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Using Charmaz's (2006) constructivist grounded theory methodology, this study sought to establish a theory that explains how nurses perceive the influence of technology on their nursing care practises. This study used individual in-depth interviews and participant observation as a primary data collection method. In addition, participant observations were conducted before participant interviews to understand the phenomenon and practises in the ICU and corroborate with the participants' stories. During semi-structured face-to-face interviews, 19 staff nurses, one nursing manager and one medical assistant from an adult general ICU at a public hospital in Malaysia shared their experiences. The grounded theory of the emancipatory practise of ICU nurses was developed by a continuous comparison analysis of transcribed interview data. The predicament of practice was explored within the context of the theme 'navigating through complexity,' which implies that nurses were confronted with a conflicting situation that prompted them to gravitate toward a more "technologized" rather than humanised approach. This option might lead to professional value conflicts and a feeling of powerlessness. In order to reconcile the conflict, nurses attempt to shape their ideal professional identity by incorporating humane and technological values into the care of their patients. A new care paradigm is incorporated into the professional identity that accommodates human needs from a technological standpoint. Emancipatory practise in the context of this research, refers to the practise in which nurses have the opportunity to self-reflect and become conscious of the significance of striking a balance between humanistic nursing and technological care. This awareness assists nurses in constructing a viable professional identity within an environment heavily influenced by technology. Emancipatory practise entails the practise that is not only done but also developed and altered as nurses attempt to construct and reconfigure how to operate in a 'complex and dynamic environment due to pervasive technology. A new practice that prioritise both technological advancements and humanistic nursing would be gaining traction, and this theory provided the health care authorities with a realistic assessment of the nursing workload necessary to facilitate this transformation.

Computing systems deployed in hospital environments routinely collect a large volume of data that has not, thus far, been widely examined. There has been increasing research into the application of machine learning techniques on these data streams to predict and prevent disease states, however limitations exist around understanding the optimal methods and availability of data to train such models which is what we aim to address in this thesis. This thesis provides an insight into the work that has already been carried out in this field and further presents state-of-the-art research of AI for prediction of physiological data across two problem domains. This thesis features a description of the first Northern Ireland research-based ICU database that will enable further research to advance the field, of which we have set up. We compare machine learning methods for the classification of cardiovascular disease. By exploring support vector machines, artificial neural networks and four ensemble methods, based on decision trees, the results show how varying their hyperparameters can affect the accuracy of the predictions. Further, this work uses two public datasets with differing characteristics in order to understand the potential differences in the uncertainty of the methods. This thesis further presents the first application of machine learning to enable lung protective ventilation. We successfully predict a given ventilator parameter within 10% accuracy of its true value and can in turn predict an average of 70% of alerts per patient, meaning clinicians can intervene and prevent injury from occurring.

Survival rates for the critical care population in the UK following discharge from acute hospital is extrapolated to be 80.8% (excluding readmissions to the same critical care unit of the same patient within the same acute hospital stay) between 1st April 2018 to 31st March 2019 in England, Wales and Northern Ireland [ICNARC - Summary Statistics, 2020]. As a direct result of patients admitted to the ICU, post-ICU patients are susceptible to high levels of physical inactivity, as well as reductions in physical function, exercise capacity and health-related quality of life (HRQoL) that can contribute to a prolonged recovery period that may last for several months or years in some patients. Follow-up provision following critical illness has evolved in different ways around the UK. The availability of these healthcare and support services following critical illness throughout the UK have been reported to play a valuable role in the recovery of physical, emotional and psychological recovery following discharge from the intensive care unit. Currently in Northern Ireland there are no organised rehabilitation services offered to patients after discharge home from critical illness, and the urgent need for research in the area has been highlighted in recent guidelines. There is a paucity of research exploring outcomes specifically related to physical activity and physical function in the post-ICU population; previous post-ICU studies have predominately focused on short-term recovery trajectories (< 6 months). This thesis focuses on survivors of critical illness following hospital discharge (up to 1-year) from the ICU.

