Surgical Intensive Care Unit Nurses Research Articles

116: DE-ESCALATING URINARY CATHETER OUTPUT MEASUREMENT REPORTING IN THE ICU: A QUALITATIVE SURVEY

Introduction: Indwelling urinary catheter utilization and catheter-associated urinary tract infection rates remain high among intensive care unit (ICU) patients despite targeted, best practice de-implementation efforts. ICU de-escalation protocols to decrease urinary catheter output measurement reporting could lead to increased urinary catheter removal. As part of our multimodal strategies to advance early urinary catheter removal in select patients, we evaluate attitudes and perceptions of urinary catheter necessity and hourly urine output measurement in the ICU. Methods: We conducted brief qualitative survey at an urban, academic medical center among surgical ICU nurses (RN’s), Advance practice providers (APP), and physicians (MD). Participants selection was random and based on if the patient had a urinary catheter in place. We assessed self-reported perceptions of hourly urine output need as well as perceived barriers toward de-escalation of urinary output measurement reporting (from hourly to q2 or q4hrs) and urinary catheter removal. Results: 51 survey responses were collected in the beginning of the academic calendar. Survey participants were 74.5 percent RN, 7.8 percent APP, and 15.7 percent MD. Most were aware of their ICU urinary catheter removal protocol (52.9%). Participants felt that for a given patient, 74.5% needed hourly urine output monitoring. The most cited indication of hourly urinary catheter measurements was “using urine measure as a marker of perfusion”, “hemodynamic instability”, and “acute kidney injury” (AKI). Missing acute changes related to perfusion or AKI was frequently reported as negative consequence of decreasing urinary catheter output measurement reporting. Being off vasopressors was the most common criteria reported to facilitate acceptance of less frequent urinary catheter output measurement reporting. Resolution of AKI and urinary retention were commonly reported as facilitators for urinary catheter removal. Conclusions: De-escalating urinary catheter output measurement reporting in the ICU is novel. There are notable barriers to this practice that need further exploration to potentially decrease urinary catheter utilization rates in the ICU.

Physical assessment skills practised by critical care nurses: A cross-sectional study.

Physical assessment skills are essential to clinical decision-making in nursing as they help nurses to identify and respond to patients' deterioration. Nurses develop confidence and can detect any out-of-range parameters in diagnosing and treating patients. Prior studies surveyed 120 skills but did not explicitly assess critical care. To determine the range of physical assessment skills practised by critical care nurses and their adoption factors. This study uses a cross-sectional survey design. A self-administered questionnaire evaluating 40 physical assessment skills was conducted with 133 staff nurses (response rate: 96.4%) in three critical care units at a Malaysian government hospital between November 2019 and January 2020. Most nurses applied 32 (80%) skills during every working shift, involving the vital signs and all body systems except the gastrointestinal system. Five skills (12.5%) were occasionally applied, while three skills (7.5%) were rarely applied or not part of most nurses' clinical practice. About 20% of the nurses did not routinely check the respiration rate. Medical and surgical intensive care unit nurses (U=1129, p < .001) and nurses who had served over 10 years (H (2) = 9.60, p=.008) used more physical assessment skills than others. Nurses felt that continuing nursing education, participating in relevant courses and implementing standardised forms to record physical assessments would improve the application of such skills. Clinical practice in these critical care settings challenges the assertion that physical assessment is vital to critical care nursing roles. Concerns highlighted by the nurses should be addressed by nursing management so that the application of physical assessment skills can be enhanced, especially in critical care settings. The findings indicated that physical assessment skills in critical care need to be improved. Education and training should emphasise these skills.

The Effects of Video Instruction on Neuroscience Intensive Care Unit Nursing Skills in Case Presentations and Neurological Examinations.

