Mary Fran Tracy

Effects of Patient-Directed Music Intervention on Anxiety and Sedative Exposure in Critically Ill Patients Receiving Mechanical Ventilatory Support: A Randomized Clinical Trial

IMPORTANCE Alternatives to sedative medications, such as music, may alleviate the anxiety associated with ventilatory support. OBJECTIVE To test whether listening to self-initiated patient-directed music (PDM) can reduce anxiety and sedative exposure during ventilatory support in critically ill patients. DESIGN, SETTING, AND PATIENTS Randomized clinical trial that enrolled 373 patients from 12 intensive care units (ICUs) at 5 hospitals in the Minneapolis-St Paul, Minnesota, area receiving acute mechanical ventilatory support for respiratory failure between September 2006 and March 2011. Of the patients included in the study, 86% were white, 52% were female, and the mean (SD) age was 59 (14) years. The patients had a mean (SD) Acute Physiology, Age and Chronic Health Evaluation III score of 63 (21.6) and a mean (SD) of 5.7 (6.4) study days. INTERVENTIONS Self-initiated PDM (n = 126) with preferred selections tailored by a music therapist whenever desired while receiving ventilatory support, self-initiated use of noise-canceling headphones (NCH; n = 122), or usual care (n = 125). MAIN OUTCOMES AND MEASURES Daily assessments of anxiety (on 100-mm visual analog scale) and 2 aggregate measures of sedative exposure (intensity and frequency). RESULTS Patients in the PDM group listened to music for a mean (SD) of 79.8 (126) (median [range], 12 [0-796]) minutes/day. Patients in the NCH group wore the noise-abating headphones for a mean (SD) of 34.0 (89.6) (median [range], 0 [0-916]) minutes/day. The mixed-models analysis showed that at any time point, patients in the PDM group had an anxiety score that was 19.5 points lower (95% CI, -32.2 to -6.8) than patients in the usual care group (P = .003). By the fifth study day, anxiety was reduced by 36.5% in PDM patients. The treatment × time interaction showed that PDM significantly reduced both measures of sedative exposure. Compared with usual care, the PDM group had reduced sedation intensity by -0.18 (95% CI, -0.36 to -0.004) points/day (P = .05) and had reduced frequency by -0.21 (95% CI, -0.37 to -0.05) points/day (P = .01). The PDM group had reduced sedation frequency by -0.18 (95% CI, -0.36 to -0.004) points/day vs the NCH group (P = .04). By the fifth study day, the PDM patients received 2 fewer sedative doses (reduction of 38%) and had a reduction of 36% in sedation intensity. CONCLUSIONS AND RELEVANCE Among ICU patients receiving acute ventilatory support for respiratory failure, PDM resulted in greater reduction in anxiety compared with usual care, but not compared with NCH. Concurrently, PDM resulted in greater reduction in sedation frequency compared with usual care or NCH, and greater reduction in sedation intensity compared with usual care, but not compared with NCH. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00440700.

Comparison of health-related quality-of-life outcomes of men and women after coronary artery bypass surgery through 1 year: findings from the POST CABG Biobehavioral Study.

BACKGROUND Women undergoing coronary artery bypass graft (CABG) surgery have a worse medical condition and fewer social and financial resources than men. Some studies have found that women recover less well than men after CABG, whereas others have found womens outcomes comparable to those of men. Past studies of health-related quality of life after CABG have too few women for adequate comparison with men and have not included patients whose data are not available at baseline (eg, emergency CABG), limiting generalizability. METHODS A longitudinal study of symptoms and health-related quality of life was conducted among patients from four clinical centers enrolling both men (n = 405) and women (n = 269) in the Post CABG Biobehavioral Study in the United States and Canada. RESULTS After 6 weeks from CABG (average 81 days), both men and women had less anxiety and symptoms related to depression than before surgery (P <.001). After 6 months (average 294 days), both men and women improved in physical and social functioning (P <.001). Although changes in scale scores were similar for men and women at each time point, women scored lower than men on these domains (P <.001, adjusted for baseline medical and sociodemographic differences) and had more symptoms related to depression through 1 year after CABG (P =.003). CONCLUSIONS Both male and female patients improve in physical, social, and emotional functioning after CABG, and recovery over time is similar in men and women. However, womens health-related quality-of-life scale scores remained less favorable than mens through 1 year after surgery.

Overcoming the Obstacles to Research-Based Clinical Practice

The utilization of research findings in the practice of critical care nursing is essential to obtain optimal patient outcomes. However, the speed and extent to which new research-based findings are applied to clinical practice falls short of expectations. The authors identify obstacles to the timely utilization of research. Strategies to overcome the obstacles to research-based clinical practice are presented.

Critical care nurses’ desire to use complementary alternative modalities (cam) in critical care and barriers to cam use

There is burgeoning literature supporting an increase in consumer demands for complementary alternative therapies/modalities (CAM). Popularity of these unconventional therapies requires critical care (CC) nurses to keep informed and to be responsive regarding patients’ use of CAM therapies. Critical care nurses were surveyed regarding their desire to use CAM and their perceptions of barriers for CAM use.

Achieving Quality Patient- Ventilator Management: Advancing Evidence-Based Nursing Care

This article presents suggestions for nurses to gain skill, competence, and comfort in caring for critically ill patients receiving mechanical ventilatory support, with a specific focus on education strategies and building communication skills with these challenging nonverbal patients. Engaging in evidence-based practice projects at the unit level and participating in or leading research studies are key ways nurses can contribute to improving outcomes for patients receiving mechanical ventilation. Suggestions are offered for evidence-based practice projects and possible research studies to improve outcomes and advance the science in an effort to achieve quality patient-ventilator management in intensive care units.

