Intensive & critical care nursing: the official journal of the British Association of Critical Care Nurses

Published by Elsevier
Print ISSN: 0964-3397
Publications
Using dilute concentration of heparin in continuous flush systems for arterial and venous invasive cannulae is an established practice in intensive care units (ICUs) throughout the UK. It is, however, practical to maintain the patency of these lines using 0.9% sodium chloride, thus reducing the possibility of drug interactions, systemic anticoagulation and cost. A small feasibility study was carried out in a 10-bedded general ICU on both arterial and venous lines using 0.9% sodium chloride over a 3-month period. The study has subsequently changed unit policy.
 
In intensive care units where heparinised arterial lines are used, frequently staff venepuncture their patients to ensure accuracy of clotting studies. The purpose of this study was to assess the practicality of using a non-heparinised continuous flush for arterial lines, which would enable blood for coagulation studies to be taken from the arterial line, thus avoiding further patient discomfort and invasion. The study has resulted in a change of unit policy.
 
In this paper we have reviewed the origin and evolution of Whiston Hospital's General Intensive Care Unit (ICU) from its humble beginnings as an offshoot of a general ward in the early 1960s. The length of service of the senior nursing staff over a period of 21 years was also calculated. The average duration of service was 16.5 years--a figure which significantly surpassed those quoted in the literature. In addition, we have outlined the development of nurse training in intensive care as well as the role of the nurses in research in the ICU. The question as to whether later college-based training was superior to the previous hospital-based course remained unanswered.
 
This survey of District Health Authorities in England and Wales forms part of a wider study into the needs of babies discharged from special care baby units in South Glamorgan Health Authority. The aim of the survey was to find out what types of care were offered to babies who had been in a Special Care Baby Unit (SCBU) and their families following the babies' discharge from hospital. This in turn raised interesting issues concerning the community care of these babies and their families which are discussed in this article.
 
Little is known about the characteristics of patients who were admitted to the coronary care unit (CCU) in the 1990s with non-ST elevation acute coronary syndromes (ACS) compared with those admitted to medical and cardiology wards in hospitals in the United Kingdom (UK). To understand if there were systematic differences in the characteristics of patients who were admitted to UK critical care units (CCU), intermediate care environments (cardiology wards) or generalist wards (acute medical ward) in an observational study carried out in the 1990s. This paper is based on a secondary analysis of PRAIS (UK), a prospective, observational, multi-centred study which recruited 1038 patients with non-ST elevation ACS. This analysis compares the characteristics of 860 of these patients dependent on whether they were cared for in a coronary care unit, acute medical ward or cardiology ward. The results showed that patients admitted to CCU were more likely to be younger, male, have a history of diabetes or have ST depression on their ECG. There was very little difference in other risk factors or prior concomitant therapy. Interestingly there were no systematic differences in treatments or outcomes other than would be expected by chance, although there were trends to higher rates of MI and heart failure in the CCU group. Our analysis shows that the main drivers of admission to CCU in the 1990s were ST depression and MI-both indicators of high risk, but older age and female gender seemed to decrease the likelihood of admission to CCU. Criteria for admission to specific specialist and non-specialist care environments should be standardised and the use of risk scores could be an important way forward.
 
The aim of the study was to describe and compare physicians' and nurses' estimated use of sedatives and analgesics in patients requiring mechanical ventilation in Danish Intensive Care Units (ICUs) in 2003. Questionnaires were mailed in January 2003 to all Danish ICUs providing mechanical ventilation (n = 48). One physician and one nurse at each site were included in the study. Thirty-nine questionnaires were returned by physicians (response rate 81%) and 43 by the nurses (response rate 90%). Physicians and nurses agreed that sedation related decisions are predominately made during rounds and that most decisions are made by physicians and nurses collaboratively. Only 9% of the nurses and 23% of the physicians reported using a written protocol for sedation, while 30% of the nurses and 44% of the physicians reported the use of sedation scoring systems. The study generally supported the hypothesis, that nurses' and physicians' would respond similarly, but there were, however, significant variations, regarding formal sedation practices. Sedation decisions are made collaboratively by nurses and physicians, while sedation protocols and scoring systems are still not systematically implemented in Danish ICUs. The most common drugs for sedation of the mechanically ventilated patient are propofol and fentanyl by continuous infusion. It is recommended that the ICUs collaborate on developing evidence-based standards for sedation and that clinical databases are introduced, which may be used to assess the efficacy of such standards.
 
This paper has explored some of the major trends that we can anticipate encountering as we enter the 21st century. Critical care nurses who wish to participate proactively in shaping their professional destiny will listen closely to what futurists have to say about life in the decades ahead. The more we know about what to anticipate, the more informed our decisions will be, and the more likely we will make our desired future a reality.
 