BACKGROUND: The emergence of neuroscience intensive care units (NSICUs) for the past decades has led to growing interest in targeted training for NSICU nurses. We sought to evaluate the use of video instruction on NSICU nurses' skills in case presentations and neurological examinations, which has timely advantages as an asynchronous and distanced learning modality. METHODS: We enrolled NSICU and surgical intensive care unit nurses who took shifts in the NSICU at our institution. Participants were observed by a neurocritical care attending physician presenting the clinical details of an admitted patient and conducting a neurological examination, with both parties completing a 10-item evaluation on NSICU nursing presentation and examination skills. Participants randomized to an intervention group were given access to an instructional video on NSICU nursing skills. A median of 21 days later, participants were observed by a physician blinded to study randomization, with both parties recompleting the evaluation. Differences between day 1 and day 21 scores were analyzed using paired sample t tests. RESULTS: Fifteen NSICU and 55 surgical intensive care unit nurses were enrolled. Surgical intensive care unit nurses in both the intervention and control groups had statistically significant improvement between day 1 and day 21 physician-rated scores, with a greater increase in the intervention group; self-rated scores did not change. For NSICU nurses, there were no differences in physician-rated or self-rated scores for either group. CONCLUSIONS: Surgical intensive care unit nurses who underwent direct observation and self-evaluation had improvement in physician-rated NSICU nursing skills, likely as these activities allowed for reflective observation in Kolb's experiential learning cycle. Greater improvement in participants who viewed an instructional video highlights its value as a teaching modality for nurses.

Collaboration Structures in COVID-19 Critical Care: Retrospective Network Analysis Study.

BackgroundFew intensive care unit (ICU) staffing studies have examined the collaboration structures of health care workers (HCWs). Knowledge about how HCWs are connected to the care of critically ill patients with COVID-19 is important for characterizing the relationships among team structures, care quality, and patient safety.ObjectiveWe aimed to discover differences in the teamwork structures of COVID-19 critical care by comparing HCW collaborations in the management of critically ill patients with and without COVID-19.MethodsIn this retrospective study, we used network analysis methods to analyze the electronic health records (EHRs) of 76 critically ill patients (with COVID-19: n=38; without COVID-19: n=38) who were admitted to a large academic medical center, and to learn about HCW collaboration. We used the EHRs of adult patients who were admitted to the COVID-19 ICU at the Vanderbilt University Medical Center (Nashville, Tennessee, United States) between March 17, 2020, and May 31, 2020. We matched each patient according to age, gender, and their length of stay. Patients without COVID-19 were admitted to the medical ICU between December 1, 2019, and February 29, 2020. We used two sociometrics—eigencentrality and betweenness—to quantify HCWs’ statuses in networks. Eigencentrality characterizes the degree to which an HCW is a core person in collaboration structures. Betweenness centrality refers to whether an HCW lies on the path of other HCWs who are not directly connected. This sociometric was used to characterize HCWs’ broad skill sets. We measured patient staffing intensity in terms of the number of HCWs who interacted with patients’ EHRs. We assessed the statistical differences in the core and betweenness statuses of HCWs and the patient staffing intensities of COVID-19 and non–COVID-19 critical care, by using Mann-Whitney U tests and reporting 95% CIs.ResultsHCWs in COVID-19 critical care were more likely to frequently work with each other (eigencentrality: median 0.096) than those in non–COVID-19 critical care (eigencentrality: median 0.057; P<.001). Internal medicine physicians in COVID-19 critical care had higher core statuses than those in non–COVID-19 critical care (P=.001). Nurse practitioners in COVID-19 care had higher betweenness statuses than those in non–COVID-19 care (P<.001). Compared to HCWs in non–COVID-19 settings, the EHRs of critically ill patients with COVID-19 were used by a larger number of internal medicine nurse practitioners (P<.001), cardiovascular nurses (P<.001), and surgical ICU nurses (P=.002) and a smaller number of resident physicians (P<.001).ConclusionsNetwork analysis methodologies and data on EHR use provide a novel method for learning about differences in collaboration structures between COVID-19 and non–COVID-19 critical care. Health care organizations can use this information to learn about the novel changes that the COVID-19 pandemic has imposed on collaboration structures in urgent care.

The relationship between surgical intensive care unit nurses' patient safety culture and adverse events.