Part I: The Effects of Music for the Symptom Management of Anxiety, Pain, and Insomnia in Critically Ill Patients: An Integrative Review of Current Literature.

Critical care environments are known for provoking anxiety, pain, and sleeplessness. Often, these symptoms are attributed to patients’ underlying physiological conditions; life-sustaining or life-prolonging treatments such as ventilators, invasive procedures, tubes, and monitoring lines; and noise and the fast-paced technological nature of the critical care environment. This, in turn, possibly increases length of stay and morbidity and challenges the recovery and healing of critically ill patients. Complementary therapies can be used as adjunctive therapies alongside pharmacological interventions and modalities. One complementary therapy with promise in critical care for improving symptoms of anxiety, pain, and sleeplessness is music. A review of current literature from Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and PubMed was conducted to examine the evidence for the use of this complementary therapy in critical care settings. This review presents the evidence on effectiveness of music for the symptom management of anxiety, pain, and insomnia in critically ill adult patients. The evidence from this review supports music in symptom management of pain, insomnia, and anxiety in critically ill patients. This review provides practice recommendations, generates dialog, and promotes future research. This review is part I of a 2-part series that focuses on evidence for use of music, aromatherapy and guided imagery for improving anxiety, pain, and sleeplessness of patients in critically ill patients.

Safety and Acceptability of Patient-Administered Sedatives During Mechanical Ventilation

Background Safety and acceptability of sedative selfadministration by patients receiving mechanical ventilation is unknown. Objectives To determine if self‐administration of dexmedetomidine by patients is safe and acceptable for selfmanagement of anxiety during ventilatory support. Methods In a pilot trial in 3 intensive care units, 17 intubated patients were randomly assigned to dexmedetomidine and 20 to usual care. Dexmedetomidine was administered via standard pumps for patient‐controlled analgesia, with a basal infusion (0.1–0.7 &mgr;g/kg per hour) titrated by the number of patient‐triggered doses (0.25 &mgr;g/kg per dose). Safety goals were heart rate greater than 40/min, systolic blood pressure greater than 80 mm Hg, and diastolic blood pressure greater than 50 mm Hg. Acceptability was based on patients’ self‐reported satisfaction and ability to administer the sedative. A 100‐mm visual analog scale was used daily to assess patients’ anxiety. Results The sample was 59% male and 89% white. Mean values were age, 50.6 years; score on the Acute Physiology and Chronic Health Evaluation, 60.1; and protocol duration, 3.4 days. Five dexmedetomidine patients had blood pressure and/or heart rate lower than safety parameters, necessitating short‐term treatment. Nurses’ adherence to reporting of safety parameters was 100%; adherence to the dexmedetomidine titration algorithm was 73%. Overall baseline anxiety score was 38.4 and did not change significantly (&bgr;day = 2.1; SE, 2.5; P = .40). Most dexmedetomidine patients (92%) were satisfied or very satisfied with their ability to self‐administer medication. Conclusions For select patients, self‐administration of dexmedetomidine is safe and acceptable.

Letting the Patient Decide: A Case Report of Self-Administered Sedation During Mechanical Ventilation

&NA; It is common for critical care nurses to administer sedative medications to patients receiving mechanical ventilation. Although patient‐controlled analgesia is frequently used in practice to promote effective selfmanagement of pain by patients, it is not known if patient‐controlled sedation can be used to promote effective self‐management of distressing symptoms associated with mechanical ventilation. A randomized pilot trial was conducted to evaluate whether patient self‐administered sedation with dexmedetomidine is safe and acceptable for self‐management of anxiety during ventilator support. This case report details the experiences of one patient enrolled in the pilot trial who was randomly assigned to the experimental dexmedetomidine intervention, completed the study protocol, and provided feedback. In a poststudy survey, the patient responded positively to the use of self‐administered sedation with dexmedetomidine during ventilator support.

APRN Consensus Model Implementation: The Minnesota Experience

In 2015, more than 16 years of strategic work resulted in the removal of statutory barriers to Minnesota advanced practice registered nurse (APRN) practice. Keys to the passage of the legislation were the creation of a formal infrastructure (Minnesota APRN Coalition) to manage financial and communication strategies, cohesion among all four roles of APRNs, engagement of strong legislative authors and bipartisan support, and valuable partnerships among the coalition and external stakeholders, such as the Minnesota Board of Nursing. The rapid implementation of the law presented the board with distinct challenges. The purpose of this article is to present the experience of implementing the 2008 APRN Consensus Model to assist other states.

Part II: The Effects of Aromatherapy and Guided Imagery for the Symptom Management of Anxiety, Pain, and Insomnia in Critically Ill Patients

This review is part II of a 2-part series that presents evidence on the effectiveness of aromatherapy and guided imagery for the symptom management of anxiety, pain, and insomnia in adult critically ill patients. Evidence from this review supports the use of aromatherapy for management of pain, insomnia, and anxiety in critically ill patients. Evidence also supports the use of guided imagery for managing these symptoms in critical care; however, the evidence is sparse, mixed, and weak. More studies with larger samples and stronger designs are needed to further establish efficacy of guided imagery for the management of anxiety, pain, and insomnia of critically ill patients; to accomplish this, standardized evidence-based intervention protocols to ensure comparability and to establish optimal effectiveness are needed. Discussion and recommendations related to the use of these therapies in practice and needs for future research in these areas were generated.