Meg Zomorodi

Instrument Development Measuring Critical Care Nurses' Attitudes and Behaviors with End-of-life Care.

Background: Although critical care nurses are expected to focus on providing life-sustaining measures, many intensive care patients actually receive end-of-life care. Objectives: The aim of this study was to develop an instrument to measure nursing attitudes and behaviors regarding end-of-life care. Method: Phase 1 was focused on item development from a content analysis of the literature and qualitative interviews of critical care nurses. Phase 2 consisted of content validity assessment and pilot testing. Phase 3 included field testing, factor analysis, and reliability estimation. Results: The Values of Intensive Care Nurses for End-of-Life (n = 695) was found to have four factors: Self-appraisal, Appraisal of Others, Emotional Strain, and Moral Distress. Reliability estimates (&agr;) were acceptable at .59-.78, but the interitem range (.12-.78) was wider than desirable. Test-retest reliability was deemed adequate based on Pearsons correlations (.68-.81) and intraclass correlation coefficients (.65-.79) but less so when considering &kgr; (.05-.30). The Behaviors of Intensive Care Nurses for End-of-Life (n = 682) was found to have two factors: Communication and Nursing Tasks. Reliability estimates were adequate when considering internal consistency (&agr; = .67 and .78, respectively), item total correlations (.30-.61), and test-retest as judged by Pearsons and intraclass correlations (.77-.81) but not when &kgr; was considered (.02-.40). The interitem correlations (.20-.35) were also lower than desirable. Discussion: Both the Values of Intensive Care Nurses for End-of-Life and the Behaviors of Intensive Care Nurses for End-of-Life were found to have conceptually linked factors and acceptable internal consistency estimates (&agr;). However, test-retest estimates were inconsistent, suggesting that further work needs to be done on the stability of these instruments.

Continuous cerebral spinal fluid drainage associated with complications in patients admitted with subarachnoid hemorrhage

OBJECT Cerebral artery vasospasm is a major cause of death and disability in patients recovering from subarachnoid hemorrhage (SAH). Although the exact cause of vasospasm is unknown, one body of research suggests that clearing blood products by CSF drainage is associated with a lower frequency and severity of vasospasm. There are multiple approaches to facilitating CSF drainage, but there is inadequate evidence to determine the best practice. The purpose of this study was to explore whether continuous or intermittent CSF drainage was superior for reducing vasospasm. METHODS The authors performed a randomized clinical trial. Within 72 hours of admission for SAH, patients with an external ventricular drain (EVD) were randomized to undergo continuous CSF drainage with intermittent intracranial pressure (ICP) monitoring (open-EVD group) or continuous ICP monitoring with intermittent CSF drainage (monitor-ICP group). RESULTS After 60 patients completed the study, an interim analysis was performed. The complication rate of 52.9% for the open-EVD group was significantly higher than the 23.1% complication rate for the monitor-ICP group (OR 3.75, 95% CI 1.21-11.66, p = 0.022). These results were reported to the Data Safety and Monitoring Board and enrollment was terminated. The odds ratio of vasospasm for the open-EVD versus monitor-ICP group was not significant (OR 0.44, 95% CI 0.13-1.45, p = 0.177). CONCLUSIONS Continuous CSF drainage with intermittent ICP monitoring is associated with a higher rate of complications than continuous ICP monitoring with intermittent CSF drainage, but there is no difference between the two types of monitoring in vasospasm. Clinical trial registration no.: NCT01169454 (clinicaltrials.gov).