Adverse events are often encountered in surgical intensive care units (ICUs), and most of them occur due to preventable errors. Establishment of a patient safety culture is recommended for preventing and reducing these errors. This study was performed to investigate the relationship between surgical ICU nurses' patient safety culture and adverse events. This was a cross-sectional descriptive study. The study was performed in the surgical ICUs of four university hospitals in Izmir province, Turkey and was conducted in accordance with the Declaration of Helsinki and approved by an Ethics Committee. The sample comprised 113 nurses working in the surgical ICUs of the hospitals between November 2018 and February 2019. Data were collected using a questionnaire that comprised a demographic form, adverse events form, and patient safety culture hospital questionnaire. Student's t test, one-way analysis of variance, and logistic regression analyses were used to evaluate the data. P values <.05 were considered significant. At the end of the study, nurses' level of patient safety culture was found to be intermediate (65.5%), with the highest average positive response rate (PRR) obtained for teamwork within the units (65.5%) and the lowest average PRR obtained for the frequency of adverse event reporting (25.3%). There was a significant correlation between patient safety culture and adverse events (r=0.027, P < .05). Surgical ICUs nurses' level of patient safety culture was average, and there was a significant correlation between patient safety culture and adverse events. Managers should establish a reliable system for reporting adverse events and encourage ICU nurses to report them. It is very important to adopt a non-punitive approach at instances when an adverse event is reported.

Implementing Cardiac Surgical Unit-Advanced Life Support Through Simulation-Based Learning: A Quality Improvement Project.

The European Association for Cardio Thoracic Surgery and the Society of Thoracic Surgeons endorse Cardiac Surgical Unit-Advanced Life Support, a protocol designed specifically for cardiothoracic surgical patients who suffer postoperative cardiac arrests. To enhance patient outcomes and to reduce death rates, cardiothoracic intensive care unit nurses must be able to perform the protocol with confidence, proficiency, and without delays. To this end, simulation-based learning (SBL) is a pedagogical method ideal for optimized learning. This quality improvement project was designed to implement a post-cardiac surgery resuscitation protocol in a nonacademic, community medical center to enhance nurse knowledge, confidence, and proficiency for optimal patient outcomes. The Cardiac Surgical Unit-Advanced Life Support is an evidence-based resuscitation protocol that was implemented using didactic, hands-on training, and SBL. It was evaluated using knowledge surveys, comparisons in nurse confidence and performance measures, and patient outcomes data. Nurses' knowledge gains (ie, mean test scores) on our test were statistically significant between 3 time points (F2,60 = 81.204, P < .001). Knowledge significantly increased from pre-education to immediate post-education (P < .001), but declined from immediate post-education to 3-month post-education assessments (P < .001); however, the 3-month post knowledge mean was still higher than the pre-education knowledge mean (P < .001). Nurses were confident in their ability to apply the protocol, although results failed to show a correlation between confidence and performance ability. Statistical significance for delay in cardiopulmonary resuscitation was found between pre- and post-nursing education patient cardiac arrest events (P = .05). Didactic and hands-on learning supported knowledge retention over time for cardiothoracic surgical intensive care unit nurses. Improving self-confidence and the application of an unfamiliar resuscitation protocol through SBL and any impact a training program has on patient outcomes will require ongoing practice and more evaluation.

Opinions of nurses on the ethical problems encountered while working as a team in intensive care units

BackgroundThe intensive care unit entails working as a team in rescuing patients from life-threatening conditions. The care being given by the team could also be done by nurses and other health professionals through the coordinated use of all medical practices.ObjectiveTo determine the opinion of nurses on the ethical problems they experienced while working as a team in the intensive care units of a university hospital.MethodThe descriptive research was conducted on nurses working in intensive care units (n = 96). A 56-item data collection form consisting of two parts developed by the researchers was used. Frequency (percent) and median were evaluated, and statistical calculations were used for group comparisons.ResultsOut of the 82 (85.4%) nurses who participated in the study, 65 (82.3%) were university graduates. About 52 (66.7%) of the participants were female with a mean age of 28.12 ± 5.84; 26 (31.6%) had intensive care certification, and 54 (65.1%) had ethical training. The internal intensive care unit nurses were less satisfied with their jobs, able to use tools, said that they had the right to refuse the patient compared to the surgical intensive care unit nurses. Discussion and conclusions: It is a positive situation for the participants to score low with ethical problems based on suggestion as the probability of meeting with their teammates. However, it is important that the problems that affect the motivation of the nurses are different according to the intensive care unit and the employees.

SBAR Tool Implementation to Advance Communication, Teamwork, and the Perception of Patient Safety Culture.

