Download Complete Issue PDF

80 Pages·2017·1.42 MB·English

American Journal of
Critical Care
September 2017 • Volume 26, Number 5
Professional
Development in
Palliative Care

Nurses’ Use of
Physical Restraints
Psychotropic Drug
Use in Restrained
Patients
Instability During
Suctioning in Infants
With Single-Ventricle
Physiology
Enrollment Challenges
in Critical Care
Nursing Research
Organizational Factors
and Quality of Care in
Closed ICUs
Measuring Stroke
Volume
Post–Intensive Care
Syndrome in Family
Decision Makers
Universal ICU Decolonization
Without Antibiotics
Evidence shows fewer infections
and lower costs when replacing
contact precautions with universal
nasal and skin decolonization.1, 2
Safely Replace MRSA CP
(cid:121)
30 Bed ICU Could Save $600k
(cid:121)
Research Shows 44% HAI Reduction
(cid:121)
Improve Patient Care and Satisfaction
(cid:121)
Compared to targeted screen and isolate, universal nasal Alcohol-based Nozin® Nasal Sanitizer® antiseptic is proven
and skin decolonization of ICU patients has shown superior to decolonize nasal S. aureus day one.3 Team up with your
infection outcomes. Also, replacing isolation CP can help Nozin advisor to assess the advantages of this program.
lower costs while improving patient care.1, 2 Now you can Learn how you can implement universal ICU decolonization
have fast, effective nasal decolonization without antibiotics. to help protect patients, improve care and lower costs.
Better Care. Lower Costs. No Antibiotics or Iodine.
Ask a Nozin advisor to develop a
custom analysis for your facility.
Nozin.com 877-669-4648 LEADER IN NASAL DECOLONIZATION
™
1. Huang SS et al. Targeted versus universal. N Engl J Med, 2013: 368(24): 2255-65. Mupirocin and CHG used in study. 2. Huang SS et al. Cost Savings of Universal Decolonization
to Prevent Intensive Care Unit Infection. ICHE, 2014: 35 (S3): S23-S31. 3. Steed L, et al. Reduction of nasal Staphylococcus aureus carriage. AJIC, 2014: 42(8): 841-846. ©2017 Global
Life Technologies Corp. All rights reserved. Made in USA. Nozin®, Nasal Sanitizer®, Leader in Nasal Decolonization™ are trademarks of Global Life Technologies Corp. Nozin® Nasal
Sanitizer® antiseptic is an OTC topical drug. No claim is made that it has an effect on any specific disease. Savings estimates are for example only. Any actual savings may vary.
American Journal of
Critical Care
www.ajcconline.org
Evidence-based interdisciplinary knowledge for high acuity and critical care
AMERICAN ASSOCIATION OF Editors in Chief
CRITICAL-CARE NURSES
President, CHRISTINE SCHULMAN, RN, MS, CNS, CCRN-K; CINDY L. MUNRO, RN, PhD, ANP
President-elect, LISA RIGGS, MSN, APRN-BC, CCRN-K; Secretary, Dean and Professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
LMOICUHISEEL LSEA LKAIDDIDN, OM, S, RANP,R ND,N APC, NMSH-BAC, , CCCCRRNN--KK;; TDrierae scutorersr,, RICHARD H. SAVEL, MD
ELIZABETH BRIDGES, RN, PhD, CCNS; KIMBERLY CURTIN, Professor of Clinical Medicine, Albert Einstein College of Medicine, New York, New York
RN, DNP, APRN, ACNS-BC, CCRN, CEN, CNL; JUSTIN DiLIBERO, RN,
DNP, CCRN, CCNS, ACCNS-AG; NIKKI DOTSON-LORELLO, RN, BSN, Clinical Advisers
CCJOCCRNNNSE,, CSCP,CT RCRN;N ,W -MK;ES ,N PRhDODI;S MFERMAORAEYRD BYGE ETT,HI RM NFM-LBYCE,N MRNSMN M,A CNCAR,K NI-RCKN;, ,D RDNEN, BPPhO, DCR, CCANNHSS,, LAImNeDriAca nB EALsLso,c RiaNt,i oMnS Nof Critical-Care Nurses SAAmReAriHca nA A. DssoEcLiaGtiAoDn Oof, CRrNit, iMcaSlN-C, AaCrNe PN-BuCrses
