Elisabeth L. George

Nurse-Patient Communication Interactions in the Intensive Care Unit

BACKGROUND The inability to speak during critical illness is a source of distress for patients, yet nurse-patient communication in the intensive care unit has not been systematically studied or measured. OBJECTIVES To describe communication interactions, methods, and assistive techniques between nurses and nonspeaking critically ill patients in the intensive care unit. METHODS Descriptive observational study of the nonintervention/usual care cohort from a larger clinical trial of nurse-patient communication in a medical and a cardiothoracic surgical intensive care unit. Videorecorded interactions between 10 randomly selected nurses (5 per unit) and a convenience sample of 30 critically ill adults (15 per unit) who were awake, responsive, and unable to speak because of respiratory tract intubation were rated for frequency, success, quality, communication methods, and assistive communication techniques. Patients self-rated ease of communication. RESULTS Nurses initiated most (86.2%) of the communication exchanges. Mean rate of completed communication exchange was 2.62 exchanges per minute. The most common positive nurse act was making eye contact with the patient. Although communication exchanges were generally (>70%) successful, more than one-third (37.7%) of communications about pain were unsuccessful. Patients rated 40% of the communication sessions with nurses as somewhat difficult to extremely difficult. Assistive communication strategies were uncommon, with little to no use of assistive communication materials (eg, writing supplies, alphabet or word boards). CONCLUSIONS Study results highlight specific areas for improvement in communication between nurses and nonspeaking patients in the intensive care unit, particularly in communication about pain and in the use of assistive communication strategies and communication materials.

Nursing implications for prevention of adverse drug events in the intensive care unit.

Adverse drug events are common in the intensive care unit setting. Despite the existence of many long-standing safety principles (such as the “five rights”) and new mechanisms to promote medication safety, there is still a gap between practice and the goal of patient safety. This is the result of the many human and system factors that impact care delivery. Research supports the role of the nurse as having a positive impact on patient outcomes. Future research requires the evaluation of new strategies and technologies to support safe medication administration. For example, patient simulation is being used to teach student and novice nurses principles of medication administration in a “safe” setting that more closely resembles the clinical environment. The Institute of Nursing repeatedly has stressed the need to address the organizational, technical, and human issues that impact patient safety, with an emphasis on the need to transform the nurse work environment to keep patients safe. This transformation will require a new level of interdisciplinary research and nursing involvement to address better care for our patients and, in particular, reduce adverse drug events.

Social Support in Critically III Adults: A Replication

This study was designed to increase understanding of social support from the viewpoint of the critically ill adults. The authors investigated what the critically ill adults described as supportive behaviors, as well as the source of those behaviors. Open-ended interviews with 10 patients yielded rich data, which are presented in the article as cases illustrating the extremes of emotional support from physicians, nurses, hospital staff, family, and friends. The themes derived from the data stress the positive feelings of the participants when they believe they are being supported and the negative feelings when the patients believe they are not supported.

The role of the clinical nurse specialist in facilitating evidence-based practice within a university setting.

There are many changes occurring within the healthcare system today, bringing forth multiple challenges for nurses. Changes in reimbursement for hospitals and staffing shortages are impacting the ways that nurses are delivering care. During these changing times, it is essential that healthcare providers strive to maintain high-quality care and patient safety. Utilizing evidence-based practice (EBP) to guide the delivery of care is one way to ensure that high-quality outcomes are achieved. EBP is one of the driving forces to improve clinical practice and ensure patient safety within the healthcare system. The clinical nurse specialist is very instrumental in facilitating quality care and implementing EBP within the healthcare setting. Through the development of a multidisciplinary committee, the clinical nurse specialist can lead professional nurses in the implementation of EBP and facilitate practice changes to improve patient outcomes.

Reducing Length of Stay in Patients Undergoing Open Heart Surgery: The University of Pittsburgh Experience

The clinical pathway, one component of the case management model, was implemented at one university medical center in the coronary artery bypass surgical group. In this article, the authors describe the development, use, and evaluation of the clinical pathway. The role of the advanced nurse practitioner as the case manager is discussed. The initial data base created by the case manager includes patient demographics, daily progress, length of stay, charges, discharge disposition, and readmissions within 15 days. Data collected on all patients undergoing coronary artery bypass graft surgery from July 94 to October 94 are reported and compared with the benchmark set with the development of the clinical pathway. Strategies developed for future improvement in the clinical pathway process and data management are identified.