Major changes in intensive care provision, nursing and nurse education over the last ten years mean that it is a crucial time to take a look at the effectiveness of the post-registration intensive care nursing course [ENB 100]. This article examines whether nurse education is able to meet the current and future challenges. A call for more research regarding the effects of nurse education courses on participants' clinical practice is advocated. Key factors examined include teaching and learning strategies, the identification of common threshold core and specific competencies, and the assessment of practice. Post-registration assessment of practice within the writers' own educational institution is evaluated. Valid and reliable assessment which differentiates between the level of skills attainment of students and identifies the stage of development of the nurse (Benner 1984) is recommended. The question of who benefits from the current provision of ENB 100 courses is considered. It is argued that clinical and educational staff should work together to ensure nurses who undertake ENB 100 courses emerge 'fit for purpose' (DoH 1997a).
 
In intensive care, patients are exposed to a strange and sometimes hostile environment, which can lead to post-traumatic psychological problems. The aim of this study was to describe an intensive care environment from a patient point of view and the events and social contacts during a patient's day. The study had an observational qualitative design. The data were generated by recording on DVD four adult intensive care patients in an intensive care unit over one day (n=96 hours). The DVD recording of two patients also included daylight (lx) and decibel (db) measurement. The material was analysed by inductive and deductive content analysis. An intensive care patient environment is made up of physical, social and symbolic environments. The hospital, ward and patient room constitute an environment that is indirectly connected to the patient. The patient bed and all that is included in it are directly connected to the ICU patient's physical environment. The social environment includes the people who are near the patient and in direct or indirect contact with them. ICU norms, regulations, values, expectations and knowledge make up the symbolic environment. Taken together, these factors constitute an intensive care unit's way of action. The symbolic environment is connected to the social environment through people and the way of action. The patient is connected to the ICUs environment, but is usually not able to influence it. It is important to eliminate things that prevent recovery and to promote feeling safe. Besides the physical environment, things that prevent recovery and increase a feeling of being safe can be found in both the social and the symbolic environment. We also need to learn more about ICU patients' subjective experiences in order to be able to describe the psychological environment.
 
Pain has been recognised as a problem within the realms of health care for many years (Szanto & Heaman 1972, Melzack 1973). The management of pain in the immediate postoperative period remains one of the most serious inadequacies of health care today (Royal College of Surgeons 1990). Recent evidence suggests that up to 75% of hospitalised patients fail to receive adequate pain relief (Carr 1990), with postoperative cardiac patients reporting detailed recollections of their pain experiences during their stay in critical care areas (Ferguson 1992). To accountable health care professionals these figures are humiliating and cannot be allowed to continue (Hollinworth 1994). Indeed, the persistance of postoperative pain can seriously compromise the status of postoperative cardiac patients (Wild 1992). An exploration of current practices in pain management for adult individuals following cardiac surgery included a review of the methods of assessment and treatment interventions employed at three English critical care units. With the literature providing substantial evidence of research into post-operative pain management the persistence of postoperative pain was questioned. Inadequacies in nursing knowledge were identified in all areas of postoperative pain management. The persistence of the theory-practice gap was identified as a major factor contributing to the maintenance of current practice. Similarly, the inappropriate use of change strategies, aimed ultimately at enhancing patient care, proved significant. The findings, which show neglect of the nursing responsibility for the provision of research-based, high quality patient care, carry implications for all nurses. Recommendations including the development of new strategies for the inclusion of existing knowledge into practice appear vital, in order that clinical practice, and ultimately patient care, can be enhanced.
 
In order to improve the patients' comfort and well-being during and after a stay in the intensive care unit (ICU), the patients' perspective on the intensive care experience in terms of memories is essential. The aim of this study was to describe unpleasant and pleasant memories of the ICU stay in adult mechanically ventilated patients. Mechanically ventilated adults admitted for more than 24hours from two Swedish general ICUs were included and interviewed 5 days after ICU discharge using two open-ended questions. The data were analysed exploring the manifest content. Of the 250 patients interviewed, 81% remembered the ICU stay, 71% described unpleasant memories and 59% pleasant. Ten categories emerged from the content analyses (five from unpleasant and five from pleasant memories), contrasting with each other: physical distress and relief of physical distress, emotional distress and emotional well-being, perceptual distress and perceptual well-being, environmental distress and environmental comfort, and stress-inducing care and caring service. Most critical care patients have both unpleasant and pleasant memories of their ICU stay. Pleasant memories such as support and caring service are important to relief the stress and may balance the impact of the distressing memories of the ICU stay.
 