Between 1919 and 1931, Clements Kadalie (c.1895-1951) rose to world-wide fame as general secretary of the Industrial and Commercial Workers’ Union of Africa (ICU). This thesis reexamines the biography of Kadalie, an immigrant worker from Central Africa who became Southern Africa’s first major black trade union leader, widely hailed as a “Moses” of his people. It situates his ideas about race, workers’ rights and freedom in a global interwar context, comparing his arguments and aspirations with other trade unionists and political leaders in Central and Southern Africa, America, Britain and India. In particular, it rehabilitates the ICU as a general, all-in trade union which demanded minimum wages, decent working conditions, and the right of all workers to freely migrate between town and country, and between states, regardless of race, nationality, skill or sex. Existing scholarship on the ICU has focused on its organisational structure in South Africa, its failed tactics, a limited cross-section of its leadership, and its spectacular “rise and fall” between 1919 and 1930. The historiography of trade unionism in Southern Africa, more broadly, has also neglected leaders’ intersecting ideas about migration and race. Drawing on new archival sources, a wide range of newspapers, oral testimonies and family papers, this thesis situates Clements Kadalie and the ICU within Southern Africa’s transnational labour market as a general trade union predominantly made up of migrant workers, and led by black immigrants from Central and Southern Africa, and the Caribbean. Breaking with the existing exclusionary strategies of craft and industrial unions, Kadalie challenged not only South Africa’s “white aristocracy of labour”, but also other black trade union leaders who envisaged raising wages through moderate petitions and anti-immigrant policies. The ICU’s ideas about race consciousness, in turn, challenged narrow exclusionary ideas about “civilised labour” and united coloured, African and Indian workers under an explicitly internationalist agenda. Touring South Africa and preaching “the ICU gospel”, Kadalie unionised black workers in their hundreds of thousands, leading a number of strikes, and winning numerous court battles and wage increases. The ICU’s new ideas about mass mobilisation, race and irreverent “young and virile” politics - heavily influenced by Kadalie’s early life in Central Africa and early years in Cape Town - went on to influence numerous trade unions, movements and parties in Southern Africa, America and Europe. At a transnational level, Kadalie pioneered new ideas about race, worker solidarity and “socialist internationalism”. This thesis contextualises Kadalie’s globally-significant ideas with local political pressures – the changing contours of imperial politics in Central and Southern Africa, the calls from black South Africans themselves for segregation, and the emergence of black moderate and communist trade union leaders who challenged Kadalie’s pioneering general organising methods. A global history of these debates, it reinterprets the history of interwar Southern Africa through the life of one Central African immigrant. Rehabilitating early radical ideas about rights, freedom and justice, it retells how Kadalie established black trade unionism as a political and economic force on the African continent, and in doing so transformed global ideas about race, class and worker organisation.

Family Presence During Resuscitation (FPDR) first proposed in 1987, has been recommended by numerous professional nursing organizations. Although studies have been conducted investigating the views of family members and healthcare professionals concerning FPDR, little is known about perceptions of nursing students. Due to this gap in the literature, we investigated the attitudes of nursing students toward FPDR as they will be future members of the largest healthcare profession in the United States. This study was guided by the Relationship Based Care Model, which is a way to provide care for our patients and their families. A descriptive cross-sectional study using Qualtrics was designed to identify the attitudes of nursing students from the largest BSN program in Northeast Ohio toward FPDR. The secondary aim was to investigate if age and work experience in a healthcare setting impacted the attitudes of nursing students towards FPDR. Funding for the project was provided by Kent State University Research Council, and Institutional Review Board approval was obtained prior to data collection which commenced in Summer 2023. By the end of Fall 2023 semester, a total of 96 participants were enrolled in the study which yielded a response rate of 53.6% of 179 eligible students enrolled in a senior-level critical care course. This study did not reach statistical significance in attitudes toward FPDR based on age and work experience in healthcare. However, 67.2% of the participants reported they would support FPDR.

The purpose of this scholarly quality improvement project was to increase utilization of current evidence-based interventions to improve mobilization with instrumentation of visible goal targets, documented mobility goals, continuous feedback, and nurse education. This project was designed to enhance nursing knowledge of current evidence-based practice and clinical practice guidelines regarding initiation of mobilization in populations of critically ill adult patients receiving extracorporeal membrane oxygenation therapy. Data was collected over three periods of time. During the first data collection period, nurses used a visual confirmation tool to record the number of times per day a patient on extracorporeal membrane oxygenation was mobilized, as defined by any nursing-initiated incidence of mobilization qualifying as a 2 or greater on the Johns Hopkins Highest Level of Mobility Scale. Nurses indicated on the Mobility Tracker the number of mobility events initiated by the nurse, or patient-initiated events with nursing assistance. Physical and occupational therapy providers were responsible for tracking events initiated by physical and occupational therapists. After the first data collection period, an evidence-based educational program for nurses was deployed followed by data period collection 2.and 3. Results: During data collection periods 1, 2, and 3, patients were mobilized to a level 2 on the Johns Hopkins Highest Level of Mobility scale at least three times daily, 40% by physical therapy, 25 % by occupational therapy, and 27% by nurses. Total mobility scores for data collection periods 1, 2, and 3, averaged 3.01, 1.75, and 1.89, respectively. Total mobility between D1 and D3 reported a change of 35.14%. Nurse-led mobilization accounted for at least two of the daily mobility counts during data collection periods 1, 2, and 3, reporting a total of 12, 5, and 2 times, respectively. No patient data was collected on five nonconsecutive days of the three data collection periods with four of the five days lacking documentation of any mobility counts for patients who were otherwise included in the project. The remaining day without data collection was eliminated due to an outlier total mobility score of 10.0. Twenty -six nurses received 1:1 education and an instructional packet on evidence-based practice by the end of D2.

For this project, we created a critically appraised topic to study the effects of early mobilization on length of hospital stay in COVID-19 patients in the ICU.