Current evidence reveals that surgical patients are more prone to adverse events when compared to any other population in the acute care setting. In a military training hospital, handoff communication between surgical intensive care unit (SICU) nurses, physicians, and anesthesia providers (certified registered nurse anesthetists and anesthesiologists) about patients being prepared for surgery was identified as a problem by an initial inquiry of the staff. This article discusses an evidence-based project (EBP) that utilized a standardized multidisciplinary Situation, Background, Assessment, Recommendation (SBAR) tool to improve communication, teamwork, and the perception of a patient safety culture between the SICU nurses and physicians and the anesthesia providers in preparation for surgery. The SICU and anesthesia departments received training on the SBAR tool, followed by a 7-week implementation period. Standardized handoff communication utilizing the SBAR method increased by 100%, and documentation of intraoperative antibiotics on the electronic medication administration record increased by 43%. Postimplementation results from the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture surpassed database benchmarks for handoffs and transitions, overall perception of patient safety culture, and teamwork across units. This project reinforced current evidence supporting the use of standardized handoff communication.

Burnout, Perceived Stress, and Job Satisfaction Among Trauma Nurses at a Level I Safety-Net Trauma Center.

Nurses are at the forefront of our health care delivery system and have been reported to exhibit a high level of burnout. Burnout and stress in trauma nurses at a safety-net hospital can negatively impact patient care. Safety-net hospitals are confronted with unique social, financial, as well as resource problems that can potentially make the work environment frustrating. The purpose of this study was to explore the levels of burnout, stress, and job satisfaction in nurses providing care to trauma patients at a Level I safety-net trauma center. A cross-sectional survey design was used to investigate principal factors including personal and professional demographics, burnout, perceived stress, and job satisfaction. Trauma nurses working at a Level I safety-net trauma center are stressed and exhibited moderate degree of burnout. The extent of emotional exhaustion experienced by the nurses varied with work location and was highest in surgical intensive care unit nurses. The level of job satisfaction in terms of opportunities for promotion differed significantly by race and the health status of the nurses. Satisfaction with coworkers was lowest in those nurses between the ages of 60-69 years. Female nurses were more satisfied with their coworkers than male nurses. In addition, the study revealed that significant relationships exist among perceived stress, burnout, and job satisfaction. Work environment significantly impacts burnout, job satisfaction, and perceived stress experienced by trauma nurses in a safety-net hospital. Nursing administration can make an effort to understand the levels of burnout and strategically improve work environment for trauma nurses in order to minimize stressors leading to attrition and enhance job satisfaction.

Empowering the "Cheerers": Role of Surgical Intensive Care Unit Nurses in Enhancing Family Resilience.

Supporting family resilience, the ability of families to rebound from stressful events, is a goal of family nursing. Critical care nurses act as liaisons between patients' families and other clinicians and thus are uniquely situated to promote family resilience. To explore how nurses perceive the experiences of long-stay surgical intensive care unit patients and their families in order to gain insights on how nurses could cultivate family resilience. A qualitative study including semistructured interviews (n = 13) and 4 focus groups (n = 17) with nurses in 3 surgical intensive care units in a large teaching hospital. Three themes were identified: expectations, support, and communication. Nurses noted that clinicians' and families' unrealistic expectations regarding the patient's recovery can foster false hope. Nurses recognized families as "cheerers" who provide support by being involved in patient care and observed how extensive family involvement can be beneficial to patients but overwhelming for families. Nurses noted that communication among providers, families, and patients is the cornerstone of creating meaningful relationships. Nurses stated that with many teams involved, discrepancies in information can occur and often confuse and disturb patients' families. Thus, nurses identified ways to enhance family resilience through routine and consistent communication. Nurses note unique stresses faced by families of patients in surgical intensive care units. Using the family resilience model, nurses can identify and enhance key family resilience factors.

Compassion Fatigue, Moral Distress, and Work Engagement in Surgical Intensive Care Unit Trauma Nurses