The Therapeutic Intervention Scoring System-28 (TISS-28) is an instrument that has been used to measure severity of illness and nursing workload in intensive care units (ICUs). To characterize the severity of illness and nursing workload using the TISS-28 in 11 ICUs of a university hospital in the city of São Paulo, Brazil. In a prospective study, data were collected from 271 patients admitted to the ICUs in December 2000 and the patients were followed up for 1 week. Most of the patients were males (60.0%) and their mean age was 51(+20.6) years. Surgical treatment (66.8%) and admissions from the operating room were predominant. The mortality rate was 25.0% and the average length of stay was 7.7 (+10.4) days. The mean TISS-28 score was 23 (range: 14-32 points). The lowest mean score was observed for patients from the Burn ICU and the highest mean score was obtained for patients from the Liver Transplant ICU. A change in TISS-28 scores was observed in the same ICU over the 7-day study period. Units differed in terms of severity of illness and nursing workload. Patients who died received a higher TISS-28 score than patients who survived (p=0.00). As the nursing staff are the largest economic investment in an ICU, so measuring nursing workload in different ICUs from different centres can contribute to the estimation of nursing staff required according to the specific demands of the units.
 
Clinical practice based on tradition or established rituals appears to be widespread amongst a variety of nurses and practice settings. However, tradition-based practice may not necessarily be based on sound scientific evidence and could potentially be harmful to patients or result in inappropriate utilization of resources. Conversely, evidence-based practice is the utilization of the best available empirical evidence in the practice setting, to facilitate sound clinical decision-making. Suctioning ventilated patients is a necessary and important aspect of patient care. However, normal saline instillation prior to suctioning, in order to loosen secretions, remains a common nursing procedure despite research suggesting that there is no clear benefit and in some instances may be harmful. Several models have been developed over the past few years to facilitate nursing practice that is based on research or the best available evidence. The Iowa Model, developed at the University of Iowa Hospitals and Clinics, serves as a framework to improve patient outcomes, enhance nursing practice and monitor health care costs. Moreover, it facilitates the application of empirical evidence to clinical practice. This paper will discuss the utilization of the Iowa Model to promote evidence-based nursing practice, with regard to normal saline instillation prior to suctioning, in the critical care unit of a 100-bed hospital in Hong Kong. Patient, staff and fiscal outcomes will also be reported.
 
Current studies reveal a lack of consensus for the evaluation of physical and psychosocial problems after ICU stay and their changes over time. The aim was to develop and evaluate the validity and reliability of a questionnaire for assessing physical and psychosocial problems over time for patients following ICU recovery. Thirty-nine patients completed the questionnaire, 17 were retested. The questionnaire was constructed in three sets: physical problems, psychosocial problems and follow-up care. Face and content validity were tested by nurses, researchers and patients. The questionnaire showed good construct validity in all three sets and had strong factor loadings (explained variance >70%, factor loadings >0.5) for all three sets. There was good concurrent validity compared with the SF 12 (r(s)>0.5). Internal consistency was shown to be reliable (Cronbach's alpha 0.70-0.85). Stability reliability on retesting was good for the physical and psychosocial sets (r(s)>0.5). The 3-set 4P questionnaire was a first step in developing an instrument for assessment of former ICU patients' problems over time. The sample size was small and thus, further studies are needed to confirm these findings.
 
This is a further development of a specific questionnaire, the 3-set 4P, to be used for measuring former ICU patients' physical and psychosocial problems after intensive care and the need for follow-up. The aim was to psychometrically test and evaluate the 3-set 4P questionnaire in a larger population. The questionnaire consists of three sets: "physical", "psychosocial" and "follow-up". The questionnaires were sent by mail to all patients with more than 24-hour length of stay on four ICUs in Sweden. Construct validity was measured with exploratory factor analysis with Varimax rotation. This resulted in three factors for the "physical set", five factors for the "psychosocial set" and four factors for the "follow-up set" with strong factor loadings and a total explained variance of 62-77.5%. Thirteen questions in the SF-36 were used for concurrent validity showing Spearman's r(s) 0.3-0.6 in eight questions and less than 0.2 in five. Test-retest was used for stability reliability. In set follow-up the correlation was strong to moderate and in physical and psychosocial sets the correlations were moderate to fair. This may have been because the physical and psychosocial status changed rapidly during the test period. All three sets had good homogeneity. In conclusion, the 3-set 4P showed overall acceptable results, but it has to be further modified in different cultures before being considered a fully operational instrument for use in clinical practice.
 
The changing of ventilator circuitry is a costly, time-consuming exercise. The current practise of changing circuits every 72 hours is not supported by research and is therefore being challenged. This literature review supports a change in practice from changing circuits every 72 hours to every 7 days or between patients, whichever occurs first. Previous research studying the time interval between circuit changes is reviewed. Contributing factors such as the contamination of tubing by various means are discussed and finally research-based proposals for future practice will be made.
 
During the 1990s newer antibiotics of the erythromycin group have been introduced. One of these, clarithromycin, may offer advantages over erythromycin in the treatment of difficult respiratory tract infections.
 