Abstract Purpose/Background Despite the increased use of palliative care in adults, only a tiny percentage of children with life-limiting illnesses or life-threatening conditions receive palliative care before dying. Palliative care has low utilization, and consults are often made late in a child’s hospitalization or diagnosis. Palliative care remains underutilized among hospitalized pediatric patients resulting in unnecessary treatments, costly and lengthy hospitalizations, and deaths occurring in the intensive care unit (ICU) rather than at home. The purpose of this scoping review is to evaluate current literature to determine the use and effect of pediatric palliative care, specifically, whether consultation of palliative care for pediatric patients cared for in the inpatient setting for at least three days decreases death in the ICU setting. Methods A literature search was conducted using an online database utilizing MeSH headings from 2013 until 2021. Eligibility criteria included peer-reviewed articles from any country but available in English. An annotated literature table was developed to synthesize findings. A critical appraisal tool was then used to narrow the six articles for scoping review. Results Literature analysis noted that early palliative care involvement could affect mortality, patient and family quality of life, and financially impact hospitals. Palliative care was shown to reduce mortality in the ICU, shift the location of death out of ICU, and provide cost savings to hospitals from unnecessary treatments, and decrease hospitalizations. Implications for Nursing Practice The scoping review yields insight into the utilization of pediatric palliative care and how it reduces mortality in the ICU and at the same time there are cost savings to hospitals. The adaptation of clear consult criteria has the potential to increase palliative care use in children and be beneficial to children, their families, and to hospitals.

Purpose/Background Delirium is an acute syndrome characterized by disturbances in cognition occurring in critically ill patients, particularly those over 65 in the intensive care unit (ICU). Numerous risk factors are associated with delirium development, with sleep being a modifiable factor. This review explores existing literature regarding the relationship between sleep deprivation and delirium development while evaluating the effectiveness of a sleep promotion protocol to decrease the incident of delirium in those ICU patients 65 years or older. Method A literature review of peer-reviewed studies from PubMed and additional search engines was completed. Articles reviewed were published within the last five years, focusing on ICU delirium, sleep deprivation, and the relationship shared between these two factors. Of these articles, eleven reviewed examined the relationship between sleep and delirium development, with several of these articles focusing on the use of sleep promotion protocol to aid in preventing delirium development for patients over 65 in the ICU. Results A mixture of studies was utilized for this review, including randomized control trials, meta-analysis, and qualitative data. Each article reviewed in the study sample (N=11) demonstrated a relationship between sleep deprivation and delirium development. In addition, six articles proposed a statistical correlation between sleep deprivation and delirium development, while eight articles revealed a reduction in delirium development when utilizing a sleep promotion protocol. Overall, utilizing different levels of evidence supports the effectiveness of implementing a sleep promotion protocol towards decreasing the development of ICU delirium for those patients 65 years or older. Implications for Nursing Practice The results from this review demonstrated relevant data regarding using a sleep promotion protocol to decrease the incidence of delirium development. Modifications of risk factors such as sleep deprivation are non-invasive, risk-free, and low-cost strategies that are beneficial towards preventing and managing delirium within the ICU setting, primarily when incorporated as part of a multicomponent plan.

Surges of COVID-19 have been seen to place large numbers of patients into the ICU. Establishing standards of care is critical not only for patient care, but to also implement a baseline of therapy to build upon with future research. COVID-19 produces a hypercoagulable state resulting in higher occurrences of clotting such as deep vein thrombosis (DVT), and pulmonary embolism (PE). Anticoagulation medications thin the blood to combat this aspect of the disease from occurring but does so at the risk of increasing bleeding potential. The purpose of this study is to evaluate the risk/benefit of anticoagulation usage between ventilated and non-ventilated COVID-19 ICU patients as both bleeding and clotting are linked to worsened outcomes. A retrospective analysis reviewed 103 COVID (+) intensive care unit (ICU) patients with approved standardized COVID anticoagulation from August 2020 through January 2021 at a small community hospital. Patient data was obtained by navigating through Citrix Visual Apps including Pharmacy, NextGen EHR, and Paragon Clinician Hub. Pros and cons observed in EHR navigation were reflected upon in Chapter 5. Primary goal is to compare the endpoint of thrombotic events along with secondary outcomes of bleeding and overall mortality between ventilated and non-ventilated patients. Chi-square tests and two-sided t-tests were utilized in obtaining significance. Significance was defined as p

El impacto negativo de la pandemia sobre las tasas de infecciones controladas ha evidenciado la necesidad de reanudar la aplicación de las recomendaciones de los Proyectos Zero (PZ). En este artículo, en primer lugar, se realiza un análisis de la situación de las unidades de cuidados intensivos de España durante la pandemia. A continuación se presenta la adaptación de las recomendaciones de cada uno de los cuatro PZ y su grado de cumplimiento y riesgo de que existan infecciones relacionadas con dispositivos invasivos y/o bacteriemias multirresistentes. Para ello, se han tenido en cuenta: 1) el documento publicado en octubre de 2020 por el Consejo Asesor del Programa de Seguridad de pacientes críticos, y 2) el estudio exploratorio realizado, un año después, por el Consejo Asesor de los PZ, junto con los líderes de los proyectos de las unidades participantes del registro ENVIN. Por último, y en base a los hallazgos encontrados, se formulan cinco recomendaciones tentativas y prioritarias.