Preparation for replacing the large proportion of staff nurses reaching retirement age in the next few decades in the United States is essential to continue delivering high-quality nursing care and improving patient outcomes. Retaining experienced critical care nurses is imperative to successfully implementing the orientation of new inexperienced critical care nurses. It is important to understand factors that affect work engagement to develop strategies that enhance nurse retention and improve the quality of patient care. Nurses' experience of moral distress has been measured in medical intensive care units but not in surgical trauma care units, where nurses are exposed to patients and families faced with sudden life-threatening, life-changing patient consequences.This pilot study is a nonexperimental, descriptive, correlational design to examine the effect of compassion satisfaction, compassion fatigue, moral distress, and level of nursing education on critical care nurses' work engagement. This is a partial replication of Lawrence's dissertation. The study also asked nurses to describe sources of moral distress and self-care strategies for coping with stress. This was used to identify qualitative themes about the nurse experiences. Jean Watson's theory of human caring serves as a framework to bring meaning and focus to the nursing-patient caring relationship.A convenience sample of 26 of 34 eligible experienced surgical intensive care unit trauma nurses responded to this survey, indicating a 77% response rate. Twenty-seven percent of the nurses scored high, and 73% scored average on compassion satisfaction. On compassion fatigue, 58% scored average on burnout and 42% scored low. On the secondary traumatic stress subscale, 38% scored average, and 62% scored low. The mean moral distress situations subscale score was 3.4, which is elevated. The mean 9-item Utrecht Work Engagement Scale total score, measuring work engagement, was 3.8, which is considered low.Content analysis was used to identify themes of Role Conflict With Management/Rules, Death and Suffering, Dealing With Violence in the Intensive Care Unit, Dealing With Family, Powerlessness, Physical Distress, and Medical Versus Nursing Values. Additional themes identified were caring, helping families, long-time interdependent relationships of colleagues, and satisfaction in trauma nursing.As work engagement increased, compassion satisfaction significantly increased, and burnout significantly decreased. Results of this study support moral distress as a clinically meaningful issue for surgical intensive care unit nurses. Moral distress scales were elevated, whereas work engagement scales were low. This finding was congruent with Lawrence's study and may reflect ongoing need for greater supports for experienced intensive care unit nurses, from both education and management. Future recommendations for research include examining the interaction of these variables in larger samples to examine additional explanatory factors as well as strategies for self-care, motivation, and behavior change.

Nurse-Perceived Barriers to Effective Communication Regarding Prognosis and Optimal End-of-Life Care for Surgical ICU Patients: A Qualitative Exploration

Integration of palliative care for intensive care unit (ICU) patients is important but often challenging, especially in surgical ICUs (SICUs), in part because many surgeons equate palliative care with terminal care and failure of restorative care. SICU nurses, who are key front-line clinicians, can provide insights into barriers for delivery of optimal palliative care in their setting. We developed a focus group guide to identify barriers to two key components of palliative care-optimal communication regarding prognosis and optimal end-of-life care-and used the tool to conduct focus groups of nurses providing bedside care in three SICUs at a tertiary care, academic, inner city hospital. Using content analysis technique, responses were organized into thematic domains that were validated by independent observers and a subset of participating nurses. Four focus groups included a total of 32 SICU nurses. They identified 34 barriers to optimal communication regarding prognosis, which were summarized into four domains: logistics, clinician discomfort with discussing prognosis, inadequate skill and training, and fear of conflict. For optimal end-of-life care, the groups identified 24 barriers in four domains: logistics, inability to acknowledge an end-of-life situation, inadequate skill and training, and cultural differences relating to end-of-life care. Nurses providing bedside care in SICUs identify barriers in several domains that may impede optimal discussions of prognoses and end-of-life care for patients with surgical critical illness. Consideration of these perceived barriers and the underlying SICU culture is relevant for designing interventions to improve palliative care in this setting.

Nurse-Perceived Barriers to Effective Communication Regarding Prognosis and Optimal End-of-Life Care for Surgical ICU Patients: A Qualitative Exploration (314-A)

Abstract Background: Integration of palliative care for intensive care unit (ICU) patients is important but often challenging, especially in surgical ICUs (SICUs), in part because many surgeons equate palliative care with terminal care and failure of restorative care. SICU nurses, who are key front-line clinicians, can provide insights into barriers for delivery of optimal palliative care in their setting. Methods: We developed a focus group guide to identify barriers to two key components of palliative care—optimal communication regarding prognosis and optimal end-of-life care—and used the tool to conduct focus groups of nurses providing bedside care in three SICUs at a tertiary care, academic, inner city hospital. Using content analysis technique, responses were organized into thematic domains that were validated by independent observers and a subset of participating nurses. Results: Four focus groups included a total of 32 SICU nurses. They identified 34 barriers to optimal communication regarding prog...