Abdominal assessment is one of a number of continuous assessments that critical care nurses undertake. Since 1988 in the Department of Critical Care Medicine (DCCM), the technique of abdominal decompression has become another therapy for severe critical illness. The critical care nurse requires to have an understanding of raised intra-abdominal pressure assessment, pressure measurement and the care of abdominal polypropylene mesh insertion in the critical care setting. Our experience has been that the use of polypropylene mesh insertion halved since 1993. A retrospective study (Torrie et al. 1996) of 68 occasions (64 patients) of polypropylene mesh insertion, showed that seven patients developed fistulas and 32 patients died. There was no dehiscence of the mesh from the fascia. Forty-two wounds had primary fascial closure (28 with primary skin closure, 3 with secondary skin closure, 11 left to granulate) and 3 of them later dehisced. At follow-up (27 patients, median 7.5 months), 6 had stitch sinuses, and 5 had incisional hernias. Care of patients with polypropylene mesh inserted requires vigilant nursing practice but decompression of raised intra-abdominal pressure can be life-saving and complications are manageable.
 
This literature review is focused on issues related to the development and usefulness of cardiac electrophysiology studies and ablation procedures. During the past decade, the efficacy of these developments has been proven. The resultant emergence of specialists trained as electrophysiologists represents an important milestone in the advancement of cardiology departments internationally. The majority of research papers on the subject have been published within the past 5 years. Most of the research has evolved from North America and Britain. On searching the literature, it was found that many gaps remain. There is a striking dearth of documented data regarding electrophysiology studies and ablation therapy within the Irish medical and nursing literature, and no previous literature review on the topic was found in a wider search. This paper provides an overview of the strengths and weaknesses associated with these procedures.
 
Abnormal behaviour has been previously reported on withdrawal of sedation in critically-ill children. This description of a child who had prolonged withdrawal symptoms lasting almost 2 weeks includes a report on his parent's comments in relation to the anxiety they felt while he was behaving abnormally. Health professionals need to be aware of the severe nature of this withdrawal reaction and its effect on the parents.
 
As a journal Editor, I examine many papers and work alongside authors to maximize the likelihood of publication. During the course of this activity, several issues concerning writing for publication have emerged. In this article, I will use these experiences to help novice writers to prepare their work for publication. I will also draw on my personal experience as an author of academic and popular papers and as a book author and editor. If you find the article useful, please do distribute it freely amongst colleagues.
 
Descriptive analysis of the geographical, organisational and logistic characteristics of the ICUs investigated Characteristics n % 
Descriptive analysis of ICU's personnel characteristics 
Descriptive analysis of ICUs' visiting policies Characteristics n % 
Compulsory equipment/procedures for ICU access 
Association between visiting hours and other variables (absolute frequency, percentage in brackets, relative frequency for categorical variables, mean values for continuous variables; Fisher's test p for categorical variables and Student's t-test p for continuous variables) 
The factors associated with policies for allowing visitors into intensive care units (ICUs) are a debated issue in the nursing literature. The aim of this survey was to describe visiting policies in the ICUs of North-East Italy and to verify the hypothesis of an association between attitudes regarding accessibility to visitors and environmental, organisational or logistic variables. Data were collected by means of questionnaires sent by mail to head nurses of ICUs. The questionnaires were completed for 104 of the 110 ICUs contacted (94.5%). Visiting hours were generally less than 4h a day (86%) and only 14% of the ICUs reported imposing no restrictions. Children under 12 years old were rarely admitted (22%). Twenty-one percent of the ICUs reported always allowing exceptions, while 77% did so only under 'particular' circumstances. Visiting times were not associated with logistic and organisational factors, but rather with the type of ICU (p=0.000), city setting (p=0.009), exceptions to rules (p=0.029), allowing more than one person (p=0.016) and opening to children (p=0.001). Restrictive visiting policies emerged; paediatric units were generally more flexible. The association between the variables regarding visiting policy, such as visiting times and exceptions to rules, or allowing more than one person or children, seem to confirm how the rules are influenced mainly by the staff's attitude, which could be changed by continuing professional education.
 
In intensive care, there appears to be an ever-increasing demand for resources and it is widely recognized that there is often a shortage of vacant beds available, compounded by an inadequate level of appropriately qualified nursing staff. Either of these deficiencies may lead to delayed or even refused admission for a patient who is critically ill. This review of the literature contains examination of the access and availability of intensive care facilities within the National Health Service and discussion of the problems that arise in gaining admission to such facilities. Being refused admission to the local intensive care unit may have important implications for a critically ill patient, resulting in transfer to another hospital, perhaps many miles away, or inadequate treatment and care in a general ward. These issues are also examined and strategies for action are proposed.
 
