Aims
To develop and psychometrically test a Theory of Planned Behaviour (TPB) questionnaire to assess nurses’ intention to use physical restraints (PRs) in intubated patients.
Design
A psychometric ...instrument validation study conducted in three phases.
Methods
A theory‐driven questionnaire was developed. Eight experts validated the content of the preliminary 58‐item questionnaire. A pilot study was conducted including 101 critical care nurses to test the reliability of the items. Construct validity and reliability were tested in a cross‐sectional study of 12 units from eight hospitals in Spain (N = 354) from October ‐ December 2017. Participants completed the questions based on the TPB, and socio‐demographic and professional variables.
Results
The instrument comprised 48 items. All the direct and indirect constructs exhibited acceptable reliability. Confirmatory factor analysis indicated satisfactory fit indices for factorial structure according to the TPB. Nurses showed favourable attitudes, low perception of social pressure and modest perception of behaviour control. Perceived behavioural control and attitude were moderately positively correlated with the intention to use restraints, whereas subjective norm revealed the lowest correlation. Overall, the model explained 33% of the variance in intention.
Conclusions
The Physical Restraint TPB questionnaire is a 48‐item self‐reporting theoretically based instrument with acceptable reliability and construct validity to identify nurses’ intentions to use PRs in intubated patients.
Impact
Unravelling the key determinants of nurses’ intentions to use PRs should be examined to tailor quality improvement projects aimed at de‐implementing restraints use in practice and to promote safer care.
Aim
To develop and psychometrically test the Behavioural Indicators of Pain Scale (ESCID) in patients with traumatic brain injury (TBI).
Design
A prospective observational study to test the ...psychometric properties of the Behavioural Indicators of Pain Scale in patients with TBI.
Method
A convenience sample of patients with TBI, who were non‐communicative and using invasive mechanical ventilation was selected. Pain was evaluated by two observers who were blinded from each other. Assessments were performed at baseline via the performance of a painful procedure (aspiration of secretions) and a non‐painful procedure (rubbing with a gauze). Assessments were repeated after application of procedures on days 1 and 6 of hospitalization in an intensive care unit. Data were collected between January–December 2016.
Results
About 134 patients were included in the study. Of these, 76.1% were men. The mean age of participants was 45.2 (SD 17.5) years. The pain score significantly increased during the painful procedure when compared with the baseline measure and non‐painful procedure (p < .001). Patients displayed a greater number of pain‐indicating behaviours during the painful procedure on day 6, compared with day 1 (p < .05). This finding coincided with a reduced level of sedation and a greater level of consciousness.
Conclusion
The ESCID scale detects pain behaviours and discriminates among the different types of stimulation in patients with brain injury, who are uncommunicative and with mechanical ventilation, with good reliability. The ability for patients with brain injury to express behaviours is limited because of the low level of consciousness and the deep level of sedation.
Impact
This research will have an impact on the practice of pain assessment in patients with brain injury, representing a first step to adapt the content of the ESCID.
目的
建立外伤性脑损伤(TBI)患者疼痛量表行为指标(ESCID)并进行心理测量。
设计
以测试外伤性脑损伤患者疼痛量表行为指标的心理测量特性的前瞻性观察研究。
方法
随机抽样一个外伤性脑损伤患者样本,他们是无法进行交流,且使用有创机械通气。由两名观察者对疼痛感进行独立盲评。在基线位置,通过疼痛性过程(吸入分泌物)和非疼痛性过程(用纱布摩擦)进行评估。在重症监护病房住院的第1天和第6天应用这些过程后,重复评估。
收集2016年1月至12月的数据。
结果
本研究共纳入134例患者。其中男性占76.1%。受访者的平均年龄为45.2岁(标准差为17.5岁)。在与基线测量和非疼痛性过程比较时,疼痛过程的疼痛评分明显偏高(p <0.001)。与第1天相比,疼痛过程的患者在第6天的表现出的疼痛指示行为更高(p <0.05)。这一发现与镇静程度的降低和意识水平的增强相吻合。
结论
疼痛量表行为指标量表能检测无法进行交流且使用机械通气的外伤性脑损伤患者的疼痛行为,区分不同类型的刺激物,结果更加可靠。外伤性脑损伤患者由于意识水平低、镇静程度深,表达行为的能力有限。
影响
本研究将对外伤性脑损伤患者疼痛评估的实践产生影响,预示着其适合疼痛量表行为指标内容的第一步。
Background
The ABCDE bundle is a set of evidence‐based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves ...clinical outcome.
Aims and Objectives
To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol).
Design
A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation.
Methods
The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied.
Results
Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two‐thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008).
Conclusions
The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation.
Relevance to clinical practice
Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV.
Delirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the ...epidemiology of delirium in the ICU.
A 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain.
In total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%).
In this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam).
Background
Early mobilization in the intensive care unit (ICU) helps improve patients' functional status at discharge. However, many barriers hinder this practice.