Exploring the impact of augmenting sedation assessment with physiologic monitors

BACKGROUND Pharmacological sedation is a necessary tool in the management of critically ill, mechanically ventilated patients. The intensive care unit (ICU) sedation strategy is to use the least amount of medication to meet safety and comfort goals. Titration of pharmacological agents is currently guided by clinical assessment tools. The purpose of this study was to determine whether the addition of a neurophysiological monitor, bispectral index (BIS), aided the ICU nurse in reducing the amount of drug used, compared to a clinical tool alone, in a general critical care population. METHODS In this prospective clinical trial, mechanically ventilated adults (N=300) were randomised to sedation assessment using only the observational assessment tool (RASS) or a combination of observational and physiologic measures (RASS+BIS). Subjects were enrolled from a medical ICU (N=154), a trauma ICU (N=72) and a general mixed-use ICU (N=74). RESULTS BIS-augmented sedation was only associated with the reduction of drug use when patients were sedated with propofol or narcotic agents (propofol [1.61 mg/kg/h vs. 1.77 mg/kg/h; p<0.0001], fentanyl [54.73 mcg/h vs. 66.81 mcg/h; p<0.0001], and hydromorphone [0.97 mg/h vs. 4.00 mg/h: p<0.0001] compared to RASS alone. In contrast, patients sedated with dexmedetomidine or benzodiazepines were given higher doses under the BIS-augmented dexmedetomidine [0.46 mcg/kg/h vs. 0.33 mcg/kg/h; p<0.0001], lorazepam [4.13 mg/h vs. 3.29 mg/h p<0.0001], and midazolam [3.73 mg/h vs 2.86 mg/h; p<0.0001]) protocol compared to clinical assessment alone. CONCLUSION The clinical evaluation of depth of sedation remains the most reliable method for the titration of pharmacological sedation in the critical care unit. However, BIS-augmented assessment is helpful in reducing the amount of propofol and narcotic medication used and may be considered an adjunct when these agents are utilised.

Perceived and actual noise levels in critical care units

PURPOSE To compare the noise levels perceived by critical care nurses in the Intensive Care Unit (ICU) to actual noise levels in the ICU. METHODS Following a pilot study (n=18) and revision of the survey tool, a random sample of nurses were surveyed twice in a 3-day period (n=108). Nurses perception of noise was compared to the actual sound pressure level using descriptive statistics. MAJOR RESULTS Nurses perceived the ICUs to be noisier than the actual values. The ICU was louder than the recommended noise level for resotrative sleep. This finding raises the question of how we can assist nurses to reduce what they perceive to be a loud environment. APPLICATION Future work is needed to develop interventions specifically for nurses to raise awareness of noise in the ICU and to provide them with skills to assist in noise reduction.

The canaries in the coal mine speak: why someone should (and should not) become a nurse.

Nurses in acute care hospitals are like the canaries used to test for lethal gases in mines—if they remain, the conditions must not be extreme. Staff nurses from 8 states responded to a questionnaire giving reasons why someone should and should not be a nurse. The almost 700 nurses responding reported that many of the reasons one should be a nurse are also the reasons one should not be one (eg, pay/benefits, respect for nursing). Extrinsic factors dominated the reasons to be a nurse, with both intrinsic and extrinsic factors being the reasons not to do so.

Development of a neuro early mobilisation protocol for use in a neuroscience intensive care unit

OBJECTIVE Through evaluation of the literature and working with a team of multidisciplinary healthcare providers, our objective was to refine an interprofessional Neuro Early Mobilisation Protocol for complex patients in the Neuroscience Intensive Care Unit. RESEARCH METHODOLOGY Using the literature as a guide, key stakeholders, from multiple professions, designed and refined a Neuro Early Mobilisation Protocol. SETTING This project took place at a large academic medical center in the southeast United States classified as both a Level I Trauma Center and Comprehensive Stroke Center. MAIN OUTCOME MEASURES Goals for protocol development were to: (1) simplify the protocol to allow for ease of use, (2) make the protocol more generalizable to the patient population cared for in the Neuroscience Intensive Care Unit, (3) receive feedback from those using the original protocol on ways to improve the protocol and (4) ensure patients were properly screened for inclusion and exclusion in the protocol. RESULTS Using expert feedback and the evidence, an evidence-based Neuro Early Mobilisation Protocol was created for use with all patients in the Neuroscience Intensive Care Unit. CONCLUSION Future work will consist of protocol implementation and evaluation in order to increase patient mobilisation in the Neuroscience Intensive Care Unit.