Within a health care system that promotes choice and autonomy, it no longer seems appropriate to exclude relatives from the resuscitation room. There is a growing body of research that suggests there are indeed many long-term benefits to be gained from witnessing the resuscitation of a loved one. There seems no doubt that relatives would like the opportunity to spend the last few valuable minutes with their loved one to say goodbye. However, it is the views of many staff working in the critical care setting that appear to be preventing witnessed resuscitation from becoming normal practice. This paper considers the staffs', the relatives' and the patients' perspectives on witnessed resuscitation and concludes that the majority of relatives should not be denied access to the resuscitation room.
 
Characteristics of the participants.
Examples of the analysis process.
The aim of this study was to describe individuals' perceptions of the psychosocial consequences of an acute myocardial infarction (AMI) and of their access to support one year after the event. The study included 20 participants (14 men and six women) who lived in rural areas and had experienced their first AMI. Eleven were offered contact with a mentor. The participants were interviewed one year after their AMI. The findings are presented in three themes: having a different life, having to manage the situation and having access to support, with 11 subthemes. During their recovery, the participants experienced psychosocial consequences, consisting of anxiety and the fear of being afflicted again. Most mentees appreciated their mentor and some of those without mentors wished they had received organised support. Participants were often more dissatisfied than satisfied with the follow-up provided during recovery. After an AMI, follow-up is important during recovery, but the standardised information provided is inadequate. During recovery, people need help dealing with existential crises. After discharge, receiving peer support from lay people with similar experiences could be valuable. The knowledge gleaned from this study could be used in education at coronary care units and in health care outside the hospital setting.
 
Following a two-day history of pyrexia, stomach pain, diarrhoea and an emergency laparotomy my wife was admitted to an intensive care unit (ICU) with septic shock. Lucy was artificially ventilated for seven days, and was treated with fluids, vasopressors and antibiotics. Her condition continued to deteriorate and on about the third day she looked as though she might die. However over the next few days Lucy began to recover and she was eventually transferred to a ward and came home three weeks after admission to hospital. During her stay in the intensive care unit, Lucy developed pneumonia, bilateral pleural effusions, acute renal failure and a pericardial effusion. Over the weeks and months that followed, Lucy began to describe her experiences and the impact that these have had on her. She described what it felt like to be a patient in the ICU and the challenges that she faced during her recovery. I am a Registered Nurse and at the time my wife was admitted to the ICU I had spent twenty years working within the field of intensive care. Until my wife had been admitted to ICU, I thought that I had a good appreciation of what it was like to be a patient or a relative in an intensive care unit. Having experienced critical care at first hand and having had an opportunity to reflect on what happened I now realise what little insight I had. I have now come to realise that as nurses in intensive care there is much we can do to alleviate the suffering and discomfort experienced by some of our patients and relatives. Perhaps by describing what happened, I will enable the reader to understand more clearly and to reflect on those factors which have a deep and lasting impact on patients and their relatives and which can be influenced by nurses at the bedside. For the purpose of this account, I have chosen to call my wife, Lucy.
 
Nurses have always looked to support their activities through the presence of unregistered co-workers. In the later part of the 20th century this workforce has evolved from a predominance of students to increasing use of variously prepared second level nurses, nursing assistants and Health Care Support Workers. The study evaluated the development of 'advanced' support workers for intensive care settings, examining the views of the multi-disciplinary team, the support workers, and making observations of the work undertaken. Ethical approval was gained via a multi-centre committee. Individual interviews, focus groups and fieldwork provided rich qualitative data. It is this, and the views of support workers themselves on which we focus in this report. Senior support workers have a potentially important, but as yet insufficiently clear role to play. Key tasks such as taking arterial blood gas symbolise their rite of passage into the role. Expectations vary by locality and by person and there is great concern over accountability for work done. Delegation of work depends as much on experience as training and individuals are reluctant to delegate to staff they have not personally assessed and come to know as 'competent'. These workers should have clear and adequately remunerated career pathways open to them, in particular into nursing and allied health disciplines, and should probably be licensed to practice.
 
The purpose of this study was to describe the pattern of dental plaque accumulation in mechanically ventilated adults. Accumulation of dental plaque and bacterial colonisation of the oropharynx is associated with a number of systemic diseases including ventilator associated pneumonia. RESEARCH METHODOLOGY/DESIGN: Data were collected from mechanically ventilated critically ill adults (n=137), enrolled within 24 hours of intubation. Dental plaque, counts of decayed, missing and filled teeth and systemic antibiotic use was assessed on study days 1, 3, 5 and 7. Dental plaque averages per study day, tooth type and tooth location were analysed. Medical respiratory, surgical trauma and neuroscience ICU's of a large tertiary care centre in the southeast United States. Plaque: all surfaces >60% plaque coverage from day 1 to day 7; molars and premolars contained greatest plaque average >70%. Systemic antibiotic use on day 1 had no significant effect on plaque accumulation on day 3 (p=0.73). Patients arrive in critical care units with preexisting oral hygiene issues. Dental plaque tends to accumulate in the posterior teeth (molars and premolars) that may be hard for nurses to visualise and reach; this problem may be exacerbated by endotracheal tubes and other equipment. Knowing accumulation trends of plaque will guide the development of effective oral care protocols.
 