Aim and objectives
To identify ...mobility levels acquired by critically ill patients and their variables.
Design
A multi‐centre cohort study was conducted in adult patients receiving invasive mechanical ventilation for at least 48 hours.
Methods
The primary outcome was level of mobility according to the ICU mobility scale. The secondary outcome was human resource availability and existence of ABCDEF bundle guidelines. A logistic regression was performed, based on days 3 to 5 of the ICU stay and significant association with active mobility.
Results
Six hundred and forty‐two patients were included from 80 ICUs. Active moving in and out of bed was found on 9.9% of patient‐days from day 8 of the ICU stay. Bed exercises, or passive transfers, and immobility were observed on 45.6% and 42.2% of patient‐days, respectively. Patients achieving active mobility (189/642, 29.4%) were in ICUs with more physiotherapist hours. Active mobility was more likely with a 1:4 nurse‐patient ratio (odds ratio OR 3.7 95% confidence interval CI 1.2‐11.2), high MRC sum‐score (OR 1.05 95% CI 1.04‐1.06) and presence of delirium (OR 1.01 95% CI 1.00‐1.02). By contrast, active mobility was hindered by higher BMI (OR 0.92 95% CI 0.88‐0.97), a 1:3 nurse‐patient ratio (OR 0.54 95% CI 0.32‐0.93), or a shift‐dependent nurse‐patient ratio (OR 0.27 95% CI 0.12‐0.62).
Conclusions
Immobility and passive mobilization were prevalent. A high MRC sum‐score and presence of delirium are protective factors of mobilization. A 1:4 nurse‐patient ratio shows a stronger association with active mobility than a 1:3 ratio.
Relevance to clinical practice
Severity‐criteria‐based nurse‐patient ratios hinder mobilization. Active mobilization may be enhanced by using nursing‐intervention‐based ratios, increasing physiotherapist hours, and achieving wider application of the ABCDEF bundle, resulting in more awake, cooperative patients.
Anaemia is a common issue in patients who are admitted to intensive care units and worsens their condition throughout the stay due to the extraction of blood for diagnostic purposes. It is also ...well-known that an important amount of the carbon dioxide produced by health services is likely attributable to blood donation, testing and manufacture, storage or distribution of blood components. This must be taken into account to perform nursing interventions consistent with the idea of sustainable health care. In this regard, within patient blood management bundles, with the objective of minimizing the use of blood products, it is recommended to use blood-sparing techniques: small volume tubes (SVT) or closed-blood sampling devices (CBSD). Published studies before 2014 (excepting two more recent ones) have shown that by themselves, both techniques reduce drawn volume but do not decrease haemoglobin reduction and/or need of transfusion. Given the lack of cost-effectiveness studies, it may be easier to implement the use of CBSD as it does not require prior consensus on the discard volume or adaptations in the processing of laboratory tests, as is the case with SVT.
To assess the incidence and determinants of ICU-acquired muscle weakness (ICUAW) in adult patients with enteral nutrition (EN) during the first 7 days in the ICU and mechanical ventilation for at ...least 48 hours.
A prospective, nationwide, multicentre cohort study in a national ICU network of 80 ICUs. ICU patients receiving invasive mechanical ventilation for at least 48 hours and EN the first 7 days of their ICU stay were included. The primary outcome was incidence of ICUAW. The secondary outcome was analysed, during days 3-7 of ICU stay, the relationship between demographic and clinical data to contribute to the onset of ICUAW, identify whether energy and protein intake can contribute independently to the onset of ICUAW and degree of compliance guidelines for EN.
319 patients were studied from 69 ICUs in our country. The incidence of ICUAW was 153/222 (68.9%; 95% CI 62.5%-74.7%). Patients without ICUAW showed higher levels of active mobility (p = 0.018). The logistic regression analysis showed no effect on energy or protein intake on the onset of ICUAW. Overfeeding was observed on a significant proportion of patient-days, while more overfeeding (as per US guidelines) was found among patients with obesity than those without (42.9% vs 12.5%; p<0.001). Protein intake was deficient (as per US/European guidelines) during ICU days 3-7.
The incidence of ICUAW was high in this patient cohort. Early mobility was associated with a lower incidence of ICUAW. Significant overfeeding and deficient protein intake were observed. However, energy and protein intake alone were insufficient to explain ICUAW onset.
Low mobility, high incidence of ICUAW and low protein intake suggest the need to train, update and involve ICU professionals in nutritional care and the need for early mobilization of ICU patients.
Abstract
Background
health-related quality of life (HRQoL) is an important patient-centred outcome in patients surviving ICU admission for COVID-19. It is currently not clear which domains of the ...HRQoL are most affected.
Objective
to quantify HRQoL in order to identify areas of interventions.
Design
prospective observation study.
Setting
admissions to European ICUs between March 2020 and February 2021.
