Elizabeth Bridges

Oral Care Practices for Orally Intubated Critically Ill Adults

BACKGROUND Ventilator-associated pneumonia is a major threat to patients receiving mechanical ventilation in hospitals. Oral care is a nursing intervention that may help prevent ventilator-associated pneumonia. OBJECTIVES To describe oral care practices performed by critical care nurses for orally intubated critically ill patients and compare these practices with recommendations for oral care in the 2005 AACN Procedure Manual for Critical Care and the guidelines from the Centers for Disease Control and Prevention. METHODS A descriptive, cross-sectional design with a 31-item Web-based survey was used to describe oral care practices reported by 347 randomly selected members of the American Association of Critical-Care Nurses. RESULTS Oral care was performed every 2 (50%) or 4 (42%) hours, usually with foam swabs (97%). Oral care was reported as a high priority (47%). Nurses with 7 years or more of critical care experience performed oral care more often (P=.008) than did less experienced nurses. Nurses with a bachelors degree in nursing used foam swabs (P=.001), suctioned the mouth before the endotracheal tube (P=.02), and suctioned after oral care (P<.001) more often than other nurses. Nurses whose units had an oral care policy (72%) reported that the policy indicated using a toothbrush (63%), using toothpaste (40%), brushing with a foam swab (90%), using chlorhexidine gluconate oral rinse (49%), suctioning the oral cavity (84%), and assessing the oral cavity (73%). Oral care practices and policies differed for all those items. CONCLUSIONS Survey results indicate that discrepancies exist between reported practices and policies. Oral care policies appear to be present, but not well used.

Wartime Critical Care Air Transport

OBJECTIVES Describe the characteristics/enroute care of casualties transported by USAF Critical Care Air Transport Teams (CCATT) during Operation Enduring Freedom/Iraqi Freedom (OEF/OIF). METHODS Retrospective review of TRAC2ES and CCATT Mission Reports (Oct 2001-May 2006). RESULTS 3492 patient moves (2439 patients). Moves by route: within Area of Responsibility (AOR) (n = 261); AOR-Landstuhl (LRMC) (n = 1995), Germany-CONUS (n = 1188). For AOR-LRMC: BI (64%), NBI (8%), Disease (25%). Among injured (n = 1491), 69% suffered polytrauma, primarily d/t explosions. Injury area: extremities (63%), head (55%), thorax (46%), abdomen (31%), neck (17%). Injury type: soft tissue (64%), orthopedic (45%), thoracic (35%), skull fracture (27%), brain injury (25%). Disease diagnoses: cardiac (15%) and pulmonary (8%). CONCLUSIONS This is the first analysis of OEF/OIF CCATT patients. Phase 1 of this study demonstrates the strengths and limitations of TRAC2ES and CCATT Mission Reports to describe the characteristics/enroute care of this unique population.

Noninvasive measurement of body temperature in critically ill patients.

Elizabeth Bridges is an assistant professor at the University of Washington School of Nursing, a clinical nurse researcher at the University of Washington Medical Center in Seattle, and is director of Deployed Combat Casualty Research Team CJTF101 in Afghanistan. Karen Thomas, is a professor at the University of Washington School of Nursing. invasive methods (PA, esopha geal, or bladder), the following methods should be used in this order: rectal, oral, and tympanic. Axillary, temporal artery, and chemical dot thermometers are not recommended. In a subsequent series of letters to the editor, the author stated that temporal artery measurements were not recommended because Lawson et al found that 20% of the temporal artery temperature measurements were greater than ±0.5°C different from the concurrent PA temperature. However, as summarized in Table 1, the bias and precision of the oral and temporal artery methods were similar, and 19% of the oral measurements were also greater than ±0.5°C different from the concurrent PA temperature, suggesting that the 2 methods are comparable. Similarly, Fetzer and Lawrence recently compared ear-based and temporal artery temperature measurements and reported that the bias between the 2 methods was -0.4±0.64°C (95% CI, -1.29 to 1.21), which is less accurate and precise than either method compared with PA temperature measurement (Table 1). Unlike the studies outlined in Table 1, the difference between the ear-based and temporal artery methods reflects the error in both measurements, and we cannot say AElizabeth Bridges, RN, PhD, CCNS, and Karen Thomas, RN, PhD, reply:

Evaluating the Joint Theater Trauma Registry as a data source to benchmark casualty care

Just as data from civilian trauma registries have been used to benchmark and evaluate civilian trauma care, data contained within the Joint Theater Trauma Registry (JTTR) present a unique opportunity to benchmark combat care. Using the iterative steps of the benchmarking process, we evaluated data in the JTTR for suitability and established benchmarks for 24-hour mortality in casualties with polytrauma and a moderate or severe blunt traumatic brain injury (TBI). Mortality at 24 hours was greatest in those with polytrauma and a severe blunt TBI. No mortality was seen in casualties with polytrauma and a moderate blunt TBI. Secondary insults after TBI, especially hypothermia and hypoxemia, increased the odds of 24-hour mortality. Data contained in the JTTR were found to be suitable for establishing benchmarks. JTTR data may be useful in establishing benchmarks for other outcomes and types of combat injuries.