CCRN-CSC-CMC; BETH WATHEN, MSN, APRN, CCRN; Chief Exec- Aliso Viejo, California Aliso Viejo, California
utive Officer, DANA WOODS, MBA Founding Coeditors
EADmIeTrOicRanIA LA OssFoFcIiCatEion of Critical-Care Nurses, 101 CHRISTOPHER W. BRYAN-BROWN, MD, and KATHLEEN DRACUP, RN, DNSc
Columbia, Aliso Viejo, CA 92656. [phone], (949)
362-2000. E-mail address: [email protected]. Web address: Editorial Board
www.ajcconline.org Publishing Manager, MICHAEL
MUSCAT; Managing Editor, KATIE L. SPILLER, MS; Art and
Production Director, LeROY HINTON; Copy Editors, MICHAEL H. ACKERMAN, RN, DNS MICHAEL A. GROPPER, MD, PhD
MELISSA BOGEN, BA, ELS; BARBARA HALLIBURTON, PhD; Rochester, New York San Francisco, California
JENNIFER LYNN HOLMES, BS, ELS; HEATHER E. SAUN-
DERS, MA; LAURIE ANNE WALDEN, DVM, ELS; Graph ics Spe- THOMAS AHRENS, RN, DNS, CCRN SANDRA HANNEMAN, RN, PhD
cialist, MATT EDENS; Peer-Review Coordinator, DENISE
St Louis, Missouri Houston, Texas
GOTTWALD; Publishing Assistant, SAM MARSELLA
ADVERTISING SALES OFFICE JOANN GRIF ALSPACH, RN, MSN, EdD KATHRYN HAUGH, RN, PhD
SLACK Incorporated, 6900 Grove Rd, Thorofare, NJ Annapolis, Maryland Charlottesville, Virginia
08086. [phone], [phone]. National
Account Manager, NICOLE RUTTER; Recruit ment JUDY L. BEZANSON, RN, DSN STEVEN HOLLENBERG, MD
Sales Represenative BERNADETTE HAMILTON; Admin- Dallas, Texas Camden, New Jersey
is trator, JOANN CAMPISI
AMERICAN JOURNAL OF CRITICAL CARE® Telephone: STIJN I. BLOT, RN, PhD CONNIE JASTREMSKI, RN, MS, CNAA
[phone]. Fax: [phone]. Copyright 2017 by Ghent, Belgium Syracuse, New York
AACN. All rights reserved. The AMERICAN JOURNAL OF
CRITICAL CARE is an official peer-reviewed publication of ELIZABETH J. BRIDGES, RN, PhD, CCNS, CCRN RUTH KLEINPELL, RN, PhD
AACN. No part of this publication may be reproduced Seattle, Washington Chicago, Illinois
or transmitted in any form or by any means, electronic
or mech an ical, including photo copying, recording or TIMOTHY G. BUCHMAN, PhD, MD, MCCM CONSTANTINE MANTHOUS, MD
by any information storage retrieval system, without
Atlanta, Georgia Bridgeport, Connecticut
perm ission of AACN. For all permission requests, please
contact the Copyright Clearance Center, Customer Ser-
vice, 222 Rosewood Dr, Danvers, MA 01923. (978) LINDA L. CHLAN, RN, PhD PETER E. MORRIS, MD
750-8400. Prices on bulk reprints of articles available Rochester, Minnesota Winston Salem, North Carolina
on request from AACN at [phone]. Printed on
acid-free paper. The AMERICAN JOURNAL OF CRITI- MARIANNE CHULAY, RN, DNSc DEBRA K. MOSER, RN, DNSc
CAL CARE is indexed in MEDLINE/PubMed, Psy- Southern Pines, North Carolina Lexington, Kentucky
cINFO, Cumu lative Index to Nursing & Allied Health
LISitIe Aralteurtrien (gC SINerAviHceLs),, CScuierrnecnet CCitoantitoenn tIsn/Cdelixn Eicxapla Mndeeddi-, MARTHA A. Q. CURLEY, RN, PhD JANET D. PIERCE, DSN, ARNP
cine, EBSCO collections, Ovid collections, and Scopus. Boston, Massachusetts Kansas City, Kansas
Annual individual subscriptions: US and possessions, RHONDA D’AGOSTINO, ACNP-BC KATHLEEN PUNTILLO, RN, DNSc
$59; Canada and Mexico, $110 (US); all other countries, New York, New York San Francisco, California
$110 (US). Institutional rates: US, print and online, $620;
print only, $450; online only, $425. Institutional rates for LYNN DOERING, RN, DNSc MARY LOU SOLE, RN, PhD
