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Hi everyone,
ICU nursing staffing's impact on patient (and other) outcomes is well documented in the literature. Nonetheless, methods (e.g. Nursing activities score) have been criticized during the last decade for not including several aspects of the nurse's work besides bedside duties.
Currently, which would be the most valid approach /tool to objectively estimate nursing staffing?
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Cristobal,
it depends on what you are most interested in. There are scores and ways for assessing workload in bedside nursing that accounts for physical and cognitive workload. Look at work by Heather Tubbs-Cooley. Also, make sure you are looking at the right measures. As I’m sure you know, tools to assess staffing models are not the same as nursing workload. I have partnered with nurse scientists at Emory to look at a combination of metrics, but it also depends on the question you are asking. Hope this helps. Feel free to DM me if you want to discuss further
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At the beginning of each shift, how nurses distribute current patients in the unit?
According to my experience, there several factors that are considered such as if the patient is on ECMO, mechanically ventilated, on a particular isolation precaution...
Also, there are nursing to patient ratios as guidelines but their account for the number rather than specific features of the patient.
Any other criteria or methods?
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Distribution of staff in the ICU depends on the availability of workforce or number of staff in the ward and patient status or it's progress. However, 1:2 is good ratio when there is good help and support for the nurse but if not, so 1:1 is relevant.
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Hi,
At the beginning of each shift, how nurses distribute current patients in the unit?
According to my experience, there several factors that are considered such as if the patient is on ECMO, mechanically ventilated, on a particular isolation precaution...
Also, there are nursing to patient ratios as guidelines but their account for the number rather than specific features of the patient.
Any other criteria or methods?
Thanks in advance for your input.
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Dear Dr. Fortunatti,
Heart-centered greetings
When Nurses shortage is critical, many important variables would be secondary!
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I am looking for an author to write a chapter for a book I am editing. The chapter is about ethnographic research into critical care. Are you interested in writing this chapter or do you know someone who may be interested?
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Revered Professor Paul M.W.Hackett,
I am happy to have known that you are writing a Book on Ethnography. I am teaching Ethnography Field Research for Rural Development more than a decade in the Department of Rural Development and Agricultural Extension, College of Agriculture, Wolaita Sodo University, Ethiopia, East Africa. I will be grateful to you Prof if I will have an opportunity to help you. I would like to know information from you Prof. I went along with my M.Sc. students to have Ethnography Field Survey on Australia funded Carbon Project near to my WSU university.
Regards
M.Senapathy
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I am trying to prepare myself for my master of critical care nursing thesis
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Hi, since you are preparing for Critical Care masters thesis, I am going to assume you mean in the ICU, in the AKI (acute kidney injury) setting. Indications for acute dialysis: All indications are relative, and that have already failed medical management (ex: reasonable dose diuretics, base supplements, etc) or medical management is contraindicated (ex: kayexelate not option for high potassium, anuric so diuretics not useful, etc) There is no absolute Blood urea nitrogen , creatinine, or cystatin C level that is a true indication for dialysis (although there will be debate about starting when BUN rises above 100 mg/dl as uremic effects may be seen more likely, see below)
Volume overload
Metabolic acidosis (lactate generated faster THANan it can be removed in some forms of lactic acidosis)
Electrolyte derangements(most often Hyperkalemia, but could be hypercalcemia, hyperuricemia in tumor lysis to prevent AKI or with AKI, other)
Hyperammonemia (inborn error of metabolism while awaiting
Intoxication by dialyzable drug or agent (most often NOT highly protein bound, other factors also affect, but databases for ability to remove drugs and toxins by different forms of dialysis available; methanol ingestion, lithium, antifreez)
Uremia: degree of AKI that interferes with physiologic functions (ex: BUN high enough that pt develops pericardial effusion, platelet function decreased, mental status changes, are examples.)