The provision of graded supervision affording progressive autonomy is fundamental to the progression of a medical learner towards competency for independent practice; the decision of how much supervision versus trust and autonomy to provide a trainee in the execution of clinical care constitutes an entrustment decision. Despite entrustment decision making occurring both daily in practice and summatively at points of matriculation through stages of medical training, the factors influencing entrustment decisions remain poorly understood across clinical contexts. This study was designed to explore the central research question of: How are entrustment decisions made in the medical intensive care unit?This qualitative case study utilized semi-structured interviews with attending pulmonary and critical care physicians in the medical intensive care unit at a major midwestern medical center to explore the entrustment decision making process as it was enacted in the clinical environment.Five major themes emerged from the data: (1) Task, circumstance, and trainee factors contribute to entrustment decision making, (2) Ad hoc entrustment decisions are enacted by supervisors with a consideration of the care team as a unit, not only an individual, (3) Autonomy does not arise only out of entrustment, but outcomes of prior autonomy inform ongoing intention to entrust, (4) Entrustment decision making includes a social process of back-and-forth akin to negotiation, and (5) Entrustment decision making is a learned skill. The process of entrustment decision making in the ICU is more complex than prior frameworks have captured; a model with more complete incorporation of the factors that influence entrustment in the ICU is presented. Lastly, recommendations for the application of our model of entrustment to improve the quality of entrustment decisions in order to better inform the use of entrustment decisions for assessment are discussed.

The purpose of this critically appraised topic (CAT) is to investigate early mobilization and its effect on preventing pneumonia in adults in the intensive care unit (ICU). The final portfolio contains four research articles from both national and international journals. Study designs included two meta-analyses, one case series, and one retrospective study. All four of the articles specifically described the effects of early mobilization on individuals in the hospital and ICU and showed positive results in reducing the likelihood of developing pneumonia. This CAT will be used to draft new practice guidelines for mentoring new managers in both occupational therapy and physical therapy.

The purpose of this critically appraised topic (CAT) is to provide the highest quality of evidence available on the implementation of exercise interventions in the early burn rehabilitation phase in adult burn victims. This portfolio contains four peer-reviewed research articles from national and international journals. The study designs include one systematic review and meta analyses, one retrospective cohort study and two randomized control trials. These articles covered three types of exercise interventions including resistance training, mobility training, and physiotherapy. Overall, the clinical bottom line of this CAT is that exercise interventions in early burn rehabilitation may be effective in improving upper extremity function, muscle strength, range of motion, quality of life, and decreasing length of stay and inflammation. Further research is needed to determine the effects of early exercise interventions in adults in the burn ICU.

Healthcare is transforming into a data-intensive industry with the expectation to double its own data every 73 days by 2020. Electronic Health Records hold a vast amount of information that has the potential of improving care delivery ranging from management tasks in hospitals to inferring diagnoses from X-ray images. The massive volume of data, such as demographic data, diagnoses, tests, prescribed medications, and procedures, can be used to predict health risk or diagnose diseases. But few pay attention to the medical notes which contain abundant and critical information written by healthcare service providers during a patient’s stay or visit to the hospital. Because of the unstructured feature in these notes, they are usually underutilized to build prediction models. This project incorporates medical notes (e.g., discharge notes) along with demographic data available in the MIMIC-III dataset, to visualize patterns and finally train a prediction model for readmission of patients in the ICU.

Previous research has shown increased saccade latencies in patients with Alzheimer’s disease and mild cognitive impairment; however, this is not well-understood in patients with delirium. The present study investigates eye-tracking metrics to evaluate the feasibility of using eye-tracking to discern delirious patients from disease control patients. We recruited 24 participants from the inpatient and intensive care units (ICU) at Massachusetts General Hospital (MGH) and assessed for delirium via CAM-S, a screening tool for delirium. Participants were instructed to follow a dot stimulus as it moves across the laptop screen as their eye movements were simultaneously tracked by a Tobii Pro Fusion eye-tracker. Our experimental paradigm involved gap saccades (central fixation extinguishes before the centrifugal target appears), overlap saccades (central fixation remains after centrifugal target onset), horizontal smooth pursuit, and circular smooth pursuit tasks. The eye-tracking metrics discussed in this study are the calibration and validation accuracies, saccade latencies and total target gaze duration. Our eye-tracking method was able to capture subjects’ gaze direction and path, but further research is needed to draw strong conclusions about the feasibility to detect oculomotor abnormalities in patients with delirium.

Background: Coronavirus disease 2019 (COVID-19) is a viral respiratory disease caused by SARS-CoV-2. Critical cases evolve into an acute respiratory distress syndrome (ARDS) with bilateral infiltrates, intrapulmonary shunting, and hypoxemia requiring intubation. A rescue treatment called prone positioning has been frequently utilized during the pandemic and known to improve dorsal lung ventilation, decreasing shunting, and improving mortality rates in non-COVID-19 ARDS literature. The clinical inquiry is whether a resource intensive procedure like pronation can benefit oxygenation, ICU length of stay, and days intubated in COVID-19 ARDS. Objective: To evaluate the effects of pronation and compare COVID-19 ARDS with a historical control group of non-COVID-19 ARDS. The specific aim is to assess whether there is a positive effect on oxygenation, ICU LOS, and days intubated. Methods: A retrospective descriptive chart review of COVID-19 ARDS versus non-COVID-19 ARDS adult patients ages 18 to 80 years at a quaternary academic center in Los Angeles, California. A convenient sample of intubated COVID-19 patients with moderate to severe ARDS based on the Berlin criteria. A historical control was age and gender matched of non-COVID-19 ARDS patients. Statistical analysis utilized Mann Whitney U, and the Wilcoxon Signed Rank Test. Results: A total of 41 patients met criteria in the COVID-19 ARDS group, and six patients in the non-COVID-19 ARDS group for a total sample size of 47 subjects. Pronation showed a positive impact on oxygenation (P/F ratios) at the end of pronation on day one (p < 0.01), day three (p < .042), and day four (p < 0.04) in the COVID-19 ARDS group compared to the non-COVID-19 ARDS group. The Wilcoxon Signed Rank Test found a positive impact on P/F ratios by pronation from day one through day six in the COVID-19 ARDS group while the non-COVID-19 group showed a positive impact on day two. Conclusion: Pronation impacted P/F ratios in COVID-19 ARDS compared to non-COVID-19 ARDS. ICU LOS and intubation days were not impacted by pronation. Oxygenation improvement was possibly related to assertive prone protocols instituted early during the exudative phase of ARDS. These results suggest there is an oxygenation benefit to pronating early.

