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PubMed2001

Outcome of adolescent trauma admitted to an adult surgical intensive care unit versus a pediatric intensive care unit.

BACKGROUND: Institutional protocol designates the adult trauma service as the primary manager of all adolescent traumas (age 14-18 years) unless admission to the pediatric intensive care unit (PICU) occurs. In the PICU, primary care becomes the responsibility of the pediatric intensivist, with trauma service as a consultant. The purpose of this study was to identify differences in the management of adolescent trauma between the pediatric intensivist in the PICU, and the adult trauma team in the surgical intensive care unit (SICU). METHODS: From January 1993 to January 1998, the medical records of all adolescent trauma patients requiring intensive care unit (ICU) management were reviewed. Depending on bed availability, patients younger than 16 were admitted to the PICU, and those 16 or older to the SICU. Demographic data obtained were age, sex, race, mechanism of injury, length of stay (LOS), ICU length of stay, days on mechanical ventilation, intubation, tracheotomy, intracranial pressure monitor, and Swan-Ganz catheter placement. Home discharge, rehabilitation placement, and death were recorded. Morbidity was measured using Injury Severity Score methodology, Pediatric Trauma Score, and Pediatric Risk of Mortality. RESULTS: One hundred nine completed records were reviewed (SICU, n = 58; PICU, n = 51). There was no statistical difference in sex, race, mechanism of injury, ICU LOS, tracheotomy, and intracranial pressure monitor placements. There was no difference in morbidity, as measured by Injury Severity Score, Pediatric Trauma Score, and Pediatric Risk of Mortality score or in outcome measurements (death, rehabilitation placement). SICU patients were older (SICU, 16.9 +/- 1.0 years; PICU, 15.4 +/- 1.0 years; p < or = 0.1 Mann-Whitney U test), more likely to be intubated (SICU, n = 42; PICU, n = 24; p < or = 0.05 Fisher's exact test), more likely to have pulmonary artery catheter placement (SICU, n = 7; PICU, n = 0), and had longer LOS (SICU, 12.2 +/- 10.6; PICU, 9.8 +/- 14.1; p < or = 0.03 Mann-Whitney U test). CONCLUSION: Adolescent trauma patients admitted to the PICU were less likely to be intubated or have a Swan-Ganz catheter placed. They had decreased LOS and days of mechanical ventilation. There was no difference in outcome measurements.

Adolescent↗
PubMedDate not supplied

Licensed practical nurses in critical care areas: intensive care unit nurses' perceptions about the role.

OBJECTIVE: The purpose of this study was to determine critical care nurses' perceptions about the reintroduction of the licensed practical nurse into critical care areas. DESIGN: A qualitative research design was used, with focus groups used as the method for data collection. SETTING: A large midwestern university-affiliated medical center. SUBJECTS: Registered nurses (RNs) and licensed practical nurses (LPNs) employed in the medical center's critical care units. PROCEDURES: RNs and LPNs were interviewed separately in groups of 3 to 8 members. Open-ended questioning was used to collect information about nurses' perceptions concerning the reintroduction of the LPN role into critical care units. Data were analyzed for themes within and across groups. RESULTS: Registered nurses were unprepared for reintroduction of the role and were unsure of legal versus hospital-directed restrictions on LPN practice. LPNs were frequently placed in situations in which they assumed patient assignments outside those described in job descriptions or unit standards. CONCLUSION: When LPNs are reintroduced into critical care units, clear descriptions of roles and responsibilities are needed as is orientation of RNs to the roles of delegator and resource nurse.

Attitude of Health Personnel↗
PubMedDate not supplied

A bereavement after-care service for intensive care relatives and staff: the story so far.

The Intensive Care Society (1998) developed Guidelines for Bereavement Care in Intensive Care Units. In response to the guidelines, a group of nurses from the intensive care units at Glenfield Hospital in Leicester have developed a bereavement after-care service for relatives and staff. So far, the service has evaluated well from the feedback received from both relatives and staff, but evaluation is ongoing and the service is being continually developed.

Aftercare↗
PubMed1995

Cardiopulmonary resuscitation in intensive care unit and non-intensive care unit patients. Immediate and long-term survival.

OBJECTIVE: To determine the effect of location within the hospital and preexisting electrocardiographic rhythm on the outcome of cardiopulmonary resuscitation, the cardiopulmonary resuscitation records for a 3-year period, including 668 hospitalized patients, were retrospectively reviewed. RESULTS: Resuscitation was successful in only 12 patients in the intensive care unit (3.3%) and 43 patients not in the intensive care unit (14.0%), 20 of whom were on a telemetry unit. Patients who survived to discharge had similar 1-year survival rates regardless of initial hospital location, although intensive care unit patients had the best 3-year survival rate, and there were no survivors at 3-years in the group that received cardiopulmonary resuscitation in the nonmonitored hospital bed. Survival was best with an initial cardiac rhythm of ventricular tachycardia or fibrillation, but all non-ventricular tachyarrhythmias were associated with survival. Age was not an apparent factor, while survival to hospital discharge favored whites over blacks. CONCLUSIONS: Futile resuscitative efforts are routinely performed in part because physicians and patients are unaware of outcome results and factors that influence survival. A wider recognition of the limitations of cardiopulmonary resuscitation should lead to advanced directives that reflect this awareness, with substantially more patients choosing not to have cardiopulmonary resuscitation.

Advance Directives↗
PubMed2006

Identifying and overcoming the barriers to high-quality palliative care in the intensive care unit.