In pediatrics, dialysis/ some for of renal replacement therapy is indicated in AKI in order to provide nutritional support that would be impossible due to necessary fluid restriction imposed to avoid volume overload. We tend to want to start renal replacement therapy earlier rather than later to AVOID complications. Great papers on mortality associated with volume overload in pediatric patients by Stuart Goldstein et al, as an example in AKI setting
CKD many of the same issues cause start of dialysis therapy (chronic) , in addition to failure to thrive, fatigue , other "uremic symptoms" before the classic indication of creatinine clearance less than 10 ml/min/1.73m2 (some target 15 ml/min/1.73m2) as absolute indication. This is pediatrics, US-style units, but many indications are universal for adults and children/infants
I'm sure other responders will add to this list! Hope this is helpful to you
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I want to do research for my degree nursing course.
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I would start by identifying what you are most interested in or has challenged your thinking or values.
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The practice of nursing in ICU varies from country to country, even within them. This is why some tasks are delegated to technical staff which probably affects the scores of the Nursing Activities Score.
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Dear Fortunatti
Fernandes etal. 2010 mentioned that, In an ICU, nurses note daily whether critical patients will require prolonged assistance regarding the performance of routine procedures both upon admission and during their stay because organ instability can occur at any time over the course of the patients' stays in these units.
Panunto 2012 stated that Nursing workload consists of the time spent by nursing staff to perform the activities for which they are responsible, whether directly or indirectly related to patient care. These activities can change depending on the patient's degree of dependency, the complexity of the disease, the characteristics of the institution, work processes, the physical layout and the nature of the professional team.
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Risk factors for CRBSI are well documented but I´m looking for a sort of screening tool in ICU pacientes with CVC.
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We´re looking to start measuring nursing workload in high complexity units. There´s evidence of the application of TISS - 28 in cardiac surgery patients but i´m not 100% sure if there is any incovenient to apply in other non surgical cardiac units.
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The limitations of the TISS-28 is it is based on how we provided critical care 20 years ago. A great deal of nursing care has changed since then that are not captured in the TISS-28. For example we keep patients more awake, promote more mobilization than before yet these items are not captured in the TISS-28.  I would argue, because it misses important advances in critical care, it has a tendency to underscore workload. 
Saying that, this tool does have a lot of validity and reliability evidence in ICUs around the world. 
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Is sodium bicarbonate installation (small amount and diluted) used for artificial airway (ETT and Tracheostomy) suctioning to remove thick secretions? Clinically and theoretically, Why and why not?
Intensivists, pulmonagists, Critical Care Nurses and researchers. 
Thank you.
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As far back as 2008 evidence identified the instillation of normal saline before endotracheal suctioning has been considered an adverse practice because of the physiological and psychological effects. More current evidence has reached similar conclusions.
This review article by Halm et al may be initially helpful: Halm et al, Instillingn normal saline with suctioning. Am J Crit Care September 2008 vol. 17 no. 5 469-472
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I want a tool to measure communication difficulty for a ventilated patient
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 thank you all.
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51 year old male ,with progressive but waxing and awning lung pathology,and bilateral moderate infiltrate ,no etiology found despite all investigation except biopsy,all modalities of ventiltation failed even ossilator didnot work?the airways are normal,compliance 16,pcv of 34cm prodyce 400ml tidal volume?
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How much PEEP , what is the resp rate  , what is the I:E ratio ?
Excluding a mechanical cause ( ie equipment failure ) the mechanisms of refractory hypoxemia and moderate hypercapnia are either decreased alveolar ventilation  because of dead space and or v/q mismatch, or through increased shunt .
  • Causes: Many - not all shunt is radio-opaque!
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I am looking for a instrument for data collection.
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Researcher can prepare a  questionnaire on care of the premature neonatal infants by following recommended books and it can be used as a self administering questionnaire .for research. prepared questionnaire  can be validated by experts in the field before implementing or collecting data- Its my point of view
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I am trying to find a good APRN to patient staffing ratio for those who are critically ill and those who are acutely ill. Any help would be greatly appreciated.