The purpose of our critically appraised topic is to provide a brief summary of assessments that may be relevant to the burn unit or ICU setting, including their validity, reliability, specificity, sensitivity, and limitations. We had a total of eight articles with the following study designs: Systematic Review (2 articles), Longitudinal Study (1 article), Comparative Analysis (1 article), Correlational Analysis (2 articles) and Methodological (2 articles). These articles looked at the reliability, validity, specificity, and sensitivity of the following assessments: Abbreviated Burn Specific Anxiety Scale (A-BSPAS), Beck Depression Inventory-II, Brief Coping Orientation to Problems Experience (B-COPE), Concise Mental Health Checklist (CMHC-9), Confusion Assessment Method for Intensive Care Units (CAM-ICU), Startle, Physiological arousal, Anger, and Numbness (SPAN), Trauma Screening Questionnaire (TSQ), The Confusion Assessment Method (CAM), and Wound-Quality of Life. We found the following assessments applicable for the burn unit or ICU: CAM, B-COPE, CAM-ICU Flowsheet. Our clinical recommendations are for these assessments to be used to perform a screening of the client's mental state, which will help the Occupational therapist develop and plan interventions.

Healthcare analytics has traditionally relied upon linear and logistic regression models to address clinical research questions mostly because they produce highly interpretable results [1, 2]. These results contain valuable statistics such as p-values, coefficients, and odds ratios that provide healthcare professionals with knowledge about the significance of each covariate and exposure for predicting the outcome of interest [1]. Thus, they are often favored over new deep learning models that are generally more accurate but less interpretable and scalable. However, the statistical power of linear and logistic regression is contingent upon satisfying modeling assumptions, which usually requires altering or transforming the data, thereby hindering interpretability. Thus, generalized additive models are useful for overcoming this limitation while still preserving interpretability and accuracy. The major research question in this work involves investigating whether particular sedative agents (fentanyl, propofol, versed, ativan, and precedex) are associated with different discharge dispositions for patients with acute traumatic brain injury (TBI). To address this, we compare the effectiveness of various models (traditional linear regression (LR), generalized additive models (GAMs), and deep learning) in providing guidance for sedative choice. We evaluated the performance of each model using metrics for accuracy, interpretability, scalability, and generalizability. Our results show that the new deep learning models were the most accurate while the traditional LR and GAM models maintained better interpretability and scalability. The GAMs provided enhanced interpretability through pairwise interaction heat maps and generalized well to other domains and class distributions since they do not require satisfying the modeling assumptions used in LR. By evaluating the model results, we found that versed was associated with better discharge dispositions while ativan was associated with worse discharge dispositions. We also identified other significant covariates including age, the Northeast region, the Acute Physiology and Chronic Health Evaluation (APACHE) score, Glasgow Coma Scale (GCS), and ethanol level. The versatility of versed may account for its association with better discharge dispositions while ativan may have negative effects when used to facilitate intubation. Additionally, most of the significant covariates pertain to the clinical state of the patient (APACHE, GCS, etc.) whereas most non-significant covariates were demographic (gender, ethnicity, etc.). Though we found that deep learning slightly improved over LR and generalized additive models after fine-tuning the hyperparameters, the deep learning results were less interpretable and therefore not ideal for making the aforementioned clinical insights. However deep learning may be preferable in cases with greater complexity and more data, particularly in situations where interpretability is not as critical. Further research is necessary to validate our findings, investigate alternative modeling approaches, and examine other outcomes and exposures of interest.

Due to advances in medical care, the number of patients surviving critical illness is on the rise. As a result, our healthcare system has a new and growing subset of patients dealing with a variety of issues related to survivorship. These issues, called post-intensive care syndrome, fall into three pillars: physical, cognitive, and psychiatric. While targeted efforts have begun to attempt to manage the physical and cognitive deficits, how to treat the psychiatric deficits remains unclear. So far, the handful of studies attempting to treat these psychiatric outcomes via a variety of approaches have had only limited success. Further, there is an inadequate understanding of the patient perception of these experiences and to better grasp this may help target future studies. The proposed study is a randomized, non-blinded, longitudinal controlled trial with the goal to limit the development of psychiatric symptoms following ICU admission. The intervention, conducted by a trained, Licensed Clinical Social Worker will take place in the form of a one time, in hospital debriefing of the ICU experience. Following the intervention, the patients will be surveyed to identify the presence of PTSD symptoms at various time intervals following hospital discharge. In addition, a number of interviews will be recorded and undergo qualitative analysis to identify cohesive themes and develop a better understanding of the patient perception of their experience. If successful, this study would lead to an improved quality of life for this patient population, as well as lessen their dependence on the healthcare system, reducing the associated financial burden following ICU admission.