all countries outside the US: print and online, $755; print
only, $585; online only, $425. Single copies: US, $40; all Los Angeles, California Orlando, Florida
other countries, $50 (US). For subscription questions: AACN
members, please call toll-free [phone] or (949) BARBARA DREW, RN, PhD THEODORE A. STERN, MD
362-2000; nonmembers, please call toll-free (800) 336- San Francisco, California Boston, Massachusetts
6348 or [phone]. Change of ad dress: Send notices
to AMERICAN JOURNAL OF CRITICAL CARE, Subscrip- LEWIS A. EISEN, MD M. CHRISTINE STOCK, MD
tion Service Depart ment, 101 Columbia, Aliso Viejo, CA Bronx, New York Chicago, Illinois
92656. Allow 4 to 6 weeks for change to take effect.
The statements and opinions contained in the articles in DOUG ELLIOTT, RN, PhD KATHLEEN M. VOLLMAN, RN, MSN, CCNS, CCRN
the AMERICAN JOURNAL OF CRITICAL CARE are solely Sydney, New South Wales, Australia Detroit, Michigan
those of the individual contributors and not of the editors or
the American Association of Critical-Care Nurses. The edi- SUSAN K. FRAZIER, RN, PhD DOUGLAS WHITE, MD, MAS
tors and the American Association of Critical-Care Nurses Lexington, Kentucky Pittsburgh, Pennsylvania
assume that articles emanating from a particular institu-
taiuotnh oarriety ,s iunbcmluidtitnedg awlli mtha tttheers appeprtraoinvainl go tfo thhuem raenq ustiusidte- DORRIE K. FONTAINE, RN, DNSc SUSAN WOODS, RN, PhD
ies and patient privacy requirements. Advertisements in Charlottesville, Virginia Seattle, Washington
this journal are not a warranty, endorsement, or approval
of the products by the editors of this journal or the Amer- MARJORIE FUNK, RN, PhD
ican Association of Critical-Care Nurses, who disclaim all New Haven, Connecticut
responsibility for any injury to persons or property result-
ing from any ideas or products referred to in the articles
or advertisements. Printed in the USA.
www.ajcconline.org(cid:3)(cid:3) (cid:3) AJCC(cid:3)AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:22)(cid:24)(cid:22)
American Journal of
Critical Care
Evidence-based interdisciplinary knowledge
for high acuity and critical care
September 2017, Volume 26, No. 5
Articles are available exclusively online at www.ajcconline.org
361
Nursing Education Palliative Care Professional Development for Critical Care Nurses:
A Multicenter Program
Wendy G. Anderson, Kathleen Puntillo, Jenica Cimino, Janice Noort, Diana
Pearson, Deborah Boyle, Michelle Grywalski, Jeannette Meyer, Edith O’Neil-Page,
Julia Cain, Heather Herman, Susan Barbour, Kathleen Turner, Eric Moore, Solomon Liao,
Bruce Ferrell, William Mitchell, Kyle Edmonds, Nathan Fairman, Denah Joseph, John
MacMillan, Michelle M. Milic, Monica Miller, Laura Nakagawa, David L. O’Riordan,
Christopher Pietras, Kathryn Thornberry, and Steven Z. Pantilat
373
Patient Safety Issues Determinants of Nurses’ Use of Physical Restraints in Surgical Intensive
Care Unit Patients
Jeanne Dolan and Sara E. Dolan Looby
380
Psychotropic Drug Use in Physically Restrained, Critically Ill Adults
Receiving Mechanical Ventilation
Melanie Guenette, Lisa Burry, Alexandra Cheung, Tara Farquharson, Marlene Traille,
Ioanna Mantas, Sangeeta Mehta, and Louise Rose
On the Cover Coming in November …
Detail from “Summer Rain” Brummel and colleagues examine subsyn-
Jane Robinson dromal delirium and institutionalization
48'' x 36'' among critically ill patients.
