Impact of Nursing Staffing on Patient Outcomes in Intensive Care Unit

Background: The impact of nursing care on patient outcomes is not well understood. The objective of this study is to assess the effects of nursing care hours per patient day, nursing skill mix, and nurse turnover on central line-associated bloodstream infection (C !"#$% rates, length of stay ( &#%, and mortality in the context of intensive care units ($C's% using interventions to reduce bloodstream infections and improve patient safety, teamwork and interdisciplinary communication. Results: (ursing care hours per patient day greater than )* hours was associated with lower C !"#$ rates. $ncreasing nursing hours per patient day was also associated with shorter &#, with the strongest relationship where nursing hours per patient day was lower (+ )* hours compared to , )* hours%. ! -igher skill mix was associated with shorter &# but higher C !"#$ rates. .e found no significant relationships of nursing turnover with any outcome, or between any nursing variables and mortality. Conclusions: &ur findings suggest that nursing care hours per patient day and nursing skill mix significantly contribute to C !"#$ prevention and &# in the $C' setting.
Impact of Intensive Care Unit Physician on Care Processes of Patients with Severe Sepsis in Teaching Hospitals

!bstract Objective: The purpose of the study was to investigate associations among intensive care unit ($C'% staffing and care processes in patients with severe sepsis. Results: $C's were classified as high- or low-intensity based on policies regarding the responsibilities of intensivists. There were no differences in baseline patient characteristics between the $C' groups. $n the high-intensity group, $C' stay for survivors was about two days shorter and hospital stay was significantly shorter by three days. /ajority of patients had high rates of enteral feeding0 however, the high-intensity group had significantly earlier initiation of enteral feeding and a significantly shorter duration of mechanical ventilation. ! shorter duration of mechanical ventilation was significantly associated with the $C' structure. Conclusions: The results showed an association between $C' physician and processes of intensive care, and high-intensity $C' was aggressive in mechanical ventilation in patients with severe sepsis.

Demand for Nursing Care from lderly People Hospitalised at an Intensive Care Unit

Background: The work aimed at assessing the demand for nursing care from elderly patients at $C's, based on the T$##-)1 scale. Results: 2ata analysis proved elderly patients3 T$##-)1 scores were highest for basic activities- 4.56 (#2-).67%, however, lower scores were reported for respiratory therapy 5.78 (#2-6.14%. ! general T$##-)1 assessment for the whole research cohort was )5.97. This means that patients should be provided with nursing care level of one nurse per two patients per shift. Conclusions: The more advanced the patients3 age the lower the assessment of therapeutic interventions within the scope of basic activities and circulation therapy, but at the same time, the higher the assessment of respiratory therapy and other interventions.

Nighttime Lighting in Intensive Care Units

The potential effect that light has on patients3 health and positive outcomes could make this simple act one of great importance. !round-the-clock care, high acuity of patients, and improved technology have transformed intensive care units ($C's% into increasingly complex and fast-paced environments where speciali:ed care is provided on a )7-hour basis. 6 !lthough the necessity of around-the-clock care is easily understood, the environment that is created and the resulting potential sleep disruptions are not always optimal for patients3 healing and successful outcomes. ); 7 /ulti-factorial issues, including noise, lighting, patient care activities, vital signs, phlebotomy, and medication administration have often been identified as potential causes of sleep disruptions in the $C'. 8 $n a study 7 on nocturnal interruptions of patient care in critical care units, a mean of 7).9 patient care interactions occurred each night, only 4 uninterrupted )- to 5-hour periods of sleep were documented in 67< nights, and 9)= of patients3 baths were performed between the hours of 4 pm and 9 am. Thirty-seven percent of sleep disturbances have been attributed to noise disruptions and patient care interactions. 9 -owever, when patients3 perception of sleep >uality in the $C' was examined, noise was not identified as the primary cause of sleep disruption. ?esearch participants indicated that monitoring of vital signs and phlebotomy were the most disruptive to their sleep while in the $C'. ighting was perceived as significantly less disruptive than most other factors measured. 8