Burns cause massive dermal wounds. Wound healing elicits a significant catabolic response and increase in energy expenditure, and thus, calorie needs. Overfeeding and/or underfeeding the overweight and obese critically ill patient can increase complications. Indirect Calorimetry (IC) is considered the ‘gold standard” for the measurement of Energy Expenditure (EE). Predictive equations are calculated to estimate EE instead. This study is a retrospective chart review. The difference between predictive energy expenditure (via Curreri formula) and measured IC were analyzed via non-parametric Wilcoxon signed rank match paired tests. Curreri equation prediction was analyzed on the ability to match IC (0% over or under prediction). A total of 13 participants met inclusion criteria. The Curreri equation showed a mean overprediction of 29% using actual body weight, 10% for ideal body weight and 2% for adjusted ideal body weight (obese only). More research with larger sample sizes is needed to further determine if the use of ideal body weight in the Curreri predictive equation will reduce significant over prediction and therefore overfeeding of energy.

Oral care is often dismissed or undervalued in the overall health and wellness of individuals and can be detrimental to patients in hospital-like settings. Although dental hygienists are educated to practice in alternative practice settings like pediatric offices, hospitals, nursing homes, schools and federally qualified health centers they are underutilized in such arenas. The purpose of this study is to learn about the University of New Mexico Hospital’s (UNMH) current oral hygiene care practices and protocols, nurses’ values and interests in inter-professional collaboration with a dental hygienist. A feedback survey was created and intended recipients included all UNMH nurses regardless of specialty unit. However, this survey was disseminated to 240 UNMH Intensive Care Unit nurses. Of the 240 nurses only 28 (11.6%) opted to participate in this survey study. The result of this study revealed the majority of nurses: value oral hygiene care in themselves and in their patients; report their nursing education did prepare them in performing oral hygiene care on patients; interested in inter-professional collaboration with a dental provider like a dental hygienist.

Delirium is a neurocognitive disorder defined as an acute disturbance in attention, awareness, and cognition with a fluctuating course not better explained by a preexisting condition (American Psychiatric Association, 2013). It is prevalent in up to 70% of hospital patients and 82% of patients in the intensive care unit (ICU; Ely, Speroff, Gordon, & Bernard, 2004; Kavanagh & Gottfried, 2007; Mcnicoll, Pisani, Ely, Gifford, & Inouye, 2005). The impact of delirium on mortality is inconsistent in the literature. Many studies have concluded that delirium prevalence is associated with increased risk of mortality (Cole, 2004; Kavanagh & Gottfried, 2007; Moskowitz et al., 2017; Pandharipande et al., 2013; Pauley et al., 2015), while others suggest delirium does not increase risk of patients dying (Levkoff et al., 1992; Wolters et al., 2014). The objective of this retrospective observational study was to determine if delirium is an independent predictor of mortality and develop a new model predicting three-month mortality of critically ill patients. Of the 165 patients followed in this study, 42 (25.5%) were deceased at three months and 123 (74.5%) survived. The most accurate model of predicting three-month mortality had an area under the curve of 0.89 (CI: 0.81 to 0.94), which included delirium burden defined as the fraction of the number of days patients were positive for individual features of delirium during their hospital stay. The main finding of the present study is the development of a new model that accurately predicts three-month mortality of critically ill patients. This study provides further evidence that delirium is an independent predictor of mortality and new evidence that delirium fraction improves the accuracy of a predictive models of mortality. We also identified individual features of delirium that are more predictive of mortality than others. Future research is needed to develop prevention measures and treatment interventions for delirium in the ICU and on hospital floors to reduce risk of patient mortality.

Background: Critical care nurses are exposed to an excessive number of clinical alarms in the patient care environment. Prior studies show that the vast majority of arrhythmia alarms are false and can lead to alarm fatigue. Patients with both true and false arrhythmia alarms present a unique challenge, because exposure to false alarms can desensitize nurses to true alarms and may lead to missed true events. Objectives: The purpose of this study was to examine patients with both true and false arrhythmia alarms and determine: (1) frequency of patients with true and false arrhythmia alarms in a sample of 461 intensive care unit (ICU) patients, (2) patient, clinical, and electrocardiographic characteristics associated with both true and false alarms, and (3) the number and types of true and false arrhythmia alarms (e.g., asystole, ventricular fibrillation, ventricular tachycardia, accelerated ventricular rhythm, pause, and ventricular bradycardia). Methods: This was a secondary analysis utilizing data from the UCSF Alarm Study. Results: In 461 ICU patients, 71 (15%) patients had a total of 10,699 true and false arrhythmias alarms: 1,348 (13%) were true and 9,351 (87%) were false. Compared to patients without true and false alarms, the presence of ventricular pacemaker, bundle branch block, altered mental status, mechanical ventilation, left ventricular assist device, and cardiac ICU admission were associated with the presence of true and false alarms (p = 0.001). Patients with both true and false alarms had longer length of ICU stay than patients without both true and false alarms (208 hours versus 75 hours; p = 0.001). Accelerated ventricular rhythm was the most common alarm (37%), followed by ventricular tachycardia (31%). Conclusion: We found that 15% of ICU patients have both true and false alarms and the vast majority are false. Further research is needed to build and test improved ECG arrhythmia algorithms that adjust for clinical and ECG characteristics associated with false alarms. Nurses’ awareness of these characteristics may help them identify patients at risk for excessive alarms and aid in developing unit specific solutions to decrease alarm fatigue.