Acrylic on canvas
2017
To view other works by
Jane Robinson, 2017
visit her website at
www.janerobinsonabstractart.com
AMERICAN JOURNAL OF CRITICAL CARE® (Print ISSN 1062-3264, Online ISSN 1937-710X) is published bi monthly (January, March, May, July, September, Nov ember)
by the American Association of Critical-Care Nurses (AACN), 101 Columbia, Aliso Viejo, CA 92656. Periodicals postage paid at Laguna Beach, CA, and additional mailing
office(s). Postmaster: Send address changes to the AMER ICAN JOURNAL OF CRITICAL CARE, Subscription Service Depart ment, 101 Columbia, Aliso Viejo, CA 92656.
(cid:22)(cid:24)(cid:23)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)AJCC(cid:3)AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) www.ajcconline.org
When stability is critical,
every piece counts.
CRRT built for the ICU
You already have a lot to consider when
it comes to caring for your acute kidney
injury patients. The PRISMAFLEX
System combines versatility with
intuitive functionality — it’s flexibility
designed for the ICU. So you can spend
more time focusing on what matters
most — your patients.
• Easily switch between
CRRT therapies
• Deliver TPE with no additional
capital equipment
•Easy set-up and use
•Wide selection of solution options
With so many pieces to consider in
treating critically ill patients, choosing
Baxter as your CRRT partner is always
the right move.
Baxter and Prismaflex are trademarks of Baxter International Inc. or its subsidiaries.
USMP/MG120/17-0022 07/17
www.renalacute.com
For more information, visit .
American Journal of
Critical Care
388
Pediatric Critical Care Patterns of Instability Associated With Endotracheal Suctioning
in Infants With Single-Ventricle Physiology
Lyvonne N. Tume, Paul Baines, Rafael Guerrero, Robert Johnson, Paul Ritson,
Elaine Scott, Philip Arnold, and Laura Walsh
395
Critical Care Research
Enrollment Challenges in Critical Care Nursing Research
Mary Lou Sole, Aurea Middleton, Lara Deaton, Melody Bennett, Steven
Talbert, and Daleen Penoyer
401
Organizational Factors Associated With Perceived Quality of
Patient Care in Closed Intensive Care Units
Nathalie McIntosh, Eva Oppel, David Mohr, and Mark Meterko
408
Cardiovascular Critical Care Measuring Stroke Volume: Impedance Cardiography vs
Phase-Contrast Magnetic Resonance Imaging
Matthew Borzage, Kimia Heidari, Thomas Chavez, Istvan Seri, John C. Wood,
and Stefan Blüml
416
Families in Critical Care
Post–Intensive Care Syndrome in Family Decision Makers of
Long-term Acute Care Hospital Patients
Amy Petrinec
357 372 425
Editorial Patient Care Page ECG Puzzler
Critical Care Is Guided by Why Increasing Nurses' Palliative Global ST-T Wave Changes:
Cindy L. Munro and Care Communication Skills Ischemic vs Nonischemic

Richard H. Savel Sarah A. Delgado Salah S. Al-Zaiti, Teri M. Kozik,
Michele M. Pelter, and Mary G. Carey
360 423
Clinical Pearls Evidence-Based Review
428
and Discussion Points Education Directory
Rhonda Board

Ronald L. Hickman
Visit AJCC’s website, www.ajcconline.org, to
submit a manuscript or for author guidelines,
full text of selected articles, OnlineNOW articles,
digital edition access, links to AACN’s online
continuing education tests, and more.
