Alberto Lucchini

Nursing Activities Score (NAS): 5 Years of experience in the intensive care units of an Italian University hospital

OBJECTIVE To retrospectively analyse the application of the Nursing Activities Score (NAS) in an intensive care department from January 2006 to December 2011. METHOD The sample consists of 5856 patients in three intensive care units (GICU: General Intensive Care Unit, NeuroICU: Neurosurgical Intensive Care Unit, CICU: Cardiothoracic Intensive Care Unit) of an Italian University hospital. The NAS was calculated for each patient every 24 hours. In patients admitted to general ICU, the following scores: SAPS 2 and SAPS 3 (Simplified Acute Physiology Score), RASS (Richmond Agitation Sedation Scale) and Braden were also recorded along with the NAS. RESULTS The mean NAS for all patients was 65.97% (Standard Deviation ± 2.53), GICU 72.55% (± 16.28), NeuroICU 59.33% (± 16.54), CICU 63.51% (SD ± 14.69). The average length of hospital stay (LOS) was 4.82 (SD ± 8.68). The NAS was high in patients with increasing LOS (p<0.003) whilst there were no significant differences for age groups except for children 0-10 years (p<0.002). The correlation of NAS and SAPS 2 was r=0.24 (p=0.001), NAS and SAPS 3 r=-0.26 (p=0.77), NAS and RASS r=-0.23 (p=0.001), NAS and Braden r=0.22 (p=0.001). CONCLUSIONS This study described the daily use of the NAS for the determination of nursing workload and defines the staff required.

Open intensive care units: a global challenge for patients, relatives, and critical care teams.

Aim: The aims of this study were to describe the current status of intensive care unit (ICU) visiting hours policies internationally and to explore the influence of ICUs’ open visiting policies on patients’, visitors’, and staff perceptions, as well as on patients’ outcomes. Methods: A review of the literature was done through MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The following keywords were searched: “visiting,” “hours,” “ICU,” “policy,” and “intensive care unit.” Inclusion criteria for the review were original research paper, adult ICU, articles published in the last 10 years, English or Italian language, and available abstract. Results: Twenty-nine original articles, mainly descriptive studies, were selected and retrieved. In international literature, there is a wide variability about open visiting policies in ICUs. The highest percentage of open ICUs is reported in Sweden (70%), whereas in Italy there is the lowest rate (1%). Visiting hours policies and number of allowed relatives are variable, from limits of short precise segments to 24 hours and usually 2 visitors. Open ICUs policy/guidelines acknowledge concerns with visitor hand washing to prevent the risk of infection transmission to patients. Patients, visitors, and staff seem to be inclined to support open ICU programs, although physicians are more inclined to the enhancement of visiting hours than nurses. Discussion: The percentages of open ICUs are very different among countries. It can be due to local factors, cultural differences, and lack of legislation or hospital policy. There is a need for more studies about the impact of open ICUs programs on patients’ mortality, length of stay, infections’ risk, and the mental health of patients and their relatives.

Tracheal Secretion Management in the Mechanically Ventilated Patient: Comparison of Standard Assessment and an Acoustic Secretion Detector

BACKGROUND: Standard indications for endotracheal suctioning are often based on clinical judgment on the deterioration of the patients condition, and/or routine suctioning. TBA Care is a secretion detector that analyses airway sounds and indicates the need for suctioning. OBJECTIVE: To determine the efficacy of TBA Care in detecting retained secretions, compared to standard indications. METHODS: We conducted a prospective randomized trial with 72 general intensive care unit patients randomized at intubation into 2 groups, differing only in suctioning indications. The control group indications were at least 3 scheduled suctionings per day or were clinically driven. The secretion-detector group indications were device signal or clinically driven. At each suctioning session we recorded the indication for suctioning and the amount of secretions removed. Patients were followed until intensive care unit discharge or extubation. Diagnosis of ventilator-associated pneumonia was confirmed via microbiological analysis of suctioned secretions. RESULTS: We analyzed 1,705 suctionings in the control group and 1,354 in the secretion-detector group. The secretion-detector group had fewer suctionings per day (3.9 ± 2.3 vs 4.8 ± 1.2, P = .002) and a lower rate of unnecessary suctionings (4% vs 12%, P < .001). In the secretion-detector group, 97% of the suctionings were performed following the signal from the TBA Care device. In the control group, clinical deterioration (65%) was the most frequent indication for suctioning. The incidence of ventilator-associated pneumonia was similar in the groups. CONCLUSIONS: TBA Care seems to give valid and timely indications for suctioning, anticipating clinical deterioration due to secretion retention and reducing unnecessary suctionings. (ClinicalTrials.gov registration NCT00932776.)

Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study☆☆☆★

PURPOSE Prone positioning (PP) improves oxygenation and outcome of patients with acute respiratory distress syndrome undergoing invasive ventilation. We evaluated feasibility and efficacy of PP in awake, non-intubated, spontaneously breathing patients with hypoxemic acute respiratory failure (ARF). MATERIAL AND METHODS We retrospectively studied non-intubated subjects with hypoxemic ARF treated with PP from January 2009 to December 2014. Data were extracted from medical records. Arterial blood gas analyses, respiratory rate, and hemodynamics were retrieved 1 to 2 hours before pronation (step PRE), during PP (step PRONE), and 6 to 8 hours after resupination (step POST). RESULTS Fifteen non-intubated ARF patients underwent 43 PP procedures. Nine subjects were immunocompromised. Twelve subjects were discharged from hospital, while 3 died. Only 2 maneuvers were interrupted, owing to patient intolerance. No complications were documented. PP did not alter respiratory rate or hemodynamics. In the subset of procedures during which the same positive end expiratory pressure and Fio2 were utilized throughout the pronation cycle (n=18), PP improved oxygenation (Pao2/Fio2 124±50 mmHg, 187±72 mmHg, and 140±61 mmHg, during PRE, PRONE, and POST steps, respectively, P<.001), while pH and Paco2 were unchanged. CONCLUSIONS PP was feasible and improved oxygenation in non-intubated, spontaneously breathing patients with ARF.

[Invasive and non-invasive ventilation: impact on nursing workload].

INTRODUCTION Non invasive ventilation (NIV) is increasingly used in intensive and non intensive wards. OBJECTIVE To detect the impact of ventilation modes on nursing workload. METHODS Retrospective observational study of 200 patients admitted to a general Intensive Care Unit (ICU). Nursing Activities Score (NAS) was used to measure the nursing workload. Patients enrolled were treated with the following ventilation modes: oxygen therapy without positive end-expiratory pressure (PEEP), helmet Continuous Positive Airway Pressure (CPAP), controlled mechanical ventilation, Invasive pressure support ventilation (I-PSV). RESULTS The overall mean NAS score of patients was 74.3% (SD ±8.88 - range 39/143) corresponding to an ideal nurse/patient ratio of 0.7 and varied with the different ventilation modes. In the days in oxygen therapy, the average NAS was 64.5% (±11.9), with helmet CPAP 69.7% (±12.7), with controlled mechanical ventilation 86.1% (SD ±15.1) and with invasive assisted ventilation 76.4% (±11.4) [p=0.0001]. In patients with helmet CPAP the NAS increased of 14% when FiO2 >0.6 and PEEP >10 compared to oxygen therapy. The average NAS score of the 15 patients (7.5%) with mask-PSV was 80.2% (±12:5). CONCLUSIONS Overall, the nursing workload of patient with helmet CPAP was lower than with invasive ventilation. In Helmet CPAP, with FiO2 >0.6 and PEEP level >10 cmH2O and mask-PSV, the nursing workload is similar to that of patients with invasive ventilation. NAS scores in patients with Invasive ventilation in the controlled mode is higher than with assisted mode.

“Extended subcutaneous route” technique: a quick subcutaneous tunnelling technique for PICC insertion

Purpose To describe a quick tunnelling technique for peripherally inserted central catheter (PICC) insertion called the “extended subcutaneous route” technique. Methods The “extended subcutaneous route” technique is described step by step. Results In 18 consecutive PICCs, inserted with extended route technique in ASST Monza, no complications during insertion were registered. In 969 catheter days observed, we identified only one accidental dislodgement. No other mid-term complications were observed. Conclusions Extended subcutaneous route technique allows the creation of a subcutaneous tunnel <5 cm, without skin incision and additional manipulation. Extended subcutaneous route technique may be feasible and useful, particularly for patients with high risk of bleeding or infection.

The strange and conflicting world of nursing

Dear Editor, We read with interest the paper by Hartog and Benbenishty published in the October issue of Intensive Care Medicine [1]. We wish to make some points about the conflicts between nurses and physicians during their work-shifts in intensive care units. The issue described by the authors recalls the concept of ‘‘moral distress’’: a challenge that comes up when a nurse gives an ethical or moral judgment about an issue, differing from others who are in charge [2]. Moral distress occurs when one person is aware of the correct actions to be done, but institutional constraints prevent their accomplishment [2]. There is a negative correlation between moral distress and good nurse–physician relationships (r = -0.25, P = 0.03), thus increasing the chance of healthcare staff conflicts [3]. Hartog and Benbenishty address the inter-professional conflicts related to numerous factors: procedural, organizational, relational, and contextual [1]. We think that the anthropological factor, related to the theory of ‘‘oppressive group behaviors’’, may play a role in this scenario [4] (Fig. 1). Roberts [4] stated that doctors and managers (the dominant groups) impose their values upon the oppressed groups (in this case nurses). This fact creates lack of self-esteem and pride, fear, silence, and self-contempt, generating emotional distress and consequent aggressive behaviors and exclusion among the members of the oppressed group [4]. This phenomenon is labeled ‘‘lateral (or horizontal) violence’’ and, when it happens, contributes to worsen the workplace climate, followed by potential negative consequences on inter-professional relationships, quality of care, and patient safety [5]; basically, the disparity of decisional power between doctors and nurses gets wider when the nursing groups are undermined by internal conflicts. On the contrary, we have scarce information about young physicians being overpowered and pressured by older and experienced ICU nurses, at least in our settings. Furthermore the low nurse to patient ratio, which is not always guaranteed to be 1:2, can increase nursing activities and tighten the socalled task time imperatives, thus reducing time for teamwork and increasing possible conflicts in the team. Lastly, in our opinion, the nursing profession carries some unique stigmata, since we have no information about similar levels of intraand inter-professional conflicts amongst other healthcare professionals such as radiographers, biomedical laboratory technologists, or physiotherapists. We believe that an enduring low social recognition of nursing may be more