In this era of technological transformation in medicine, there is need to revolutionize the approach and procedures involved in the treatment of diseases to have a restructured understanding of the role of data and technology in the medical industry. Data is a key factor in diagnosis, management, and treatment of patients in any medical institution. Proper management and usage of patient’s data will go a long way in helping the society save money, time and life of the patient. Having data is one thing and providing a system or means of translating the data is another issue.This dissertation is proposing a design of a Point of Care system for the Intensive Care Unit (a.k.a ICU_POC), which is a system that integrates the capabilities of the bedside monitors, bedside eFlowsheet and the Electronic Medical Records in such a manner that the clinicians interact with one another in real time from different locations, to view, analyze, and even make necessary diagnoses on patients’ ailment based on their medical records. It demonstrates how patient data from the monitors can be imported, processed, and transformed into meaningful and useful information, stored, reproduced and transferred automatically to all necessary locations securely and efficiently without any human manipulation.ICU_POC will grant physicians the remote capability in managing patients properly by providing accurate patient data, easy analysis and fast diagnosis of patient conditions. It creates an interface for physicians to query historical data and make proper assumptions based on previous medical conditions. The problem lies in managing data transfer securely between one hospital EMR database and the other for easy accessibility of data by the physicians. This work is challenged by designing a system that could provide a fast, accurate, secure and effective (FASE) diagnosis of medical conditions of the patients in the ICU. The proposed system has the potential of reducing patients’ length of stay in the ICU by equipping the physicians with an easy way of managing patients’ data seamlessly and diagnosing conditions quickly. This, in turn, will reduce the cost of care generally in the society.

Patient safety and nursing communication are crucial to the nursing handoff during transition of care from the emergency department (ED) to the intensive care unit (ICU). The Institute of Medicine published To Err is Human: Building a Safer Health System (1999) and Crossing the Quality Chasm (2001) highlighting ED handoffs as a safety measure. In 2006, the Joint Commission recognized handoffs with the National Patient Safety Goal 2E. The purpose of this evidence-based practice project was to determine if implementation of a standardized handoff would improve nursing communication and patient safety during transition of care from the ED to the ICU. Rogers’ Diffusion of Innovation Theory was used as the theoretical framework. The Stetler Model guided this project at a non-profit, 205-bed hospital, in the Midwest. The intervention included the development of a standardized handoff that (a) utilized a specific handoff tool, (b) minimized interruptions and multitasking, (c) enabled nurses to ask questions when information was unclear, (d) included anticipatory changes in patient’s condition, (e) ensured timing of the patient transfer was appropriate, (f) and confirmed ancillary staff was notified and available. Data for demographics of ED and ICU nurses, pre- and post-implementation questionnaires, and patient transfer times from ED to ICU were collected. Descriptive analysis was used to investigate nursing demographics regarding age, gender, race, and education. Two identical questions were asked of the nurses in the pre-and post-implementation questionnaires. Paired t-tests analyzed the nurses’ responses and found significant improvements in nursing communication (t=7.23, df=46, p<=0.00) and patient safety (t=5.76, df=46, pt-test analyzed the patient transfer times from the ED to ICU. Patient transfer time decreased significantly pre (M=82.85 minutes; SD = 18.24) to post (M=75.47 minutes; SD = 17.74) intervention (t=1.974, df=283, p=0.0049). The patient transfer time from ED to ICU decreased by more than seven minutes. The p value indicates strong evidence against the null hypothesis. The clinical site adopted aspects of this standardized handoff for implementation not only in transfer of care from the ED to the ICU, but for handoffs throughout the hospital.

Fever in critically ill adults: monitoring, management, and outcomes Fever is a common occurrence in intensive care unit (ICU) patients and is routinely treated with antipyretic therapies. Evidence to inform guidelines for fever management in ICUs is limited due to the low level of evaluable data. The introduction (Chapter 1) provides the background and significance of fever management in ICU patients. The question of whether fever should be suppressed based on its impact on outcomes in all ICU patients or in specific subpopulations, such as sepsis, neurological injury, and acute respiratory distress syndrome (ARDS), remains unanswered. To describe the impact of fever on outcomes of ICU patients with ARDS, a secondary analysis was completed and found that early in the ARDS trajectory, fever is associated with improved survival rates (Chapter 2).A common limitation of studies investigating body temperature alterations in ICU patients is the lack of standard measurement of core body temperature. To address this limitation for the primary clinical trial of this dissertation and to evaluate a prospective continuous core temperature monitoring device for use in ICU patients, a method-comparison study was completed (Chapter 3). This method-comparison study tested the agreement and precision of a novel technology for continuous thermometry with standard thermometry methods in febrile ICU patients. Fever suppression remains widespread and acetaminophen is the most common first line therapy used by ICU clinicians. There is a lack of high-grade evidence about the antipyretic efficacy and the acute hemodynamic effects of the more recently available intravenous (IV) formulation of acetaminophen in ICU patients. To better understand the therapy response and potential acute adverse effects of this commonly administered medication in febrile critically ill patients, a randomized, double blind, placebo-controlled trial to evaluate the effect of IV acetaminophen on body temperature and hemodynamic responses was conducted (Chapter 4).