An Official Publication of the American Association of Critical-Care Nurses
(cid:22)(cid:24)(cid:25)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)AJCC(cid:3)AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) www.ajcconline.org
E
ditorial
C C I G W
RITICAL ARE S UIDED BY HY
By Cindy L. Munro, RN, PhD, ANP, and Richard H. Savel, MD
T
he American Association of Critical-Care In quantitative research, why enables us to understand
Nurses (AACN) National Teaching Institute cause and effect. In qualitative research, why enables
and Critical-Care Exposition (NTI) gathers us to find meaning. Asking why encourages us to
thousands of critical-care nurses together every May. examine current practice and to propose and test
The event offers opportunities to learn, to connect, new interventions and approaches.
and to be inspired. Unveiling the new AACN theme, Research investigations often begin with a search
and the original artwork that illustrates it, is a high- for why certain clinical outcomes occur in particular
light of NTI. AACN themes exemplify our mission, patients or under particular circumstances. For exam-
vision, and values. The NTI president’s SuperSession, ple, why are some patients at higher risk for pressure
which provides a transition between themes, is par- ulcers? Investigations of risk factors and protective
ticularly meaningful to members. It is a time for the factors associated with patients’ conditions answer
outgoing president to reflect about how the previous early questions about differential susceptibility. Think-
year’s theme engaged critical care nurses, and for the ing about why facilitates identification of variables
president-elect to unveil the AACN theme for the and helps researchers begin to hypothesize relation-
upcoming year. Past presidents’ themes are archived ships among those variables. Why is the foundation
on the AACN website,1 and those themes showcase for the development of theoretical and conceptual
the inspiration that anchors critical care nursing. On models to describe those relationships and provides
May 24, 2017, Christine Schulman revealed a power- the scientific premise for development and testing
ful theme for her 2017-2018 presidency: “Guided by of novel interventions.
Why.”2 She reflected on the power of asking why as This issue of AJCC offers 2 examples of studies
“a tool to accomplish our goals: as a compass, as an designed to inform future intervention research. Dolan
anchor, as a voice about things that matter,” and as and Looby3 asked what factors influenced thought
a “guiding beacon for what we can—what we must— processes of nurses in the surgical intensive care unit
do to ensure that every patient gets the excellent care as they decided to initiate or discontinue use of physi-
they deserve.” cal restraints in critically ill patients. That is, why do
“Guided by Why” can also serve as a potent nurses decide to use, or not to use, restraints? Better
frame for critical care research and evidence-based understanding of nurses’ decision-making will lead to
practice. Seeking to understand why provides both interventions that are more likely to be successful in
philosophical and scientific underpinnings for critical reducing use of physical restraints. In other instances,
care. Asking why informs our theoretical and con- initial observations may not provide evidence about
ceptual frameworks, research questions, and analyses. why, but rather may lead to additional questions.
Another study of restraints in this issue4 used a prospec-
tive observational design, and those researchers found
(cid:165)(cid:19)(cid:17)(cid:18)(cid:24)(cid:1)(cid:34)(cid:78)(cid:70)(cid:83)(cid:74)(cid:68)(cid:66)(cid:79)(cid:1)(cid:34)(cid:84)(cid:84)(cid:80)(cid:68)(cid:74)(cid:66)(cid:85)(cid:74)(cid:80)(cid:79)(cid:1)(cid:80)(cid:71)(cid:1)(cid:36)(cid:83)(cid:74)(cid:85)(cid:74)(cid:68)(cid:66)(cid:77)(cid:14)(cid:36)(cid:66)(cid:83)(cid:70)(cid:1)(cid:47)(cid:86)(cid:83)(cid:84)(cid:70)(cid:84)
(cid:69)(cid:80)(cid:74)(cid:27)(cid:73)(cid:85)(cid:85)(cid:81)(cid:84)(cid:27)(cid:16)(cid:16)(cid:69)(cid:80)(cid:74)(cid:15)(cid:80)(cid:83)(cid:72)(cid:16)(cid:18)(cid:17)(cid:15)(cid:21)(cid:17)(cid:20)(cid:24)(cid:16)(cid:66)(cid:75)(cid:68)(cid:68)(cid:19)(cid:17)(cid:18)(cid:24)(cid:23)(cid:17)(cid:19) that the majority of critically ill patients requiring
www.ajcconline.org(cid:3)(cid:3) (cid:3) AJCC(cid:3)AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:22)(cid:24)(cid:26)
Asking why encourages us to examine
current practice and to propose and test
new interventions and approaches.