This study was designed to determine the degree of intervention of causal and emotional factors in work stress in intensive care unit (ICU) nursing staff. A questionnaire to assess stress causes (27) and associated emotions (33) was given to 123 people (85 registered nurses and 38 auxiliary nurses) aged 22-56, working in ICUs in different hospitals in Palma de Mallorca. Descriptive and factorial analyses were carried out. Respondents gave most stress causes a medium score (3.5-6.5 points), the highest values corresponding to staff shortage (mean = 6.71), bad management organisation (mean = 6.65) and little free time (mean = 6.5). These causes are grouped in seven factors which account for 65.51% of variance and are particularly related to organisational problems, training and personal relationships, work demands and physical and emotional overload. The most important emotions for this sample are: responsibility (mean = 6.61), impotence (mean = 6.23) and desire to excel (mean = 6.080). Such emotions are divided into seven factors which explain 65.31% of the variance and define states of personal satisfaction, depersonalisation, anxiety, low self-esteem, helplessness and arrogance. Surprisingly, the main factor with the value 5.08 and a variance of 15.42%, corresponds to positive or pleasant emotions. The results corroborate previous research findings on work stress, provide a simplified tool for assessing this and show the need to quantify the degree of such manifestations in the assessments.
 
to evaluate accuracy, sensitivity, specificity and inter-rater agreement of AVPU (Alert, Voice, Pain, Unresponsive) when used by non-specialist nursing staff assessing consciousness, and to investigate users' views. Video-recorded simulations of assessments of consciousness were developed and verified by an expert panel. Participants scored simulations using AVPU and completed questionnaires eliciting views on the scale. AVPU scores were compared with functional levels agreed by the panel. A large urban teaching hospital. Fifty-one participants scored 255 simulations. Overall accuracy was 82.4% (95% CI=77.7-87.1%), sensitivity 0.94 (95% CI=0.90-0.98), specificity 0.74 (95% CI=0.66-0.82) and inter-rater agreement (un-weighted kappa) 0.782. Accuracy was low for simulations depicting an orientated patient whose eyes open to speech (49% correct) and a confused patient with spontaneous eye opening (61.5% correct). Sensitivity and agreement for levels corresponding to "Alert" and "Voice" were 0.81 (95% CI=0.69-0.93) and kappa=0.506. Participants expressed uncertainty about aspects of AVPU's use. AVPU had low rates of accuracy, sensitivity and agreement in distinguishing between "Alert" and "Voice", and low specificity overall, suggesting it may be unsuitable for early warning scoring. Participants expressed doubts about the use of AVPU. Copyright © 2014 Elsevier Ltd. All rights reserved.
 
The purpose of this paper is to describe the development, implementation and evaluation of a new critical care curriculum based on the tenets of collaborative workplace learning. It also examines lecturers' and clinical educators' issues, and explores students' evaluations of the old curriculum compared with those of the new curriculum. Three data collection methods were used for this study. Comprehensive notes were maintained of the meetings conducted with lecturers, clinical educators and representative students during the development and implementation of the course. Three focus group interviews were conducted with students before the introduction of the new curriculum and three focus group interviews were conducted during first semester following implementation of the new curriculum. Quality-of-teaching surveys were also completed by two groups of critical care course students: one group before and one group following the introduction of the new curriculum. Major findings in this study included: developing a sense of ownership of the curriculum for clinical educators, clinical educators' difficulties with addressing their responsibilities, amalgamating theoretical learning with clinical practice, and tackling students' workload. This paper demonstrates the value of using the collaborative workplace learning approach in strategically addressing the challenges of developing and conducting a university critical care course.
 
The implementation of tight glycaemic control (TGC) is becoming accepted best practice within intensive care units throughout the world. It is recommended by the Surviving Sepsis Campaign and is included in the sepsis care bundle. The major impact of TGC is currently thought to be associated with reduced morbidity and mortality. The process of achieving TGC is, however, not without risk. In particular, the need for frequent, accurate blood glucose measurement and the possibility of prolonged, unrecognised hypoglycaemia are of concern. There is also the potential for patients who exhibit significant insulin resistance to require the administration of large amounts of insulin. The transfer of patients from the intensive care unit to the operating theatre or for computerised tomography during intensive insulin therapy is also hazardous. The purpose of this paper is to describe a series of nurse led pilot studies which aimed to introduce the process of TGC whilst maintaining patient safety. The results demonstrate the effectiveness of a staged approach and the achievement of TGC.
 