Thanks!
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Do you use any electronic database to monitoring / measuring quality indicators at your ICU? Whitch indicators? What type of Database? Can you suggest a related article?
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I`m a critical care nurse from Chile and we work on a basis of 12 hours shifts called "4ª turno" (fourth shift) which means a 4 day rotation starting with a day shift (8:00 am to 20:00 pm), second day night shift (20:00 pm to 08:00 am of the next day), third day and fourth day are free.
I would like how works the 8 hours shifts because some hospitals in my country are trying to change to this kind of work.
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in our center we have the following schedule:
2 Morning (06:00 AM - 14:00)
2 Evening (14:00 - 22:00)
2 Nights (22:00 - 06:00 AM)
this is very convenient and correlated with higher satisfaction and less sickness rates
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Trying to gather resources for standardized or widely accepted assessments used in the rehabilitation portion of burn care.
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The protocol of rehabilitation is divided in three stage acute, subacute and chronic,
It is expalening in my research you can see that in journal were it is publich
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How have you managed the transition? Has you experience matched your expectations?
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After educating the nurses you can led them to practice with the patients under your supervision if they become good you can assess the effect of your educational intervention on the patients outcomes thanks
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Failure to rescue is shorthand for failure to rescue (i.e., prevent a clinically important deterioration, such as death or permanent disability) from a complication of an underlying illness (e.g., cardiac arrest in a patient with acute myocardial infarction) or a complication of medical care. Failure to rescue rates used for both research purposes and as quality indicators are typically derived from hospital administrative databases. However, it is not clear how identify it, so what are the best indicators to measure it?
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I also think that retrospective analysis is the only option. Is it accurate to limit failure to rescue to cardiac arrest? Perhaps one of the early warning system frameworks (EWS; http://www.ihi.org/resources/Pages/ImprovementStories/EarlyWarningSystemsScorecardsThatSaveLives.aspx) could be used to expand the conceptualization of "failure to rescue" . It seems that failure to respond, or a delay in response, at any point when the evidence (i.e., vital signs, O2 sat) suggests an intervention could be on a continuum of failure to rescue.  
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For my assignment.
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Training and continuous education contribute effectively.. I hope this paper could help 
Nurse Level of Education, Quality of Care and Patient Safety in the Medical and Surgical Wards in Malaysian Private Hospitals: A Cross-sectional Study
Warm regards, 
Mu'taman Jarrar
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How many days Arctic sun can be used to maintain temperature?
Head injury protocol can be disconnected abruptly? If not, what criteria can be used to taper and disconnect the protocol.
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PCO2 more than 30 mmHg for more than 48 h
ICP less than 20 which usually cant be measured in clinical bases unless the patient was already have a shunt.
Yet in practice sings of increased ICP are taken in mind such as vomiting, nausea , focal neurologic deficit, and headache
you can see that by chechking papilledam .
usually for 5-7 days after injury
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Self-efficacy refers to the extent of an individual’s belief in his or her abilities. Because self-efficacy is based on feelings of self-confidence and control, it is a good predictor of motivation and behavior. This is particularly ingesting in nursing field, there are different questionnaire used to measure self efficacy, is there someone confident with some of the availed tools?
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HI Rosario, as Edwin points out, self-efficacy is task specific, which people often confuse and why the general self-efficacy scale is questionable. I am not sure what specific task you are looking for in nursing, but I have developed an Evidence-Based Practice Self-Efficacy Scale, that measures one's confidence in how to approach and and implement EBP. We have published preliminary validity and reliability of the scale and have further supporting data not yet published. If interested, let me know and I will gladly get you a copy at no cost. We have a request form online at the University of Iowa Hospitals & Clinics, Hundreds of providers across the country and in several other countries have requested to use the scale. 
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I am currently looking for recent articles on stress and coping mechanisms among critical care nurses.
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In the following article "super nurse" is not used, but the research supports best coping strategies for Critical Care and Emergency Department nurses.