Continuous ST Segment !onitoring in the Intensive Care Unit

Cardiac monitoring of critically ill patients enables 5 basic features to be detected@ rate abnormalities, rhythm disturbances, and ischemic patterns. .hen it was developed, continuous computeri:ed #T-segment monitoring proved an invaluable resource for detecting ischemia in critically ill cardiac patients. Considered a technological bonus if instituted correctly, this essential device for detection of myocardial ischemia is underused in the 'nited #tates.6 Axperts in the field of electrocardiographic (ACB% monitoring are currently advocating for continuous #T-segment monitoring for detection of silent myocardial ischemia (#/$% in all areas where patients undergo cardiac monitoring because #T-segment monitoring is a simple, inexpensive, and noninvasive means of providing valuable diagnostic information.) Therefore, in this article, we analy:e and interpret the research studies behind the recommendations in the )**1 !!C( practice alert on #T-segment monitoring. The intent is to provide critical care clinicians with evidence-based rationales to substantiate revisions of current monitoring practices and to provide realistic strategies for implementation of new practices.

Skilled Cardiac !onitoring at the Bedside: "n "lgorithm #or Success

The !merican !ssociation of Critical-Care (urses (!!C(% posted ) practice alerts to address issues in cardiac monitoring in )**7 and updated them in !pril )**1.6,) The alerts addressed ) main reasons for use of cardiac bedside monitoring. The first reason is to detect and provide early intervention for episodes of myocardial ischemia and injury.5,7 Correct ACB lead selection is crucial for detection of these episodes.6,8;4 .hen the correct lead or leads are used, #T-segment monitoring provides important information for patient care, provided alarms are set appropriately. "ecause aggressive early treatment improves outcomes in patients who have myocardial ischemia and injury, #T-segment monitoring should be used by all nurses who work in areas with cardiac monitoring.6,5;<,6*,66 The second reason for cardiac bedside monitoring is to detect serious dysrhythmias that may re>uire treatment. $f patients are not monitored by using the recommended lead for dysrhythmia interpretation, nurses and physicians correctly diagnose a wide C?# tachycardia only 57= of the time, and erroneous interpretation can lead to inappropriate treatment.8 The !!C( practice alerts6,) identified expected practice for monitoring #T-segments and dysrhythmias. 2uring practice discussions in committees and at the bedside, some nurses at /ayo Clinic, ?ochester, /innesota, remarked that they did not understand application of the

concepts covered in the alerts. The ACB lead monitoring algorithm was developed to provide a tool to assist bedside nurses in combining the ) concepts.

Nurse Led Im$lementation o# a Sa#e and %##ective Intravenous Insulin &rotocol in a !edical Intensive Care Unit
Background ?ecent evidence has linked tight glucose control to worsened clinical outcomes among adults in intensive care units. Objective To evaluate the effectiveness and safety of a nurse-led intravenous insulin protocol designed to achieve conservative blood glucose control in patients in a medical intensive care unit. !ethods ! nurse-led intravenous insulin protocol was developed, targeting blood glucose levels at 66* to 674 mgDd . -ypoglycemia was defined as a blood glucose level less than <* mgDd . Eatients admitted to the medical intensive care unit who re>uired an insulin infusion were enrolled in the study. "lood glucose levels in those patients were compared with levels in 685 historical control patients admitted to the unit in the 6) months before the protocol was implemented who re>uired an insulin infusion. Results (inety-six patients were enrolled and treated with the protocol. The protocol and control groups had similar characteristics at baseline. /ore measurements in the protocol group than in the control group (79.5= vs 59.6=, P+.**6% were within the target glucose range (66*;674 mgDd %. -yperglycemia (blood glucose ,)** mgDd % occurred less often in the protocol group than in the control group (67.1= vs )*.6=, PF.**5%. -ypoglycemic events (blood glucose +<* mgDd % also occurred less often in the protocol group (*.*<= vs *.15=, P+.**6%.

&atient Satis#action and 'ocumentation o# &ain "ssessments and !anagement "#ter Im$lementing the "dult Nonverbal &ain Scale