Average leg pH: soap versus pH cleanser.
Colony Count by Site and Cleansing Product. Total colony forming unit (CFU/mL) count by product over 10 days
Average arm pH: soap versus pH cleanser.
Objectives: To test the effects of two different cleansing regimens on skin surface pH and micro-flora, in adult patients in the intensive care unit (ICU). Research methodology: Forty-three patients were recruited from a 23-bed tertiary medical/surgical ICU. The nineteen patients in Group One were washed using soap for daily hygiene care over a four week period. In Group 2, 24 patients were washing daily using an acidic liquid cleanser (pH 5.5) over a second four week period. Skin pH measurements and bacterial swabs were sampled daily from each for a maximum of ten days or until discharged from the ICU. Main outcome measures: Skin surface pH and quantitative skin cultures (colony forming units). Findings: Skin pH measurements were lower in patients washed with pH 5.5 cleanser than those washed with soap. This was statistically significant for both the forearm (p = 0.0068) and leg (p = 0.0015). The bacterial count was not statistically significantly different between the two groups. Both groups demonstrated that bacterial counts were significantly affected by the length of stay in ICU (p = 0.0032). Conclusion: This study demonstrated that the product used in routine skin care significantly affects the skin pH of ICU patients, but not the bacterial colonisation. Bacterial colonisation of the skin increases with length of stay.
 
Acinetobacter in the ICU presents a challenge worldwide due to its capacity for long-term survival on environmental surfaces. This report describes a multimodal infection control program designed to control a sustained outbreak Acinetobacter colonization. Multimodal interventions implemented by unit-appointed infection control nurses in an Australian intensive care unit (ICU) during a sustained outbreak of Acinetobacter colonization. In the first 12 months of the outbreak, the mean monthly colonization rate was 3.1 (+/-1.2) cases per 100 bed-days (increased from 0.5 [+/-0.4] in the previous 6 months). In the subsequent 20-months, the mean monthly colonization rates declined to 1.5 (+/-1.5) cases per 100 bed-days (P=0.004). Hand hygiene compliance increased from 33% (95% CI 30-36%) before action plan implementation to 49% (95% CI 46-52%) measured 6-months after implementation. Compliance subsequently dropped to 39% (95% CI 36-42%) 12-months after implementation. The median volume of alcohol/chlorhexidine hand rub solution used per 1000 bed-days increased from 24L (interquartile range (IQR) 12-47L) to 148L (IQR 120-165L) per 1000 bed-days (P<0.001). Introduction of ICU-appointed infection control nurses, who then led multimodal interventions, was effective in reducing the rate of Acinetobacter colonization.
 
An outbreak of Acinetobacter baumannii colonization and infection occurred in 19 patients over a 14-month period during 1998-1999 on a neurosurgical intensive care unit. During efforts to control the outbreak a significant correlation was observed between the number of environmental isolates of A. baumannii obtained during each monthly screening and the number of patients with A. baumannii colonization/infection in the same calendar month (P=0.004). Use of 1000 ppm hypochlorite solution and the introduction of new cleaning protocols reduced the number of environmental isolates. Failure to maintain low levels of environmental contamination with A. baumannii resulted in increases in patient colonization. This study showed that high standards of cleaning play an integral role in controlling outbreaks of A. baumannii in the intensive care unit setting.
 
In the Surveillance Report, bacteraemia was not defined specifically within the document. However, it was implied that bacteraemia was present if blood cultures were positive. No clinical information concerning the effect of bacteraemia on the patients or the degree of haemodynamic support required was described. Nor was the movement of patients between specialties indicated. This information would have been helpful to clinicians because it would demonstrate the increased severity of illness experienced by patients and the concomitant increase in services required to meet these needs, although of course prevention should be the key response to the data provided. It is evident from the two reports that infection of the bloodstream is described utilizing different terms, i.e. bacteraemia and catheter-related bloodstream infection. This is potentially confusing and efforts should be made to encourage the use of consistent terminology across specialties, e.g. infection control, critical care, oncology The potential for confusion also arises where evidence is pooled utilizing both CRI and CR-BSI as endpoints for the research reviewed. The recommendation associated with flushing the CVC with heparinized saline solution does not consider a patient's coagulopathy to be a contraindication, only the manufacturer's recommendations. This appears to be a limitation of the guidelines and may place the patient at risk. The recommendation also does not indicate if this is only to be performed when the catheter or lumen is not in use, or if heparin should be administered if it is in use. Finally, the categories used to denote the level of evidence are not defined in the document. It can be assumed that Category 1 relates to randomized controlled trials, which demonstrate homogeneity or/and narrow confidence intervals; whilst categories 2 and 3 relate to cohort studies and pooled data. It should be expected that a document of this nature should establish criteria or refer the reader to the primary source for categorization. Eggimann and Pittet (2000) have undertaken an excellent review of central venous catheter related infections in intensive care units. The evidence accrued and recommendations made mirrors the two reports outlined above. It is imperative we take action to reduce the incidence of CR-BSI and it is hoped that this Editorial has provided a basis for discussion and action; and will stimulate debate.
 