Adriaenssens, Jef, Veronique De Gucht, and Stan Maes. "The Impact of Traumatic Events on Emergency Room Nurses: Findings from a Questionnaire Survey." International Journal of Nursing Studies 49 (2012): 1411-422.
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Intermittent pneumatic compression devices role in DVT prophylaxis is an area that needs to be discovered still more deeply. The design of these machines, pressure exerted on legs and the optimal time to be used still need to be researched.
All are an important confounding factors that need to be addressed by randomized control trials before concluding : Did it work, or not?
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We use IPC in all our patients who undergo pneumonectomy for five days postoperatively, combined with enoxoparin for six weeks. The rationale is to prevent (mostly fatal) embolic events in the unique remaining lung. This procedure is now in place for six years and we had no such events in this timeframe. (it is of course an event that is rare, but before we used ICP, major embolic events were seen in about 1% of pneumonectomy patients; we do 40+ pneumonectomies a year, so calculating the odds it seems an improvement).
For the use: the first three days the IPC is running 24/24, when the patient is fully mobilized the IPC is only used during the night. Most patients complain, not of discomfort wearing them, but from the noise the pumps make.
This is of course a totally different population from stroke patients, but we feel it works
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The nature to which the problem to be looked at within the given area of ICU is what constraints if any contribute to an untimely admission. As this is an area which locally has not been identified as having collected data on the timely admission to ICU, it was an area which needed to be investigated.
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Hi Julie - yes, I see the same in the ED setting, there is a considerable body of literature in relation to aspects of ED and hospital overcrowding, and I think for most specialty areas, where the back flow from high levels of hospital occupancy has resulted in failure of patient flow. It becomes a hospital wide problem (and essential a social problem as well) as wards cannot accommodate the patients from ICU due to their lack of space, which is linked to inability to discharge patients often associated with inadequate or insufficient community support systems. One of the challenges is to address the 'silo' effect that often occurs in health care, where individual areas focus on their own concerns without looking at the 'bigger picture'. It can be difficult to get buy in to processes aiming to improve patient flow, with out recognition that it needs to be a hospital wide approach.
Unfortunately, responses often do not occur until sentinel events raise the profile of the issue, and as you identify this is often in the form of increased mortality. Certainly in relation to ED practice, one of the factors that has led to greater priority in relation to overcrowding has been the development of research that has clearly linked patient outcomes (increased length of stay and mortality in particular) to this phenomenon. It has been shown that failure to be able to move patients on to the more appropriate areas is linked with measurable negative outcomes. I think that the need for such research is one way to highlight the issue and its severity. There also need to be moves ant a socio-political level, with increased public awareness of the issues and the potential outcomes, and a willingness to re-look at the traditional processes and priorities within the health care system. As you so rightly note, with the increasingly aged population, chronic disease and co-morbidities associated this issue will only expand.
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Researching the topic.
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I feel it depends the culure of the ICU. If the medical staff do not respond to the alarm and let it go off for long then a lot of noise will be produced. Some alarms are just so loud, such as high frequency ventilator, and unbearable. If all medical staff respond to alarm appropriately then we do not need a very loud alarm system and will improve the quality of patient care.
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Today, life can be sustained indefinitely by the use of machinery and intubations. As medical expertise and technology continue to spread, moral, ethical and legal issues arise.
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Euthanasia is illegal in the US but Assisted suicide or Physician aid in dying (PAD), is legal in the states of Washington, Oregon, Montana, and Vermont. While machinery and intubations can prolong life, they also can be legally removed to ensure death with dignity. Even feeding tubes can be removed legally. Often issues occur when the patient does not have a living will or advanced directives and the family members do not agree on what should be done. It is often difficult to see a loved one in the persistent unresponsive state. It is also difficult to make the decision that this loved one should be taken off machinery or tube feedings, thus causing their death. The Terri Schiavo case is an example of the difficulties families face.