Tom Ahrens

Hemodynamic applications of capnography.

The measurement of the pressure of exhaled carbon dioxide (PetCO2) via capnography has several useful hemodynamic applications. This article discusses integrating PetCO2 values with hemodynamic assessment. Capnography can be applied to hemodynamic assessment in three key ways: (1) identification of end-expiration during pulmonary artery and central venous pressure measurements, (2) assessment of pulmonary perfusion and alveolar deadspace, (3) assessment of cardiopulmonary resuscitative efforts. The article presents research, sample waveforms for end-expiration identification, and case examples.

Outlier management. Influencing the highest resource-consuming areas in acute and critical care.

Outliers account for a large amount of technology utilization and resources consumed in acute care, despite accounting for only a small portion of the total patient population. Most current efforts to reduce costs, such as re-engineering and downsizing, are nonspecific methods of controlling costs. Focusing efforts in high-cost areas, such as outlier management, is much more likely to improve patient care and improve the use of technology while achieving real advances in cost control. Most hospitals will have to build an infrastructure to support outlier management, which includes developing clinical staff. These processes will take time and careful planning, but they are essential for the effective management of technology utilization and outliers. The failure to employ focused efforts like outlier management will result in the superficial treatment of high costs in acute care. The benefit to employing these methods leads to the best use of technology and the improved management of a difficult patient population.

Nurse clinician model of managed care.

Many different models of delivering nursing care have been proposed, each with specific advantages and disadvantages. One such model, the nurse clinician model, uses the strengths of advanced clinical practice as the cornerstone for improving quality in patient care. The increase in quality simultaneously produces an efficient and cost-effective system, as indicated by the results of a multiyear study at our institution. While other effective models exist, those that emphasize advanced clinical practice, such as the nurse clinician model, are most likely to achieve improved patient outcomes and conserve resource expenditures.

Clinical Application: Using Oxygenation Profiles to Manage Patients

Cellular oxygenation is dependent on both tissue oxygenation and pulmonary oxygenation. The use of profiles can help to make the assessment of tissue and pulmonary oxygenation more thorough. Although oxygenation profiles have limitations, an understanding of them can provide useful information to the critical care nurse. Oxygenation profiles enable the nurse to trend a patients progress and response to nursing and medical interventions. A sophisticated assessment relies not merely on physical assessment alone but incorporates continuous mixed venous oxygenation and oxygenation profiles to assess a patients tissue and pulmonary oxygenation status.

Multisociety Task Force for Critical Care Research: Key Issues and Recommendations: Executive Summary

In 2009 the four largest professional societies involved in critical care in the United States – the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM) – formally established the Critical Care Societies Collaborative (CCSC) to explore common issues. At that time, in spite of the importance of critical care, there was no consensus on the agenda for critical care research in the United States. To overcome deficiencies in the conduct and expansion of critical care research, experts from each of the four CCSC component societies joined with a successful clinical research collaborative, the US Critical Illness and Injury Trials Group (USCIITG), and formed the Multisociety Strategic Planning Task Force for Critical Care Research. The task force was charged with defining a comprehensive agenda for critical care research based upon input from a broad range of participants and relevant stakeholders.