The effects of preoperative visiting on the compliance of postoperative patients in SICU

Objective To investigate the value of preoperative visiting on improving compliance of postoperative patients in surgical intensive care unit (SICU) . Methods A total of 100 esophageal cancer patients were divided into control group and visiting group randomly. Patients in visiting group were accepted visiting by SICU nurses on 1 day before operation. We designed a questionnaire according to the features of patients with esophageal cancer. The cooperative levels of postoperative patients in SICU was observed and the questionnaire was filled in. The compliance was compared then. Results The patients in visiting group were more compliant the patients in control group significantly ( P ＜ 0. 05 ) . Conclusions Preoperative visiting can improve the compliance of postoperative patients in SICU. Key words: Intensive care unit, Preoperative visiting, Nursing

Improved nurse job satisfaction and job retention with the transition from a “mandatory consultation” model to a “semiclosed” surgical intensive care unit: A 1-year prospective evaluation*

The change from a "mandatory consultation" to a "semiclosed" surgical intensive care unit (SICU) model will impact nurses considerably. We hypothesize that nurse job satisfaction, job turnover rates, and hospital costs for temporary agency nurses will improve and these improvements will be more dramatic in SICU sections with greater involvement of a dedicated surgical critical care service (SCCS). Prospective longitudinal survey. Tertiary-care university hospital. SICU staff nurses. Change from mandatory consultation to semiclosed SICU. We surveyed SICU nurses during the year-long transition to a semiclosed SICU service (five time points, 3-month intervals). The first four surveys included ten questions on nurse job satisfaction. The final survey included two additional questions. All questions were on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Nurse job turnover rates and money spent on agency nurses were compared over time; 503 of a possible 914 surveys were completed (55% overall return rate). Nurse job satisfaction scores significantly improved over time for all questions (p < .05). Hospital spending on agency nurses decreased significantly (p = .0098). The yearly nurse job turnover rate dropped from 25% to 16% (p = .15). The scores for both year-end statements ("I am more satisfied with my job now than 1 year ago" and "The SCCS management of all orders has improved my job satisfaction") were significantly higher in sections with greater SCCS involvement (p = .0070 and p < .0001). Nurse job satisfaction improved significantly with the transition to a semiclosed SICU. This higher satisfaction was associated with a significant decrease in spending on temporary agency nurses and a trend toward increased staff nurse job retention. SICU sections with greater SCCS involvement had more dramatic improvements. This semiclosed SICU model may help retain SICU nurses in a competitive job market in which experienced nurses are in short supply.

A cluster of catheterized urinary isolates associated with opening the closed system of urinary drainage: Identification, investigation, and correction

BACKGROUND: This 586-bed acute care facility in Birmingham, Alabama, was alerted to a significant increase in hospital-associated catheterized urine isolates from June through July 2004. OBJECTIVES: Identify processes putting patients at risk, correct process breakdowns, and share information for future prevention with other clinical staff. METHODS: Data-mining services are provided to the medical center. Monthly reports are generated to detect unsuspected patterns of infection within the hospital and community. In July 2004, infection control (IC) received an alert describing a 700% increase (p=0.013) in patients with non-duplicate hospital-associated catheterized urine isolates from patients in the surgical intensive care unit (SICU). In addition to data-mining, the IC department maintains traditional surveillance for device-related infections. An increase in urinary tract infection (UTI) rates corresponded to the pattern reported by the data-mining service. Upon IC investigation it was discovered that during a recent product conversion, the surgical packs did not include urometer trays. The SICU nurses were breaking open the closed system to add urometers. During the investigation into this cluster, it was discovered that the patients on the rehabilitation unit were also experiencing an unacceptably high incidence of UTIs. The rehabilitation staff routinely disconnected the urinary drainage tubing to utilize leg bags. RESULTS: Interventions included adding drainage bags with urometer trays to the standard surgical packs. Education was provided to the SICU staff about the importance of maintaining a closed system. Education was also provided for the rehabilitation staff. Emphasis was placed on the importance of maintaining closed systems and hand hygiene. After the intervention, periodic feedback on the occurrence of positive urine isolates and UTI rates was provided to the unit director to share with the staff. CONCLUSION: Investigation of a cluster of hospital urinary isolates revealed previously unsuspected practices in additional hospital units. Interventions reduced or eliminated the incidence of UTIs in both areas.

The 360-degree evaluation: Increased work with little return?