mechanical ventilation who were physically restrained identified as the root cause may not be the only or
in one facility did not receive any psychotropic drugs the most important problem to be addressed. The 5
around the time of restraint; if psychotropic drugs whys approach emphasizes depth and follows a
were given, they were more likely to be given after single line of reasoning to a conclusion. Especially
physical restraints were applied than before restraint in the complex setting of the intensive care unit,
application. Understanding the why underlying these this approach may undervalue the breadth required
patterns will provide important guidance in designing to consider multiple, interacting, causal factors as
effective interventions to improve practices related well as contributing factors. We would argue that
to restraint. the concern lies not with asking why, but rather with
When events do not go as planned in the inten- sacrificing examination of many possible whys for
sive care unit, asking why may help us to consider the simplicity of a single (perhaps misleading) why.
optimal solutions and avoid future similar events. Both knowledge generation (research) and appli-
A technique called “the 5 whys” is widely used in cation of knowledge to practice (evidence-based
root-cause analysis and has made its way into health practice and quality improvement) are necessary to
care systems safety and quality improvement.5,6 The improve outcomes for critical care patients. Asking
5 whys technique is a component of many quality questions about why is an excellent place to start.
improvement programs developed for industrial Why can guide us to additional questions, including
settings, including Toyota Production System (TPS), how and what.7 Let’s strive to be “guided by why”!
Lean, and Six Sigma; it may also be applied to
problem solving outside of these programs. Work- The statements and opinions contained in this editorial
are solely those of the coeditors in chief.
ing backward from the event to a single root cause
by asking a series of why questions, the technique
FINANCIAL DISCLOSURES
is used to retroactively identify the root cause of a None reported.
problem. The underlying assumption is that a solu-
tion addressing the root cause (rather than proxi- REFERENCES
1. American Association of Critical-Care Nurses. Presidents’
mal causes) will be most effective in preventing a Speeches. https://www.aacn.org/about-aacn/president-
recurrence of the event. Getting to the root cause speeches. Accessed July 31, 2017.
2. American Association of Critical-Care Nurses. Guided by
may require more or fewer than 5 why questions, Why. Christine Schulman President-Elect’s Keynote NTI
but the essence of the technique is to continue ask- 2017. https://www.aacn.org/~/media/aacn-website/about-us
/presidents-address/nti2017presidentelectaddress.pdf.
ing iterative questions about why until a solution Accessed July 31, 2017.
to the underlying problem is obvious. Recent cri- 3. Dolan J, Looby SED. Determinants of nurses’ use of physical
restraints in surgical intensive care unit patients. Am J Crit
tiques of the 5 whys suggest that a search for a sin- Care. 2017;26(5):373-379.
gle causal pathway, leading to a single root cause, 4. Guenette M, Burry L, Cheung A, Farquharson T, Traille M,
Mantas I, Mehta S, Rose L. Psychotropic drug use in physi-
amenable to a single solution, may be too simplis- cally restrained, critically ill adults receiving mechanical
tic. In the world of health care, events are likely to ventilation. Am J Crit Care. 2017;26(5):380-387.
5. Card AJ. The problem with ‘5 whys’ [published online Septem-
arise from a confluence of causes. A single problem ber 2, 2016]. BMJ Qual Saf. doi:10.1136/bmjqs- 2016- 005849.
6. Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem
with root cause analysis. BMJ Qual Saf. 2017;26(5): 417-422.