Initiatives to improve end-of-life care in intensive care units face several important barriers. These include inflated expectations for critical care therapies, which are shared by many clinicians and many patients and families; preoccupation with an unattainable level of prognostic certainty, delaying attention to palliative needs; and fragmentation of the healthcare team into separate "silos" of disciplines and specialties. The article reviews these barriers and relevant empirical evidence. Specific strategies to improve intensive care unit palliative care, including consultation by palliative care specialists, and palliative care quality measurement are discussed.

Decision Making↗
PubMed2004

Intensive care physicians' attitudes concerning distribution of intensive care resources. A comparison of Israeli, North American and European cohorts.

OBJECTIVE: To evaluate the attitudes of Israeli intensive care physicians regarding intensive care unit (ICU) triage issues. DESIGN: An opinion survey using questionnaires similar to those used in a previous study in the United States. SETTING AND PARTICIPANTS: Forty-three physicians, members of the Israel Society of Critical Care Medicine (45%). RESULTS: Important factors for admission to the last ICU bed were: small likelihood of surviving hospitalization, irreversibility of acute disorder, nature of chronic disorders and the physician's personal attitude. Most respondents would admit a patient with a predicted survival of a few weeks (70%) or a patient whose quality of life would be poor according to the physician's (98%) or patient's (77%) definition, to the last ICU bed. The personal attitude of the respondents and their own view of the patient's quality of life were considered as important as the quality of life as viewed by the patient. Israeli physicians tended to refuse patient admission into the ICU more than their US counterparts. Most Israeli physicians refused to discharge an ICU patient in order to admit another, despite bed shortage. CONCLUSIONS: The attitudes of Israeli intensive care physicians towards distribution of ICU resources differ from those of their United States counterparts; they are more paternalistic and comply less with requests for admission. Such attitudes are comparable to those expressed by some European intensive care physicians, highlighting the existence of diversity in the factors important to physicians' decision-making.

Attitude of Health Personnel↗
PubMed2002

Family satisfaction with care in the intensive care unit: results of a multiple center study.

OBJECTIVE: To determine the level of satisfaction of family members with the care that they and their critically ill relative received. DESIGN: Prospective cohort study. SETTING: Six university-affiliated intensive care units across Canada. METHODS: We administered a validated questionnaire to family members who made at least one visit to intensive care unit patients who received mechanical ventilation for >48 hrs. We obtained self-rated levels of satisfaction with 25 key aspects of care related to the overall intensive care unit experience, communication, and decision making. For family members of survivors, the questionnaire was administered while the patient was still in the hospital. For family members of nonsurvivors, the questionnaire was mailed out to the family member 3-4 wks after the patient's death. MAIN RESULTS: A total of 891 family members received questionnaires; 624 were returned (70% response rate). The majority of respondents were satisfied with overall care and with overall decision making (mean +/- sd item score, 84.3 +/- 15.7 and 75.9 +/- 26.4, respectively). Families reported the greatest satisfaction with nursing skill and competence (92.4 +/- 14.0), the compassion and respect given to the patient (91.8 +/- 15.4), and pain management (89.1 +/- 16.7). They were least satisfied with the waiting room atmosphere (65.0 +/- 30.6) and frequency of physician communication (70.7 +/- 29.0). The variables significantly associated with overall satisfaction in a regression analysis were completeness of information received, respect and compassion shown to the patient and family member, and the amount of health care received. Satisfaction varied significantly across sites. CONCLUSIONS: Most family members were highly satisfied with the care provided to them and their critically ill relative in the intensive care unit. Efforts to improve the nature of interactions and communication with families are likely to lead to improvements in satisfaction.

Consumer Behavior↗
PubMed2006

Defining and measuring quality palliative and end-of-life care in the intensive care unit.

Quality of health care is primarily concerned with the provision of health services that intend to lead to valued health outcomes and are based and driven by evidence. Among other desired health outcomes are patient-and-family-centered values consistent with proficient palliative and end-of-life care in the intensive care unit. The research in palliative and end-of-life care has elucidated important domains for quality care-in general, major targets for improvement are known. However, assessment of quality at local and national levels remains relevant as innovators select where to begin quality improvement efforts and the healthcare system evaluates the efficacy and potential harm from care delivery transformations. In this article, I endeavor to impart a practical framework for quality of end-of-life care assessment with the goal of guiding the selection of initiatives and evaluating cycles of innovation. I will ground this quality evaluation by reviewing palliative and end-of-life care and the known domains for quality palliative care. Although the field has identified candidate indicators for evaluating palliative and end-of-life care in the intensive care unit, future work is needed to operationalize assessment for important aspects of care with valid, reliable, acceptable, efficient, and responsive measures.

Family↗
PubMed2006

Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: challenges and opportunities for moving forward.

Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.

Cooperative Behavior↗
PubMed2006

Levels of care in the intensive care unit: a research program.

A multidisciplinary research program on levels of care was conducted in 15 adult intensive care units in North America, Europe, and Australia. The program addressed advance directives for cardiopulmonary resuscitation, provision of advanced life support, and clinicians' discomfort with evolving treatment plans. The results indicated that the factors that determined the establishment of directives for advance life support differed from the factors that informed a decision to limit or withdraw support after admission to an intensive care unit. In addition, clinicians' prognoses were imprecise and often an underestimation of the probability of short-term survival. Finally, some degree of discomfort was common in care providers in the intensive care unit, most often because they thought interventions were excessive and not compatible with an acceptable future quality of life. The provision of advanced life support mandates explicit decision making about how life-support measures should be used.

Adult↗