In vitro evaluation of fluid reflux after flushing different types of needleless connectors

Purpose To evaluate fluid reflux, when disconnecting syringe, for different needleless connectors. Materials Nine connectors were tested; 540 measurements were carried out. Results The connectors tested showed very different performances, about reflux, on disconnection of the syringe used for flushing. The calculated reflux volumes are: Max Zero® - BD: 6.90 (±2.47) mm3; MicroClave Clear® - ICU Medical: 6.14 (±1.46) mm3; Bionecteur® - Vygon: 1.24(±0.73) mm3; Neutron® - ICU Medical: 0.12 (±0.15) mm3; SmartSite® Carefusion: 33.51 (±11.50) mm3; Safe Plus® - Cremascoli: 23.54 (±3.56) mm3; NeutraClear® - Cair: 9.36 (±1.87) mm3; NeutroX® - Cair: 0.33 (±0.31) mm3; Dasa® BTC: 2.38 (±1.67) mm3. Differences between investigated devices were statistically significant (p<0.001). Discussion It is difficult to establish the best quality-price ratio for needleless connectors. It is important to consider several variable factors: continuous or discontinuous infusion, catheter type, usage environment and caliber of catheter used. It would therefore be useful to have an indication of the intraluminal space potentially affected by blood reflux in relation to a specific device. Conclusions Needleless connector is one of the main factors involved in keeping catheter patency. It is important to perform the best choice among the connectors available. An empirical reflux measurement, relative to the needleless connector and the catheter in use, can be obtained using an 18G cannula.

Pain assessment scales in nonverbal critically ill adult patients: ventilator-related issues

critical points regarding these scales. First, the CPOT and the BPS do not have a specific item for patients who are in a coma (Glasgow Coma Scale ≤8), with artificial airways (eg, tracheostomy tube), who are breathing spontaneously without receiving mechanical ventilation. Other important concerns are items that evaluate patients’ compliance with ventilators. When patients cough we expect to hear the sound of ventilator alarms, which occurs only if alarms have been adequately set up. Consequently, the evaluation of this item is dependent on the variability of clinical settings and health care professionals. Another element that can make it difficult to recognize a patient “fighting with the ventilator” is the use of ventilation modes based on active expiration valves (eg, BIPAP, Drager; DuoPAP, Hamilton; BiVent, Siemens; Bi-Level, Puritan BennettCovidien). These ventilation modes let the patients breathe spontaneously, without activating the ventilator alarms. The identification of patient-ventilator asynchronies is made by the direct observation of patients and the interpretation of ventilator waveforms. A recent European survey has shown a wide variability in ventilator education provided to ICU nurses. Unfortunately we do not know how many nurses are “comfortable” with ventilator graph interpretation, even if 83% consider waveform analysis education “important” or “very important.” Presently, there is a lack of papers published about this issue. Finally, some clinical conditions, not necessarily related to pain, can determine the activation of ventilator alarms due to patients’ dyssynchronies: hiccup and seizures. These conditions can determine false positive results. We hope that our observations can be helpful to improve these pain assessment tools for critically ill patients. CCN

Preventing workplace incivility, lateral violence and bullying between nurses A narrative literature review.

Abstract Introduction: according to available literature workplace incivility, lateral violence and bullying among nurses are widely diffused. Their negative consequences and the outcomes on nurses and healthcare organizations have been well described. However, real pro-active and reactive actions to manage these issues, seem to be poorly recognized and investigated. Aim: to summarize the results of international studies regarding the prevention of individual and collective reactions towards workplace incivility, lateral violence, and bullying between nurses. Methods: a narrative literature review was performed. Results: 7 original papers were included in this review. The implementation of zero tolerance policies and passive dissemination of information about these phenomena showed to be clearly ineffective. Conclusions: The limited number of evidence based studies and the typologies of interventions (mainly educational rather than team building programs and assertive communication) show inadequate effectiveness plus a lacking in the scientific evidence-based support. The need to find out innovative and “creative” solutions to face these problems has been suggested by different authors.