High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality's National Quality ...Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance.
Prospective, multisite, observational study of performance of key intensive care unit palliative care processes.
A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital.
Consecutive adult patients with length of intensive care unit stay ≥5 days.
None.
Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: Identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance.
Across three intensive care units in this study, performance of key palliative care processes (other than pain assessment and management) was inconsistent and infrequent. Available resources and strategies should be utilized for performance improvement in this area of high importance to patients, families, and providers.
Little is known about the painfulness of procedures commonly performed in acute and critical care settings.
To describe pain associated with turning, wound drain removal, tracheal suctioning, femoral ...catheter removal, placement of a central venous catheter, and nonburn wound dressing change and frequency of use of analgesics during procedures.
A comparative, descriptive design was used. Numeric rating scales were used to measure pain intensity and procedural distress; word lists, to measure pain quality.
Data were obtained from 6201 patients: 176 younger than 18 years and 5957 adults. Mean pain intensity scores for turning and tracheal suctioning were 2.80 and 3.00, respectively (scale, 0-5), for 4- to 7-year-olds and 52.0 and 28.1 (scale, 0-100) for 8- to 12-year-olds. For adolescents, mean pain intensity scores for wound dressing change, turning, tracheal suctioning, and wound drain removal were 5 to 7 (scale, 0-10); mean procedural distress scores were 4.83 to 6.00 (scale, 0-10). In adults, mean pain intensity scores for all procedures were 2.65 to 4.93 (scale, 0-10); mean procedural distress scores were 1.89 to 3.47 (scale, 0-10). The most painful and distressing procedures were turning for adults and wound care for adolescents. Procedural pain was often described as sharp, stinging, stabbing, shooting, and awful. Less than 20% of patients received opiates before procedures.
Procedural pain varies considerably and is procedure specific. Because procedures are performed so often, more individualized attention to preparation for and control of procedural pain is warranted.
The technology and expertise of critical care practice support patients through life-threatening illnesses. Most recover; some die quickly; others, however, linger--neither improving nor acutely ...dying, alive but with a dwindling capacity to recover from their injury or illness. Management of these patients is often dominated by the question: Is it appropriate to continue life-sustaining therapy? Patients rarely participate in these pivotal discussions because they are either too sick or too heavily sedated. As a result, the decision often falls to the family or the surrogate decision maker, in consultation with the medical team. Decisions of such import are emotionally stressful and are often a source of disagreement. Failure to resolve such disagreements may create conflict that compromises patient care, engenders guilt among family members, and creates dissatisfaction for health care professionals. However, the potential for strained communications is mitigated if clinicians provide timely clinical and prognostic information and support the patient and family with aggressive symptom control, a comfortable setting, and continuous psychosocial support. Effective communication includes sharing the burden of decision making with family members. This shift from individual responsibility to patient-focused consensus often permits the family to understand, perhaps reluctantly and with great sadness, that intensive caring may involve letting go of life-sustaining interventions.
Quench the Thirst Arai, Shoshana R.; Butzlaff, Alice; Stotts, Nancy A. ...
Biological research for nursing,
10/2014, Letnik:
16, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Thirst, as a symptom, has long been considered the most prevalent clinical complaint patients voice in healthcare settings. Yet, rarely have researchers examined thirst by its correlation with ...physiologic factors. This review was undertaken to examine the relationships between thirst ratings and factors mediating its primary physiologic correlates: plasma osmolality (pOsm) and arginine vasopressin peptide (AVP). A literature search was undertaken to identify clinical studies in human subjects that investigated the relationship of thirst to specific physiologic thirst-related correlates and associated thirst mediators. Thirst was induced in 17 selected clinical studies by hyperosmolar infusion, through water deprivation or exercise weight-loss regimens. Positive linear relationships between the subjects' thirst ratings and rising serum pOsm levels confirmed the presence of intact osmotic thirst drives. However, there were significant variations in normal compensatory rises in AVP levels that followed the rises in plasma osmolality after the subjects were exposed to cold, physical pre-conditioning and water immersion tests. Notably, older adults in the studies reported diminished thirst ratings. Weak correlations suggest that angiotensin II may play only a minor role in thirst mediation. Atrial natriuretic hormone's inhibitory effect on thirst was inconsistent. Findings indicated that older adults are at higher risk for profound dehydration due to sensory deficits along with failure to correct volume losses. The thirst trials results support the close correlation between serum pOsm values and patients' thirst ratings, with the exception of the older adult.