Clinical Practice Guideline: Safe Medication Use in the Icu

Objective: To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. Data Sources: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. Study Selection: Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. Data Extraction: Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. Data Synthesis: The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. Conclusions: This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

A process for instituting best practice in the intensive care unit

Goals of health care are patient safety and quality patient outcomes. Evidence based practice (EBP) is viewed as a tool to achieve these goals. Health care providers strive to base practice on evidence, but the literature identifies numerous challenges to implementing and sustaining EBP in nursing. An initial focus is developing an organizational culture that supports the process for nursing and EBP. An innovative strategy to promote a culture of EBP was implemented in a tertiary center with 152 critical care beds and numerous specialty units with diverse patient populations. A multi-disciplinary committee was developed with the goal to use evidence to improve the care in the critical care population. EBP projects were identified from a literature review. This innovative approach resulted in improved patient outcomes and also provided a method to educate staff on EBP. The committee members have become advocates for EBP and serve as innovators for change to incorporate evidence into decision making for patient care on their units.

Troponin targets cardiac injury: Learn about troponin levels so you can give your patient the best possible care.

15 Cardiac Insider IN THE PAST 2 DECADES, more blood tests have been developed for cardiac biomarkers, which have a role in diagnosis, prognosis, and intervention.1 (See Testing serum cardiac biomarkers.) Troponin is currently the selected biomarker for detecting cardiac injury, because it’s involved in the interaction between actin and myosin and a resulting cardiac contraction. In myocardial injury, troponin is released from the bonds of these contractile proteins and becomes detected in the circulation. Troponin, a three-protein complex consisting of troponins I, T, and C, is found in cardiac and skeletal muscle. Most of these proteins stored in myofibrils (bound) are key for calcium-regulated cardiac and skeletal contraction.2 Some troponin is also found in the cytosol (unbound). Troponins I (cTnI) and T (cTnT) are cardiac tissue-specific, but troponin C (cTnC) isn’t.3 Injured cardiac muscle releases troponin into the bloodstream. Thus, increased levels of cardiac troponin may suggest myocardial injury.2 Troponin released after cardiac injury usually remains elevated (its half-life is about 2 hours), leading to better identification of cardiac injury.2 Monoclonal antibodies can now detect cardiac troponins, resulting in immunoassays for blood measurement.

Overcoming nursing barriers to intensive care unit early mobilisation: A quality improvement project

OBJECTIVES To increase adherence with intensive care unit mobility by developing and implementing a mobility training program that addresses nursing barriers to early mobilisation. DESIGN An intensive care unit mobility training program was developed, implemented and evaluated with a pre-test, immediate post-test and eight-week post-test. Patient mobility was tracked before and after training. SETTING A ten bed cardiac intensive care unit. MAIN OUTCOME MEASURES The training programs efficacy was measured by comparing pre-test, immediate post-test and 8-week post-test scores. Patient mobilisation rates before and after training were compared. Protocol compliance was measured in the post training group. RESULTS Nursing knowledge increased from pre-test to immediate post-test (p<0.0001) and pre-test to 8-week post-test (p<0.0001). Mean test scores decreased by seven points from immediate post-test (80±12) to 8-week post-test (73±14). Fear significantly decreased from pre-test to immediate post-test (p=0.03), but not from pre-test to 8-week post-test (p=0.06) or immediate post-test to 8-week post-test (p=0.46). Post training patient mobility rates increased although not significantly (p=0.07). Post training protocol compliance was 78%. CONCLUSION The project successfully increased adherence with intensive care unit mobility and indicates that a training program could improve adoption of early mobility.

Transcatheter aortic valve implantation options for treating severe aortic stenosis in the elderly: the nurse's role in postoperative monitoring and treatment.

Severe calcific aortic stenosis (AS) is a progressive cardiac disease that predominantly affects elderly adults. The hallmark symptoms of AS include exertional dyspnea, angina, and syncope. Adults of advanced age do not usually seek treatment for symptoms until their quality of life is greatly diminished. The 2 standard treatments for severe AS are open aortic valve replacement and percutaneous valvuloplasty. As adults age, their comorbid medical conditions often make them too high of a surgical risk for traditional aortic valve replacement, and percutaneous valvuloplasty, although less invasive, often produces only temporary relief of AS symptoms. To provide severe AS patients with alternative less risky treatment options in their later years, transcatheter aortic valve implantation (TAVI) devices were developed. Through this overview of the disease progression of AS and the different TAVI devices and the insertion procedures, a better understanding of the initial postoperative nursing care associated with postoperative TAVI patient management will be achieved.