Background !ccurate assessment and management of pain in critically ill patients who are nonverbal or cognitively impaired is challenging. (o widely accepted assessment tool is currently in place for assessing pain in these patients. Objectives To evaluate the effect of implementing a new pain assessment tool in a traumaDneurosurgery intensive care unit. !ethods #taff and patient satisfaction >uestionnaires and retrospective chart reviews were used before and after implementation of the (onverbal Eain #cale. The >uestionnaire responses, fre>uency of pain documentation, and amount of pain medication given were compared from before to after implementation. Results /ost staff (<1=% ranked the tool as easy to use. $mplementation of the tool increased staff confidence in assessing pain in nonverbal, sedated patients (8<= before vs 16= after implementation, P F .*)% and increased the number of pain assessments documented by the nursing staff for noncommunicative patients per day in the intensive care unit ().) before vs 5.7 after, P F .*)%. Eatients reported decreased retrospective pain ratings (1.8 before vs <.) after, P F .*7% and a trend toward a decrease in the time re>uired to receive pain medication (51= before vs 6*= after re>uiring G8 minutes to receive medication, P F .*9%. Conclusions $mplementation of the (onverbal Eain #cale in a critical care setting improved patients3 ratings of their pain experience, improved documentation by nurses, and increased nurses3 confidence in assessing pain in nonverbal patients.

Clinical %##ectiveness o# a Critical Care Nursing Outreach Service in (acilitating 'ischarge (rom the Intensive Care Unit
Background $mproved discharge planning and extension of care to the general care unit for patients transferring from intensive care may prevent readmission to the intensive care unit and prolonged hospital stays. /orbidity, mortality, and costs increase in readmitted intensive care patients. Objectives To evaluate the clinical effectiveness of a critical care nursing outreach service in facilitating discharge from the intensive care unit and providing follow-up in general care areas. !ethods ! before-and-after study design (with historical controls and a 9-month prospective intervention% was used to ascertain differences in clinical outcomes, length of stay, and costDbenefit. Eatients admitted to intensive care units in 5 adult teaching hospitals were recruited. The service centered on follow-up visits by specialist intensive care nurses who reviewed and

assessed patients who were to be or had been discharged to general care areas from the intensive care unit. Those nurses also provided education and clinical support to staff in general care areas. Results $n total, 6758 patients were discharged during the 9-month prospective period. ength of stay from the time of admission to the intensive care unit to hospital discharge (P F .18%, readmissions during the same hospital admission (8.9= vs 8.7=, P F .15%, and hospital survival (P F .1*% did not differ from before to after the intervention. Conclusions !lthough other studies have shown beneficial outcomes in !ustralia and the 'nited Hingdom, we found no improvement in length of stay after admission to the intensive care unit, readmission rate, or hospital mortality after a critical care nursing outreach service was implemented.

O$timi)ing Nutrition in Intensive Care Units: %m$o*ering Critical Care Nurses to Be %##ective "gents o# Change
O!servational studies have consistently revealed wide variation in nutritional practices across intensive care units and indicated that the provision of ade"uate nutrition to critically ill patients is su!optimal# To date$ the potential role of critical care nurses in implementing nutritional guideline recommendations and improving nutritional therapy has received little consideration# %actors that influence nurses& nutritional practices include the lac' of guidelines or conflicting evidence(!ased recommendations pertaining to nurses& practice$ strategies for implementing guidelines that are not tailored to !arriers nurses face when feeding patients$ strategies to communicate !est evidence that do not capitali)e on nurses& preference for see'ing information through social interaction$ prioriti)ation of nutrition in initial and continuing nursing education$ and a lac' of interdisciplinary team colla!oration in the intensive care unit when decisions on how to feed patients are made# %uture research and "uality improvement strategies are re"uired to correct these deficits and successfully empower nurses to !ecome nutritional champions at the !edside# Using nurses as agents of change will help standardi)e nutritional practices and ensure that critically ill patients are optimally fed#

Communication b+ Nurses in the Intensive Care Unit: ,ualitative "nal+sis o# 'omains o# &atient Centered Care
Background -igh->uality communication is a key determinant and facilitator of patientcentered care. (urses engage in most of the communication with patients and patients3 families in the intensive care unit. Objective To perform a >ualitative analysis of nurses3 communications. !ethods Athnographic observations of 568 hours of interactions and 85 semistructured interviews with 55 nurses were conducted in a )9-bed cardiac-medical intensive care unit in an academic hospital and a )9-bed general intensive care unit in a Ieterans !ffairs hospital in Eortland, &regon. Communication interactions were categori:ed into 8 domains of patientcentered care. $nterviews were analy:ed to identify major themes in nurses3 roles and preferences for communicating with patients and patients3 families within the domains. Results /ost communication occurred in the domains of biopsychosocial information exchange, patient as person, and clinician as person. (urses endorsed the importance of the domains of shared power and responsibility and therapeutic alliance but had relatively few communication interactions in these areas. Communication behaviors were strongly influenced by the nurses3 roles as translators of information between physicians and patients and the patients3 families and what the nurses were and were not willing to communicate to patients and patients3 families. Conclusions Critical care, including communication, is a collaborative effort. 'nderstanding how nurses engage in patient-centered communication in the intensive care unit can guide future interventions to improve patient-centered care.

