH adherence rate. Periodic monitoring and necessary feedback is critical to improve HH adherence rate/compliance. Aim: To know the impact of the HH training of Healthcare Workers (HCW) on HH adherence rate. Materials and Methods: This prospective study was conducted at SMS Multispecialty Hospital, Ahmedabad, Gujarat, India. The study was conducted for the duration of six months (October 2019-March 2020). Total 416 opportunities were accessed in two sessions {203 pretraining and 213 post-training} among different HCWs of ICU and NICU. HH adherence rate was measured by direct observation methods by trained, non participating neutral person as per World Health Organisation (WHO) HH guidelines. HH training was given to HCWs (doctors, nursing staff and attendant) of Intensive Care Unit (ICU) and Neonatal Intensive Care Unit (NICU). Pre and post-training HH adherence rate was calculated among HCWs of ICU and NICU in respect to WHO’s five movement of HH. Chi-square test was used to do statistical analysis. Results: Pre and post-training HH adherence rate of HCWs of ICU is 41% and 69% respectively. However, pre and post- training HH adherence rate of HCWs of NICU was 52% and 75%, respectively. Both ICU and NICU post-training HH adherence rate of HCWs was improved which was statistically significant (p-value &lt;0.00001). Both pre and post-training, compared to doctors, nursing staff had better HH adherence rate (45%, 67% in ICU and 58% and 78% in NICU). Hand rub was preferred method of HH (93%). Conclusion: The HH training improved the HH adherence rate of HCWs of ICU and NICU. Induction and periodic training of HCWs improves HH adherence rate of HCWs.

Improving wellbeing in intensive care units

Introduction: Intensive Care Units (ICU) are inherently stressful workplaces. Stress impacts staff’s emotional resilience, health, and capacity to provide care. Many industries acknowledge the advantages of promoting “healthy workplaces”. Despite the benefits, limited research has explored how wellbeing can be improved for ICU staff.

The need for clinical ethics consultation: a monocentric observational survey study in the intensive care unit (Consul.E.T.I. study)

BackgroundThe current organizational structure of the Italian healthcare system does not include the institutionalization of clinical ethics services.To describe the need for structured clinical ethics consultation services for ICU staff members in the intensive care unit (ICU), a monocentric observational survey study was performed utilizing a paper-based questionnaire.ResultsA total of 73 healthcare professionals (HCPs) responded out of a team of 84 people (87%). The results showed that the need for ethics consultation in the ICU is urgent, the institutionalization of the clinical ethics service is perceived as useful and should be a priority, and the issues on which the HCPs would like ethics consultation to focus are various and belong to “end of life” topics.ConclusionsHCPs believe that the clinical ethicist should become an integral part of ICU healthcare teams, offering consultations similar to the other specialistic consultations carried out in hospitals.

Survey of intensive care unit staff views on a newly introduced reusable isolation gown.

AHR explores major national and international health issues and questions. Our readership includes managers, policy makers and clinical staff in health organisations including government departments, hospitals, community centres and aged-care facilities as well as all others with an interest in the health industry. It enables health professionals to keep their fingers on the pulse of the nation´s health decisions and to know what the most influencial commentators and decision makers are thinking. It also publishes new research from practitioners - managers and clinicians - and reports of breakthrough projects that demonstrate better ways of delivering care.

Assessment of venous thromboembolism prophylaxis practice in medical-surgical adult ICU: A cross sectional study

BackgroundVenous thromboembolism (VTE) is a condition in which blood clots develop in the deep veins, especially in the lower limb veins. Intensive care unit (ICU) patients have a greater risk of thrombotic events due to additional risk factors such as immobilization, mechanical ventilation, and central catheters. In medical-surgical critically ill patients, the occurrence of symptomatic or asymptomatic DVT without thromboprophylaxis is 13–31%. ObjectiveTo assess the practice of venous thromboembolism prophylaxis in medical-surgical adult ICU. MethodsAll consecutive critically ill patients in ICU from January 10, 2021, to Jun 9, 2021, were included in the study. Data were collected using reviewing the patient chart and interviewing the responsible body in ICU including the residents and nurses. The same patient was not included twice within the same cycle, or in the second cycle, if he/she was still in the ICU at the time of the second cycle excluded by observing previous patient ID. The data was processed and analyzed by using SPSS version 20 and Microsoft Excel 2010. ResultA total of 90 surgical-medical ICU patients were observed. All of the patients in the sample were receiving some form of VTE prophylaxis (100%), but none of them (0%) had the risk stratification documented in the chart. Conclusionand recommendations: It's critical to emphasize the importance of VTE risk stratification documentation in patients' charts. We recommend that the ICU staffs to follow a specific protocol for VTE risk stratification and prophylaxis dosing based on well-known guidelines and recommendations and that once that protocol is implemented, an awareness and education campaign be applied.

Bundle care - prevention of pneumonia in patients mechanically ventilated in COVID-19 pandemia - a challenge for patients and personnel safety

Intensive care units are characterized by the high risk of infections in patients. Pneumonia is one of the most common forms of infection with a high risk of death. Hence, to improve patient safety, specific packages of procedures, the so-called "bundle care," are recommended by experts in the field. The usage of selected protective procedures carries the risk of transmitting microbes from patients to staff, which in the case of pathogens such as SARS-CoV-2 can have serious health consequences for staff. Therefore, medical staff of intensive care units should strictly follow recommendation concerning healthcare workers safety and the rules of isolation, which in the current pandemic should be supplemented with specific elements. The paper presents an overview of the optimization of patient care and staff safety within the so-called "bundle care" in the COVID-19 pandemic. Med Pr. 2021;72(6):721-8.

An investigation on the cognition of neonatal pain assessment and analgesia management among medical staff in the neonatal intensive care unit.

To investigate the current status of the cognition of neonatal pain assessment and analgesia management among medical staff in the neonatal intensive care unit (NICU). A self-made scale was developed according to "Expert consensus on neonatal pain assessment and analgesia management (2020 edition)" and was used to distribute questionnaires to the medical staff in the NICU from the member units of Jiangsu Province Medical Quality Control Centre of Neonatal Department to evaluate their levels of understanding the basic knowledge, assessment, and management of neonatal pain. A total of 957 questionnaires (from 383 doctors and 574 nurses) were collected. Doctors and nurses had mean correct rates of 38% and 39% respectively in answering the questions on the basic knowledge of neonatal pain. They had median correct rates of 0% and 50% respectively in answering the questions on neonatal pain assessment, and mean correct rates of 73% and 68% respectively in answering on analgesia management. Compared with those who did not receive the training on neonatal pain, the medical staff who received such training had significantly higher correct rates in answering the questions on the basic knowledge of neonatal pain and neonatal pain assessment (P<0.05). The medical staff from tertiary hospitals had significantly higher correct rates in answering the questions on the basic knowledge of neonatal pain and neonatal pain assessment than those from secondary hospitals (P<0.05). The medical staff in the NICU have insufficient cognition of neonatal pain, and thus it is necessary to carry out the special training on neonatal pain, focusing on the promotion and practical application of "Expert consensus on neonatal pain assessment and analgesia management (2020 edition)", in order to improve the level of neonatal pain assessment and analgesia management among medical staff in the NICU.