To test a 360-degree resident evaluation tool on our trauma/critical care services to determine if multiple raters yielded equivalent information compared with traditional faculty evaluations. Prospective evaluation. Residents, nurses, faculty, and staff at an academic medical center. The evaluation tool was developed based on extensive qualitative analysis of 13 major medical specialties' Residency Review Committee (RRC) criteria relative to the ACGME competencies and then revised with content specific to surgery. The evaluation contained 19 items divided into ACGME competency areas. Each item was scored on a 1 to 9 Likert scale: 1 = not meeting expectations and 9 = exceeding expectations. Residents on the trauma and surgical intensive care unit rotations evaluated themselves, and they were also evaluated by chief residents, surgical intensive care unit fellows, faculty, surgical intensive care unit nurses, trauma nurse clinicians, and nurse practitioners. Multiple analyses of variance were used to compare ratings by rater groups. Ten residents were evaluated on the trauma service from April to August 2003. Between 74 and 106 evaluations were obtained per resident per competency area. Average scores across the competencies were remarkably similar, ranging from 6.18 for practice-based learning and systems-based practice to 6.54 for professionalism. Although there was variability within rater groups, ratings were not statistically different between groups for any ACGME competency. The 360-degree evaluation provide limited new information compared with traditional faculty ratings. Follow-up studies are required to confirm this finding with larger samples of residents and surgical specialties.

Mediastinal exploration in the surgical intensive care unit.

A continuing education program was developed after a need was identified within the surgical intensive care unit (SICU) for critical care nurses to be able to assist the cardiothoracic surgeon in performing an emergent mediastinal reexploration in the postcardiac surgical patient when an operating room team was unavailable. The program is targeted for SICU nurses experienced in caring for these patients.

Sedating critically ill patients: factors affecting nurses' delivery of sedative therapy

Critical care nurses often have wide discretion in managing the sedative therapy of patients receiving mechanical ventilation. Little is known about the factors and processes that influence sedative practice. To determine if nurses' personal beliefs about and attitudes toward critical illness and their goals for sedation influence the nurses' sedative practice, to discover whether social factors influence sedative therapy, and to describe the processes that nurses use to assess patients' need for sedative therapy. Audiotapes of focus group interviews with 5 groups of 34 experienced medical and surgical intensive care unit nurses from 2 hospitals were transcribed verbatim. Two investigators independently analyzed the verbatim text, and a sample of the participants validated the category summaries and interpretations. Patients' family members can affect sedative practice directly or indirectly, and demands for efficient delivery of care can influence sedative therapy. Primary indications for sedation included patients' comfort and amnesia and prevention of patients' self-injurious behaviors. Conflicts between physicians and nurses arose when explicit and shared goals for sedation were lacking. Participants noted that numerous factors impede routine use of sedation protocols even though use of the protocols may improve communication and promote uniformity of sedative practice. Social, personal, and professional factors influence sedative therapy. Future research should establish the relative importance of these factors and determine whether their impact is attenuated when sedation protocols are implemented.

A large outbreak of infections caused by a strain of staphylococcus aureus resistant to oxacillin and aminoglycosides

An extensive outbreak of nosocomial infections caused by oxacillinand aminoglycoside-resistant Staphylococcus aureus (OARSA) occurred over a 16 month period. A total of 349 isolates of OARSA were obtained from 174 patients. Colonization with OARSA was found in 92 patients. There were 120 infections in 82 patients; 50 were surgical wound infections, 13 were nonsurgical wound infections, six were pneumonias, 15 were urinary tract infections, 12 were intravenous site infections, and there were 19 episodes pf bacteremia (seven transient, 12 persistent). In patients with persistent bacteremia, the mortality rate was 33 percent. In patients treated for persistent bacteremia with vancomycin, the survival rate was 80 percent. Infections were highly associated with the surgical intensive care unit, and 90 percent of the isolates of OARSA tested had the same phage-type. Elderly patients with significant underlying disease, a history of previous surgery or of prior antimicrobial therapy appeared to be at increased risk for OARSA infections. OARSA were resistant to multiple antibiotics besides oxacillin, but all isolates were sensitive to vancomycin and rifampin. Three surgical intensive care unit nurses were found to be nasal carriers of OARSA, and one nurse had dermatitis of both hands colonized with OARSA. Following the removal of these nurses from the surgical intensive care unit and the institution of strict infection control measures, the number of OARSA infections and colonizations decreased to less than one per month. OARSA produces serious nosocomial disease, and epidemiologic intervention was effective in controlling this outbreak.