For many nurses the thought of conducting a research study, even one based in one centre, is daunting but coordinating a multi-centred study across different countries with different cultures can seem overwhelming. Some of the practical problems of doing research across different cultures are predictable and can be planned for, while others may surface as the study is started and need to be reacted to as they happen. Clear lines of communication are therefore essential. This article discusses some of the issues and problems that can occur using examples from a large multi-national nursing study by the RACHEL group.
 
The National Patient Safety Agency (NPSA) reviews patient safety incidents throughout the National Health Service (NHS) in the United Kingdom and aims to initiate preventative measures. Recent alerts include injectable medication, oral syringes for enternal administration, preventing hyponatraemia in children and anticoagulation. This article gives an insight into the rationale and steps currently being undertaken to respond to these recommendations.
 
The use of physical restraint has been linked to delirium in ICU patients and a range of physical and psychological outcomes in non-ICU patients. However, the extent of restraint practice in ICUs is largely unknown. This study was designed to examine physical restraint practices across European ICUs. A prospective point prevalence survey was conducted in adult ICUs across European countries to examine: physical and chemical restraint use during the weekend and weekdays, reasons for physical restraint use, timing of restraint use, type of restraint used and availability of restraint policies. Thirty-four general (adult) ICUs in nine countries participated in the study providing information on 669 patients with details of physical and chemical restraint use in 566 patients. Prevalence of physical restraint use in individual units ranged from 0 to 100% of patients. Thirty-three per cent of patients were physically restrained; those that were restrained were more likely to be ventilated (χ(2)=87.56, p<0.001), sedated (χ(2)34.66, p<0.001), managed in a larger unit (χ(2)=10.741, p=.005) and managed in a unit with a lower daytime nurse:patient ratio (χ(2)=17.17, p=0.001). Larger units were more likely to use commercial wrist restraints and smaller units were more likely to have a restraint policy, although these results did not reach significance. As an initial exploration, this study provides evidence of the range of restraint practice across Units in Europe. Variation in the number of units per country limits generalization of findings. However, further examination is needed to determine whether there is a causal element to these relationships. Attention should be paid to developing evidence based guidelines to underpin restraint practices.
 
Nursing appears to be regularly subjected to new and 'fashionable' ideas and practices, many of which come from the USA. Examples of these include the nursing process and models of nursing. In the pursuit of professionalization of nursing, the need for such innovations is supported by the author. What cannot be supported, however, is the haphazard way in which some of these initiatives are often badly introduced and accepted into the profession in the absence of any research supporting their benefits. This article seeks to explore the notion of reflective practice, some of the reasons it has been introduced, as well as some of the problems associated with investigating its benefits. The different types of reflective practice are discussed along with their implications for professional practice. Attempts are made to explain the difference between reflection and the mere recall of events, as well as some possible explanations as to why reflective practice has not been embraced by clinical nurses in the way it should or could have. Finally, the subject of how reflective practice could be practically implemented in clinical areas is discussed and an example for a model of reflection given.
 
When becoming an intensive care patient life changes dramatically. In order to save life, different actions are performed by the caregivers and the patient's ability to exercise self-determination is non-existent. After the acute phase the patient is more awake and the possibilities for self-determination change. The purpose of this study was to describe intensive care nurses' (ICNs) views of patient's self-determination in an intensive care unit and to systematize ICNs' nursing actions for supporting patient's self-determination from an action- and confirmation-theoretic perspective. In order to answer these questions, 17 interviews with ICNs were conducted by the use of the Critical Incident Technique (CIT). The transcripts were then analysed using a hermeneutic analysis method and structured by the SAUC model for confirming nursing. The main findings were that the ICN thought that the ICU patient's self-determination was low and restricted. It was more common that the ICN acted to strengthen the patient's self-determination in nursing care, but there were no specific nursing goals for patient's self-determination. The most common actions for supporting self-determination were supplying the patient with information and engaging the patient in making a day plan. The nursing implications are that the ICN's view of human being as an acting subject is important for the ICN's awareness to recognise the patient's own personal resources to handle the critically ill situation and that the ICN's competence to manifest qualified nursing is necessary for strengthening patient's self-determination.
 
Top-cited authors
Ingegerd Bergbom
  • University of Gothenburg
Dag Lundberg
  • Lund University
Wendy Chaboyer
  • Griffith University
Bengt Fridlund
  • Linnaeus University Sweden and University of Bergen Norway and Jönköping University Sweden