7. Simak S. Start with why: how great leaders inspire action
About the Authors
[video]. TEDx Puget Sound. 2009. https://www.youtube.com
Cindy L. Munro is coeditor in chief of the American Journal /watch?v=u4ZoJKF_VuA&feature=youtu.be. Accessed July
of Critical Care. She is dean and professor, School of 31, 2017.
Nursing and Health Studies, University of Miami, Coral
Gables, Florida. Richard H. Savel is coeditor in chief of
the American Journal of Critical Care. He is director, Adult To purchase electronic or print reprints, contact American
Critical Care Services, at Maimonides Medical Center Association of Critical-Care Nurses, 101 Columbia, Aliso
and a professor of clinical medicine at the Albert Einstein Viejo, CA 92656. Phone, [phone] or [phone]
College of Medicine, both in New York City. (ext 532); fax, [phone]; e-mail, [email protected].
(cid:22)(cid:24)(cid:27)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)AJCC(cid:3)AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) www.ajcconline.org
Automated Urine Output Monitoring
Accurate Recordings, Direct to EHR!
Simply Hang and Record.
(cid:23) Uses any standard Foley bag.
(cid:23) Automates your current protocols.
(cid:23) Intuitive system – easy to use.
No Risk
Trial
SYSTEM ICU
Replacing old equipment?
Consider Sensica UO!
Contact us at [email protected]
or 888-441-1525 for more information
or to arrange a free trial.
www.AdaptecMed.com
SUBSCRIBE TO THE
American Journal of
Critical Care
Today!
Don’t miss a single issue of the premier source for
evidence-based critical care practice. AJCCoffers the latest
advances in multidisciplinary clinical research, with features
that highlight bedside applications of select
research articles.
Each issueof AJCCbrings you the most current clinically
relevant content at your fingertips. You will have the latest
research by leaders in critical care. PLUS,you will
have access to information on the journal website, including
the latest clinical references, supplemental publications
and content that is only online.
Get our best deal – $100 for 2 years ($185 outside the U.S.)
or $59 for 1 year ($110 outside the U.S.) for individuals.
(Institutional pricing on request.)
Order online at:http://ajcc.aacnjournals.org/site/subscriptions/
Or call:[phone] or [phone]
Clinical Pearls
Putting Evidence-Based
Care in Your Hands
Rhonda Board, RN, PhD, CCRN, Section Editor
Clinical Pearls is designed to help implement evidence-based care at the bedside by summarizing some of the most clinically useful
material from select articles in each issue. Readers are encouraged to photocopy this ready-to-post page and share it with colleagues. Please
be advised, however, that any substantive change in patient care protocols should be carefully reviewed and approved by the policy-setting
authorities at your institution.
Post–Intensive Care Determinants
Syndrome in of Physical
Family Decision Makers Restraint Use
The significant morbidity and disability that Physical restraints are
family members of patients in the intensive often used to prevent
care unit (ICU) can experience has been rec- patients in intensive
ognized in the past decade. The Society of Critical care units (ICUs) from
Care Medicine calls this condition post–intensive pulling on or dislodging
care syndrome (PICS). However, as more and therapeutic devices such as
more adult ICU patients require long-term acute endotracheal tubes and
care hospitalization (LTACH), little is known dialysis catheters. Research-
about PICS in the families of these patients. ers have examined the prev-
Petrinec studied LTACH family decision alence of restraint use in
makers during the hospitalization and up to 2 the ICU, but little is known about nursing determinants of restraint initiation
months after discharge. She found the following: and discontinuation.
• About 10% met the criteria for a provi- Dolan and Looby interviewed surgical ICU nurses about their experi-
sional diagnosis of posttraumatic stress disorder. ences. They identified 3 general categories of factors considered:
• Moderate to severe anxiety symptoms • Patient safety: All nurses reported that patient safety was the primary
during hospitalization decreased over time. factor in determining restraint use, especially with intubated patients.
• Problem-focused coping strategies were • Patient behavior: Specific behaviors of orientation and functional capac-
the type used the most at all time points. ity determined both initiation and successful discontinuation of restraints.