Im$lications o# the Ne* International Se$sis -uidelines #or Nursing Care

Sepsis is a serious worldwide health care condition that is associated with high mortality rates$ despite improvements in the a!ility to manage infection# New guidelines for the management of sepsis were recently released that advocate for implementation of care !ased on evidence( !ased practice for !oth adult and pediatric patients# Critical care nurses are directly involved in the assessment of patients at ris' for developing sepsis and in the treatment of patients with sepsis and can$ therefore$ affect outcomes for critically ill patients# Nurses& 'nowledge of the recommendations in the new guidelines can help to ensure that patients with sepsis receive therapies that are !ased on the latest scientific evidence# This article presents an overview of

new evidence(!ased recommendations for the treatment of adult patients with sepsis$ highlighting the role of critical care nurses

"dmission to the Intensive Care Unit and .ell being in &atients .ith "dvanced Chronic Illness
&ur$ose To describe the association of intensive care with trajectories of functional, emotional, social, and physical well-being in patients with 5 common advanced illnesses. !ethods Cross-sectional cohort study of 7) patients admitted to the intensive care unit selected from )6* patients with stage $I breast, prostate, or colon cancer or stage $$$b or $I lung cancer0 (ew Jork -eart !ssociation class $$$ or $I congestive heart failure0 and chronic obstructive pulmonary disease with hypercapnea (Eco) G 79 mm -g%. #cores on subscales of the Kunctional !ssessment of Chronic $llness Therapy-Beneral survey were measured monthly for 9 months before and after admission to the intensive care unit and were analy:ed by using the unit admission date as a point of discontinuous change to illustrate trajectories before and after the admission. Results &verall, trajectories of well-being declined sharply after admission to the intensive care unit. 2eclines in physical, functional, and emotional well-being were statistically significant. 2uring the 9 months after admission, physical, functional, and emotional well-being scores trended back up to baseline while social well-being scores continued to decline. Conclusions .ell-being trajectories declined sharply after admission to the intensive care unit, with recovery in the subse>uent 9 months, and may be characteri:ed by common patterns. These results help to better describe intensive care as a marker for advancing illness in patients with advanced chronic illness.

%nd Tidal Carbon 'io/ide as a !easure o# Stress Res$onse to Clustered Nursing Interventions in Neurologic &atients
Background Buidelines recommend rest periods between nursing interventions for patients with a neurologic diagnosis but do not specify a safe number of interventions.

Objectives To examine the physiological stress response to clustered nursing interventions in neurologic patients receiving mechanical ventilation. !ethods Erospective, comparative, descriptive design to examine effects of clustered interventions (,9 interventions in a single nursing interaction% versus nonclustered interventions on patients3 stress. #tress response was defined as a 6*= change in end-tidal carbon dioxide from before the interaction to (6% 8 and 6* minutes after the start of the interaction, ()% at the end of the interaction, and (5% 68 minutes after the interaction. Results The mean percent change in end-tidal carbon dioxide at 8 minutes differed significantly between patients with clustered interventions and patients with nonclustered interventions (9.<= vs L*.)=0 P F .**6%. Eatients with clustered interventions were significantly more likely than patients with low clustering to exhibit a stress response at 8 minutes ()7.5= vs *=0 P F .*6%. Conclusions (eurologic patients receiving mechanical ventilation who experienced 9 or more clustered nursing interventions showed a higher mean change in end-tidal carbon dioxide than did patients who received fewer than 9 clustered interventions. These findings suggest that providing fewer interventions during 6 nursing interaction may minimi:e induced stress in neurologic patients receiving mechanical ventilation.

