Dorrie K. Fontaine

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult

Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD; Donald B. Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD; William M. Coplin, MD; David W. Crippen, MD, FCCM; Barry D. Fuchs, MD; Ruth M. Kelleher, RN; Paul E. Marik, MDBCh, FCCM; Stanley A. Nasraway, Jr, MD, FCCM; Michael J. Murray, MD, PhD, FCCM; William T. Peruzzi, MD, FCCM; Philip D. Lumb, MB, BS, FCCM. Developed through the Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), in collaboration with the American Society of Health-System Pharmacists (ASHP), and in alliance with the American College of Chest Physicians; and approved by the Board of Regents of ACCM and the Council of SCCM and the ASHP Board of Directors

Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

Objective:To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002. Methods:The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks® database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (–) an intervention. A strong recommendation (either for or against) indicated that the intervention’s desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase “We recommend …” is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase “We suggest …” is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. Conclusion:These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Prioritizing the organization and management of intensive care services in the United States: The PrOMIS Conference

Objective:Adult critical care services are a large, expensive part of U.S. health care. The current agenda for response to workforce shortages and rising costs has largely been determined by members of the critical care profession without input from other stakeholders. We sought to elicit the perceived problems and solutions to the delivery of critical care services from a broad set of U.S. stakeholders. Design:A consensus process involving purposive sampling of identified stakeholders, preconference Web-based survey, and 2-day conference. Setting:Participants represented healthcare providers, accreditation and quality-oversight groups, federal sponsoring institutions, healthcare vendors, and institutional and individual payers. Subjects:We identified 39 stakeholders for the field of critical care medicine. Thirty-six (92%) completed the preconference survey and 37 (95%) attended the conference. Interventions:None. Measurements and Main Results:Participants expressed moderate to strong agreement with the concerns identified by the critical care professionals and additionally expressed consternation that the critical care delivery system was fragmented, variable, and not patient-centered. Recommended solutions included regionalizing the adult critical care system into “tiers” defined by explicit triage criteria and professional competencies, achieved through voluntary hospital accreditation, supported through an expanded process of competency certification, and monitored through process and outcome surveillance; implementing mechanisms for improved communication across providers and settings and between providers and patients/families; and conducting market research and a public education campaign regarding critical care’s promises and limitations. Conclusions:This consensus conference confirms that agreement on solutions to complex healthcare delivery problems can be achieved and that problem and solution frames expand with broader stakeholder participation. This process can be used as a model by other specialties to address priority setting in an era of shifting demographics and increasing resource constraints.

Therapeutic considerations in the management of agitated or delirious critically ill patients

Agitation and delirium in the critical care unit are common problems that at times are difficult to treat. The difficulty stems from few placebo‐controlled or even blinded trials evaluating various therapies. In addition, the literature in these areas is scattered through various journals in a variety of disciplines. Pharmacologic and nonpharmacologic techniques may achieve the therapeutic objective for these patients. Since no one drug will achieve the goals in every patient, therapy must be tailored to the characteristics and needs of each individual.

The evolving role of the acute care nurse practitioner in critical care.

Purpose of reviewThe newest nurse practitioner role is the acute care nurse practitioner. This paper presents the latest data on the role from both a US and international perspective. Recent findingsNow present in the USA for at least 15 years, the acute care nurse practitioner role has become well established in critical care settings and is moving into international healthcare. The few outcome studies conducted to date demonstrate the acute care nurse practitioner provides quality patient and family care, improves patient satisfaction, is cost effective, and is an answer to the hospitals shortage of medical residents with new restrictions on working hours. SummaryThe role of acute care nurse practitioners in critical care is increasing worldwide. Most countries are experimenting with this latest nurse practitioner as an extended-role healthcare provider with many potential benefits to patients and their families, as well as the healthcare system.

True collaboration: envisioning new ways of working together.

An Invitation The American Association of Critical-Care Nurses released its Standards for Establishing and Sustaining Healthy Work Environments in 2005. Through literature review and focus groups, 6 key components emerged as essential for the creation of a healthy work environment. True collaboration, one of the six, is the focus of our discussion. In the paragraphs that follow, we invite you to imagine what collaboration could look like in your organization and how you can implement strategies for enhancing collaboration. Through this vision, we can improve patient safety and create work environments that foster engagement and meaningful contribution. Together, we can bring into existence clinical environments in which we are all working together, not just side by side.

Achieving Transformational Change: Using Appreciative Inquiry for Strategic Planning in a School of Nursing

To achieve transformational change, a transformational approach is needed. The Appreciative Inquiry (AI) summit is a method that has been used to achieve transformational change in business for at least 20 years, but this innovative alternative approach is unknown to nursing. At the University of Virginia School of Nursing, an AI Summit was designed to bring all staff, faculty, student representatives, and members of the community together to rewrite the schools strategic plan. New connections within the school, the university, and the community were made when 135 participants engaged in the appreciative, 4-step AI process of discovering, dreaming, designing, and creating the schools future. During the summit, 7 strategic teams formed to move the school toward the best possible future while building on the existing positive core. This article describes 10 steps needed to design an AI summit and implications for using this method at other schools of nursing.

Meeting the Nursing Faculty Shortage Challenge: An Accelerated Doctoral Program in Nursing

In 2003, the Gordon and Betty Moore Foundation partnered with a major west coast school of nursing to create an accelerated doctoral program in nursing. The programs chief aim was to address the nursing shortage by increasing the number of nurse faculty by funding 42 doctoral students in five cohorts. Students accepted into the accelerated program receive a generous stipend and commit to earn their doctorate in 3 years and teach for 3 years after graduation at 1 of 17 area nursing programs. Two cohorts have graduated from the accelerated program and are currently in faculty positions. This article describes the accelerated doctoral program and the academic progression and postgraduation employment of the first two cohorts.

Prioritizing Clinician Wellbeing: The University of Virginia's Compassionate Care Initiative:

Background: Working in healthcare is increasingly challenging for nurses, physicians, and other health professionals. Ongoing high stress takes a toll on clinicians and interferes with the quality of their patient care. Fostering clinician wellbeing needs to be a priority; if not, the human and financial consequences are significant. Objective: To describe the University of Virginia (UVA) School of Nursings Compassionate Care Initiative (CCI) as an example of an organizational case study that is engaged in multi-pronged efforts to cultivate a resilient healthcare workforce committed to high-quality, compassionate, relationship-based care. Methods: This case report de scribes the development, implementation, and evaluation of the CCI at UVA. Various elements of the program are reviewed, which include harnessing talents and interests of the larger institution in the establishment of Compassionate Care Ambassadors, outreach to the community, innovative student-specific educational activities, and a national media program. Conclusion: The UVA CCI is a successful model of an organizational effort to promote clinician wellbeing and resilience. Aspects from this program can be adapted to other organizations that are committed to addressing this critical issue in US healthcare today.

Promoting a Healthy Workplace for Nursing Faculty and Staff

Promoting a healthy workplace in academic nursing settings is vital to recruit new faculty and enhance the work life of all faculty and staff for retention and happiness. When a healthy work environment is fostered, incivility becomes unacceptable, and individuals embrace a culture where all can flourish. This article addresses the imperative of a healthy workplace, with practical suggestions for making the academic setting in schools of nursing one of optimism and confidence where future generations of nurse leaders are developed.