• Avoidant coping was associated with • Nonrestraint alternatives: The vigilance of the nurse greatly influenced
increased severity of PICS. decision-making and included nurse to patient ratio, availability of nonnurse
• Quality-of-life scores were lower than providers, and the patient’s visibility to the nurse. Interventions such as fre-
US norms. quent reorientation, ensuring patients’ comfort, and placing tubes out of sight
The author recommends early recognition reduced the use of restraints.
of PICS in order to provide opportunities for Nurses’ contributions are vital for determining best patient practices for
focused family interventions. educational initiatives and hospital policies related to use of restraints.
See Article, pp 416-422 See Article, pp 373-379
Instability With Endotracheal Suctioning Integrating Palliative Care Nursing Into
in Single-Ventricle Infants the Intensive Care Unit
Infants with single-ventricle physiology undergo surgical The focus of palliative care is to improve the quality of life
palliation soon after birth but continue to have imbalance for patients with serious and complex illnesses and includes
between pulmonary and systemic blood flow. Endotracheal symptom management, emotional support, and family
tube suctioning (ETS) is a routine procedure to maintain tube communication. Despite the success of nursing education pro-
patency but has been associated with various adverse events grams such as the national End-of-Life Nursing Education Con-
such as hypoxemia, bradycardia, and cardiac arrest. To date, sortium (ELNEC) project, nurses continue to perceive barriers to
no published research has been focused on the effects of this integration of palliative care in the intensive care unit (ICU).
procedure in these children. Anderson and colleagues developed and implemented a
Tume and colleagues examined the processes and adverse system-wide training program called Integrating Multidisci-
events associated with ETS conducted by bedside nurses in the plinary Palliative Care into the ICU (IMPACT-ICU) in 5 medical
first 48 hours after surgical palliation. They found the following: centers. The purpose was to train advanced practice nurses
• Most suctioning was unplanned and in response to an and nurse educators to provide palliative care education and
acute clinical change such as arterial desaturation. support to bedside nurses. Findings from the program included
• Many adverse events occurred with the open suction the following:
method, and most events occurred during the night shift. • Increased access of bedside nurses to specialty palliative care
• Clinical guidelines were not always followed by bed- • Higher skill and engagement reported by bedside nurses
side nurses. • Improved quality of interdisciplinary communication
Because significant hemodynamic instability can occur, The authors note that engagement of stakeholders at multiple
the authors recommend that ETS be planned early and with a levels and disciplines facilitated the successful implementation
consistent approach to reduce risks and variability in technique. of IMPACT-ICU.

See Article, pp 388-394 See Article, pp 361-371
(cid:165)(cid:19)(cid:17)(cid:18)(cid:24)(cid:1)(cid:34)(cid:78)(cid:70)(cid:83)(cid:74)(cid:68)(cid:66)(cid:79)(cid:1)(cid:34)(cid:84)(cid:84)(cid:80)(cid:68)(cid:74)(cid:66)(cid:85)(cid:74)(cid:80)(cid:79)(cid:1)(cid:80)(cid:71)(cid:1)(cid:36)(cid:83)(cid:74)(cid:85)(cid:74)(cid:68)(cid:66)(cid:77)(cid:14)(cid:36)(cid:66)(cid:83)(cid:70)(cid:1)(cid:47)(cid:86)(cid:83)(cid:84)(cid:70)(cid:84)(cid:13)(cid:1)(cid:69)(cid:80)(cid:74)(cid:27)(cid:73)(cid:85)(cid:85)(cid:81)(cid:84)(cid:27)(cid:16)(cid:16)(cid:69)(cid:80)(cid:74)(cid:15)(cid:80)(cid:83)(cid:72)(cid:16)(cid:18)(cid:17)(cid:15)(cid:21)(cid:17)(cid:20)(cid:24)(cid:16)(cid:66)(cid:75)(cid:68)(cid:68)(cid:19)(cid:17)(cid:18)(cid:24)(cid:18)(cid:21)(cid:21)
(cid:22)(cid:25)(cid:19)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)AJCC(cid:3)AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) www.ajcconline.org