'ecreasing Ina$$ro$riate Unable to "ssess Ratings #or the Con#usion "ssessment !ethod #or the Intensive Care Unit
Background The Confusion !ssessment /ethod for the $ntensive Care 'nit (C!/-$C'% is a validated tool for diagnosing delirium in the $C' and yields 6 of 5 ratings@ positive, negative, and unable to assess ('T!%. $t was hypothesi:ed that an educational campaign focused on establishing patients3 arousal as comatose versus noncomatose before initiating the C!/-$C' would decrease the incidence of inappropriate 'T! ratings. Objectives To compare the incidence of inappropriate 'T! ratings before and after an educational campaign. !ethods !n interventional, >uasi-experimental study was conducted in a surgical $C' at a tertiary academic medical center. ! nursing educational campaign was conducted from /arch 6 to /arch <, )*6). Eatients admitted to the surgical $C' from 2ecember )8, )*66 through Manuary )8, )*6) were included in the baseline cohort, and patients admitted from /arch 4 through !pril 4, )*6) were included in the posteducation cohort. $nclusion criteria were admission to the surgical $C' for at least )7 hours and at least 6 C!/-$C' assessment.

Results The baseline cohort included 45 patients and the posteducation cohort included 49 patients. Eatients were 76= less likely to receive an inappropriate 'T! rating after the educational campaign (5)= N5* of 45O baseline vs 64= N61 of 49O, P F .*5%. Eatients with concurrent mechanical ventilation were more likely to receive an inappropriate 'T! rating in the baseline cohort (odds ratio, 5*.<0 48= C$, 1.4;6*8.40 P + .**6% and the posteducation cohort (odds ratio, 68.80 48= C$, 7.6;84.80 P + .**6%. Conclusion The educational campaign decreased the incidence of inappropriate 'T! ratings.

The Critical Care .ork %nvironment and Nurse Re$orted 0ealth Care1"ssociated In#ections
Background Critically ill patients are susceptible to health care;associated infections because of their illnesses and the need for intravenous access and invasive monitoring. The critical care work environment may influence the likelihood of infection in these patients. Objective To determine whether or not the critical care nurse work environment is predictive of nurse-reported health care;associated infections. !ethods ! retrospective, cross-sectional design was used with linked nurse and hospital survey data. (urses assessed the critical care work environment and provided the fre>uencies of ventilator-associated pneumonias, urinary tract infections, and infections associated with central catheters. ogistic regression models were used to determine if critical care work environments were predictive of nurse-reported fre>uent health care;associated infections, with controls for nurse and hospital characteristics. Results The final sample consisted of 5)6< critical care nurses in 5)* hospitals. Compared with nurses working in poor work environments, nurses working in better work environments were 59= to 76= less likely to report that health care;associated infections occurred fre>uently. Conclusion -ealth care;associated infections are less likely in favorable critical care work environments. These findings, based on the largest sample of critical care nurses to date, substantiate efforts to focus on the >uality of the work environment as a way to minimi:e the fre>uency of health care;associated infections.

&redictive 2alidit+ o# the Braden Scale #or &atients in Intensive Care Units
Background Eatients in intensive care units are at higher risk for development of pressure ulcers than other patients. $n order to prevent pressure ulcers from developing in intensive care patients, risk for development of pressure ulcers must be assessed accurately. Objectives To evaluate the predictive validity of the "raden scale for assessing risk for development of pressure ulcers in intensive care patients by using 7 years of data from electronic health records. !ethods 2ata from the electronic health records of patients admitted to intensive care units between Manuary 6, )**<, and 2ecember 56, )*6*, were extracted from the data warehouse of an academic medical center. Eredictive validity was measured by using sensitivity, specificity, positive predictive value, and negative predictive value. The receiver operating characteristic curve was generated, and the area under the curve was reported. Results ! total of <<4* intensive care patients were included in the analysis. ! cutoff score of 69 on the "raden scale had a sensitivity of *.487, specificity of *.)*<, positive predictive value of *.667, and negative predictive value of *.4<<. The area under the curve was *.9<) (48= C$, *.995;*.915%. The optimal cutoff for intensive care patients, determined from the receiver operating characteristic curve, was 65. Conclusions The "raden scale shows insufficient predictive validity and poor accuracy in discriminating intensive care patients at risk of pressure ulcers developing. The "raden scale may not sufficiently reflect characteristics of intensive care patients. Kurther research is needed to determine which possibly predictive factors are specific to intensive care units in order to increase the usefulness of the "raden scale for predicting pressure ulcers in intensive care patients.