Evidence-Based Practice Habits: Transforming Research Into Bedside Practice

ctions speak louder than words. If that statement is true clinically, it could be said that nursing practice is more connected to tradition than it is evidence based. Many common practices in critical care nursing continue today despite clear and reliable research that contradicts them. The barriers to research implementation that were identified 3 decades ago—lack of time, insufficient administrative support, and limited access to information—are still daunting clinicians today. The importance of basing practice on research is well understood. The barrier is the actual transformation Evidence-Based Practice Habits: Transforming Research Into Bedside Practice

Pulmonary artery pressure monitoring: when, how, and what else to use.

The integration of data from a pulmonary artery catheter when used as part of a goal-directed plan of care may benefit certain groups of critically ill patients. Integral to the successful use of the pulmonary artery catheter is to accurately obtain and interpret invasive pressure monitoring data. This article addresses commonly asked clinical questions and considerations for decision making under complex care conditions, such as obtaining hemodynamic measurements when the patient is prone or has marked respiratory pressure variations or increased intraabdominal pressure. Recommendations to optimize the invasive pressure monitoring system are presented. Finally, functional hemodynamic indices, which are more sensitive and specific indices than static indices (pulmonary artery and right artrial pressure) of the ability to respond to a fluid bolus, will be introduced.

Advancing Critical Care Joint Combat Casualty Research Team and Joint Theater Trauma System

Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.

Occurrence of Secondary Insults of Traumatic Brain Injury in Patients Transported by Critical Care Air Transport Teams From Iraq/Afghanistan: 2003-2006

Traumatic brain injury patients are susceptible to secondary insults to the injured brain. A retrospective cohort study was conducted to describe the occurrence of secondary insults in 63 combat casualties with severe isolated traumatic brain injury who were transported by the U.S. Air Force Critical Care Air Transport Teams (CCATT) from 2003 through 2006. Data were obtained from the Wartime Critical Care Air Transport Database, which describes the patients physiological state and care as they are transported across the continuum of care from the area of responsibility (Iraq/Afghanistan) to Germany and the United States. Fifty-three percent of the patients had at least one documented episode of a secondary insult. Hyperthermia was the most common secondary insult and was associated with severity of injury. The hyperthermia rate increased across the continuum, which has implications for en route targeted temperature management. Hypoxia occurred most frequently within the area of responsibility, but was rare during CCATT flights, suggesting that concerns for altitude-induced hypoxia may not be a major factor in the decision when to move a patient. Similar research is needed for polytrauma casualties and analysis of the association between physiological status and care across the continuum and long-term outcomes.

Ecological model of disaster management

The ecological model of disaster management provides a framework to guide occupational health nurses who are developing disaster management programs. This ecological model assumes that disaster planning, preparedness, response, and recovery occur at various levels of the organization. These nested, increasingly complex organizational levels include individual and family, workplace, community, state, tribal, federal, and global levels. The ecological model hypothesizes that these levels interact and these dynamic interactions determine disaster planning, preparedness, response, and recovery outcomes. In addition to the features of the hazard or disaster, it is also assumed that parallel disaster planning, preparedness, and response elements, logistical challenges, and flexibility, sustainability, and rehabilitation elements occur at each level of the ecological model. Finally, the model assumes that evaluation of response and recovery efforts should inform future planning and preparedness efforts.

Care of the critically ill patient in a military unique environment: a program of research.

The goal of the Air Force Nursing Research Program at WHMC is to conduct research on topics unique to Air Force and military nursing. The nine stressors of flight and the military environment of care have been used as a conceptual model to guide the development of research studies. The studies conducted to date describe how the environment affects practice and when the environment directly affects the patient. The studies conducted are examples of the numerous military nursing research projects supported by funding from the TSNRP. The research funded by TSNRP contributes to the body of nursing knowledge by supporting scientific research, particularly knowledge that is unique to the military. As our nation faces the threat of chemical and biologic attacks, terrorism, and increased deployment of soldiers to battlefields in remote locations throughout the world, it is more important than ever that we ensure the advancement of military nursing research. Supporting research that advances healthcare in peace and in war is critical to the care of our military members and their families. This will require that research funds continue to be available to support military nursing research, that a strong infrastructure to provide resources in support of nursing research programs continues to exist, and that the military nursing corps continues to attract, train, and retain PhD prepared nurse researchers. Given the results of the research completed to date, the following evidence-based practice can be applied to the care of the patient described at the beginning of this article: The nurse positions the patient in the center of the cargo compartment, away from the bulkhead, toward the front of the aircraft, the warmest location during flight. While enroute, the patient will need to be positioned on an aerovac mattress, repositioned frequently, and have his/her heels elevated at all times. Additional padding may be needed for areas adjacent to the litter cross members to reduce pressure on the skin in areas prone to pressure ulcer formation. Should the patient need endotracheal suctioning, the nurse knows that hyperoxygenation-hyperinflation is effective in preventing suctioning-induced hypoxemia. In addition, the suction pressure will need to be increased to account for the effects of altitude without exceeding the pressure limits on the transport ventilator and causing catastrophic ventilator failure. Because there is not enough room on the litter for the chest tube drainage tubing to lay straight, it will be coiled and should dependent loops develop, they should be drained every 15 minutes. This is Air Force nursing research in practice.