Subjects
patients aged 70 years or older admitted with COVID-19 disease.
Methods
collected determinants include SOFA-score, Clinical Frailty Scale (CFS), number and timing of ICU procedures and limitation of care, Katz Activities of Daily Living (ADL) dependence score. HRQoL was assessed at 3 months after ICU admission with the Euro-QoL-5D-5L questionnaire. An outcome of ≥4 on any of Euro-QoL-5D-5L domains was considered unfavourable.
Results
in total 3,140 patients from 14 European countries were included in this study. Three months after inclusion, 1,224 patients (39.0%) were alive and the EQ-5D-5L from was obtained. The CFS was associated with an increased odds ratio for an unfavourable HRQoL outcome after 3 months; OR 1.15 (95% confidence interval (CI): 0.71–1.87) for CFS 2 to OR 4.33 (95% CI: 1.57–11.9) for CFS ≧ 7. The Katz ADL was not statistically significantly associated with HRQoL after 3 months.
Conclusions
in critically ill old intensive care patients suffering from COVID-19, the CFS is associated with the subjectively perceived quality of life. The CFS on admission can be used to inform patients and relatives on the risk of an unfavourable qualitative outcome if such patients survive.
Abstract
Aim
To translate and culturally adapt the FRAIL scale into Spanish and perform a preliminary test of diagnostic accuracy in patients admitted to intensive care units.
Design
Cross‐sectional ...diagnostic study.
Methods
Five intensive care units (ICU) in Spain were participated. Stage 1: Three native Spanish‐speaking bilingual translators familiar with the field of critical care translated the scale from English into Spanish. Stage 2: Three native English‐speaking bilingual translators familiar with critical care medicine. Stage 3: Authors of the original scale compared the English original and back‐translated versions of the scale. Stage 4: Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the comprehension and relevance of each of the items of the Spanish version in 30 patients of 3 different age ranges (<50, 50–65 and >65 years).
Results
The FRAIL scale was translated and adapted cross‐culturally for patients admitted to intensive care units in Spain. The process consisted of four stages: translation, back translation, comparison and pilot test. There was good correspondence between the original scale and the Spanish version in 100% of the items. The participating patients assessed the relevance (content validity) and comprehensibility (face validity) of each of the items of the first Spanish version. The relevance of some of the items scored low when the scale was used in patients younger than 65 years.
Conclusions
We have cross‐culturally adapted the FRAIL scale, originally in English, to Spanish for its use in the critical care medical setting in Spanish‐speaking countries.
Implications for Professionals
Physicians and nurses can apply the new scale to all patients admitted to the intensive care units. Nursing care can be adapted according to frailty, trying to reduce the side effects of admission to these units for the most fragile patients.
Reporting Method
The manuscript's authors have adhered to the EQUATOR guidelines, using the COSMIN reporting guideline for studies on the measurement properties of patient‐reported outcome measures.
Patient or Public Contribution
In a pilot clinical study, we applied the first version of the FRAIL‐Spain scale to intensive care unit (ICU) patients. Five nurses with more than 5 years of ICU experience and five critical care physicians assessed the relevance (content validity) and comprehensibility (face validity) of the five items of the first Spanish version. Relevance was assessed using a 4‐point Likert scale ranging from 1 (no relevance) to 4 (high relevance), and comprehensibility was assessed as poor, acceptable or good. Each health professional applied the scale to three patients (total number of patients = 30) of three different age ranges (<50, 50–65 and >65 years) and recorded the time of application of the scale to each patient. Although the frailty scales were initially created by geriatricians to be applied to the elders, there is little experience with their application in critically ill patients of any age. Therefore, more information is needed to determine the relevance of using this scale in critical care patients. In this pilot study, we considered that nurses and critical care physicians should evaluate frailty using this adapted scale in adult patients admitted to the Intensive Care Units.
To evaluate the effect of the implementation of a nursing-driven protocol of sedation on duration of intubation.
Before-and-after prospective study.
18-bed medical-surgical intensive care unit.
...Patients receiving mechanical ventilation longer than 48 hrs who were ready to wean.
During the observational period, sedatives and analgesics were adjusted according to physicians' orders. During the intervention period, sedatives and analgesics were adjusted by nurses according to an algorithm-based sedation guideline, including a sedation scale.
A total of 356 patients were included in the study (176 patients in the observational period and 189 patients in the intervention period). There were no significant differences in the duration of intubation between the two periods (median, 7 interquartile range, 5-13 days vs. 7 interquartile range, 5-9 days). In a Kaplan-Meier analysis, the probability of successful extubation was higher during the intervention period than during the observational period (log-rank = 0.02). During the intervention period, patients were more awake without a significant increment in the nurse workload; however, there was no significant decrease in the total doses of sedatives and analgesics administered.
The implementation of a nursing-driven protocol of sedation may improve the probability of successful extubation in a heterogeneous population of mechanically ventilated patients.
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