Rapid response teams (RRTs) can effectively foster discussions about appropriate goals of care and address other emergent palliative care needs of patients and families facing life-threatening ...illness on hospital wards. In this article, The Improving Palliative Care in the ICU (IPAL-ICU) Project brings together interdisciplinary expertise and existing data to address the following: special challenges for providing palliative care in the rapid response setting, knowledge and skills needed by RRTs for delivery of high-quality palliative care, and strategies for improving the integration of palliative care with rapid response critical care. We discuss key components of communication with patients, families, and primary clinicians to develop a goal-directed treatment approach during a rapid response event. We also highlight the need for RRT expertise to initiate symptom relief. Strategies including specific clinician training and system initiatives are then recommended for RRT care improvement. We conclude by suggesting that as evaluation of their impact on other outcomes continues, performance by RRTs in meeting palliative care needs of patients and families should also be measured and improved.
Critical care nurse communication training has largely been limited to didactic materials, interactive training for nurse supervisors, or brief participatory learning programs within the context of ...comprehensive end-of-life care educational seminars. Preliminary evidence suggests that an interactive approach can also be effective in communication skills training for intensive care unit (ICU) nurses.
We implemented a 1-day educational intervention in five acute care hospitals within Veterans Integrated Service Network (VISN) 3 (New York-New Jersey region) of the Department of Veterans Affairs and focused solely on communication skills and targeted specifically to nurses providing bedside care for critically ill patients. A "learner centered" approach to skills training that has several integral components was employed. AMONG THESE ARE: a cognitive, evidence-based foundation upon which to build new skills; a method such as role-play that allows participants to practice newly learned skills; and an affective component, during which trainees can freely discuss their impressions of the exercise or explore difficulties that may have been encountered. Before and after the program we conducted a detailed assessment of participants' self-rated communication skills and of the techniques and materials we used.
Post-program responses documented significant improvement in self-evaluated skills for each of the core tasks we assessed. Evidence suggests that communication with patients and families in the ICU can be most effectively approached in an interdisciplinary way. For nurses to fully realize their potential for optimal communication as members of the multidisciplinary team, they must be equipped with the necessary skills. We believe this new program helps to expand the range of approaches for training nurses in essential communication skills.
Family-centered care is an important component of holistic nursing practice, particularly in critical care, where the impact on families of admitted patients can be physiologically and ...psychologically burdensome. Family-centered care guidelines, developed by an international group of nursing, medical, and academic experts for the American College of Critical Care Medicine/Society of Critical Care Medicine, explore the evidence base in 5 key areas of family-centered care. Evidence in each of the guideline areas is outlined and recommendations are made about how critical care nurses can use this information in family-centered care practice.
The purpose of this secondary data analysis of findings from a larger procedural pain study was to examine several factors related to pain during tracheal suctioning. In addition to tracheal ...suctioning, other procedures studied included turning, wound drain removal, femoral catheter removal, placement of a central venous catheter, and wound dressing change. A total of 755 patients underwent the tracheal suctioning procedure that was performed primarily in intensive care units (93%). A 0–10 numeric rating scale, a behavioural observation tool, and a modified McGill Pain Questionnaire-Short Form were used for pain assessment. Pain intensity scores were significantly greater during the tracheal suctioning procedure (
M
=
3.96, S.D.
=
3.3) than prior to (
M
=
2.14, S.D.
=
2.8) or after (
M
=
1.98, S.D.
=
2.7) tracheal suctioning. Few patients received analgesics prior to or during the procedure. Surgical, younger, and non-white patients reported higher pain intensities. Although mean pain intensity during tracheal suctioning was mild, almost the half of the patients reported moderate-to-severe pain. Individualized pain management must be performed by healthcare providers in order to respond to patients’ needs as they undergo painful procedures such as tracheal suctioning.
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