ABSTRACTObjective: To describe family members’ experiences with bereavement 13 months after the death of a family member in an adult ICU.Definition: Bereavement is an undefined time period after the death of a loved one, when family members or friends may experience grief and mourn the loss of the deceased. In varying degrees this may include physical, cognitive, behavioral and spiritual / religious experiences for the family member. For some people this period can be stressful and cause distressing symptoms. Design: An exploratory, descriptive analysis using semi-structured interviews.Setting: Interviews were conducted over the telephone. Handwritten responses were received by mail.Participants: 17 family members of 17 deceased ICU patients from two ICUs in a tertiary medical center in the Western United States represent the sample for this study.Methods and Results: A qualitative, descriptive technique was used for data analysis. Two independent raters coded transcripts of audiotaped interviews, handwritten responses to open- ended survey questions and one unsolicited letter in order to assess family members’ experiences with bereavement support provided by the ICU. Comments from family members were categorized into themes focusing on ICU family bereavement experiences. Three main themes emerged and consisted of: 1) bereavement as a unique experience for each family member, 2) situations occurring during the ICU encounter remained significant for family members beyond a year after the death, and 3) social, cultural and spiritual events after the death hold importance for ICU family members over time.Conclusions: Bereavement is a notable experience for family members of deceased ICU patients. The themes identified in this study add insight into the experiences of these surviving familyivv members. The results of this study may guide future clinical interventions to help supportbereaved ICU family members.Keywords: ICU, family bereavement, bereavement intervention, qualitative study.

Clinical alarms have become an indispensable part of medical environment, but issues related to alarm artifacts, false alarms, and alarm fatigue have been identified. A national online survey administered to hospitals stated healthcare workers determined that 81% of respondents agreed that alarms occur frequently, 77% agreed that excessive clinical alarms disrupt patient care, and 78% agreed that reduced trust in alarms cause caregivers to disable them (Korniewicz, Clark, & David, 2008). Studies have suggested that preparation of skin of the patient improves electrode-skin contact, thereby resulting in fewer artifacts (Hermens, Freriks, Disselhorst-Klug, & Rau, 2000). Additionally, clinical studies have shown that the electrode-skin interface is frequently overlooked as a major source of artifact affecting many electro-physiologic recordings (Oster, 1998). The purpose of the thesis is to evaluate how the implementation of procedural changes, specifically implementing a patient's chest preparation procedure prior to electrode placement influences the rate of clinical alarms, (i.e., critical or warning cardiac alarms) in an intensive care unit (ICU). Data from clinical alarms were collected from a regional hospital in South Carolina. The data contained the number of clinical alarms recorded with and without nurse administered chest preparation. Functional data analysis was used to evaluate if chest preparation procedure had a significant impact on the rate of clinical alarms produced over an 8-hour shift. The results suggest that there is no significant reduction in the alarm frequency after the implementation of nurse administered chest preparation. However, a nominal decrease in the number of alarms per hour per patient and some preliminary trends were observed during the data analysis that warrants the need for future research in this direction.

Hospitalization in the pediatric intensive care unit (PICU) is stressful for families and disruptive for their normal lives. As new technology has become available, the number of children requiring prolonged stays in the PICU has increased. This mixed methods study explored stress in families whose children were hospitalized in the PICU for more than one week, collecting data one to two weeks after admission, then four to five weeks later. The purpose was to describe sources of stress for families whose children require extended hospitalization in the PICU and explore how sources of stress change over time. Data collection included semi-structured interviews and completion of the Family Inventory of Life Events (McCubbin, Thompson & McCubbin, 1996) and Family System Stressor Strength Inventory (Berkey & Hanson, 1991) at each time point. Nine parents of eight children participated in the first phase of data collection; two mothers participated in the second phase. Data analysis revealed the following themes related to Aim 1 (sources of stress): separation, not knowing, child’s illness and distress, care and caring, emotional stress, physical stress, job and financial stress, and what we’ve been through before. Themes related to Aim 2 (change over time) were: stress builds, and stress decreases as the unknowns become known. Analysis of Time 2 data revealed similarities in sources of stress compared to Time 1, but there was a shift in the relative priority and contribution that each stressor made to the overall perception of stress as hospitalization became prolonged and the child’s condition improved; participants reported aspects of care and caring as most important at this point. A new subtheme in the original care and caring theme was also identified: considering the child’s entire picture. Findings demonstrated sources of stress directly related to the child’s acute illness as well as stress resulting from the child’s hospitalization and ongoing healthcare needs, all of which contributed to the perception of family stress. Over time, stress was compounded and there was a shift from the primary stressors of unknowns and separation of the family to stressors related to the care and caring provided by the team.

Healthy work environments (HWEs) are associated with improved patient outcomes, higher nurse retention rates, and enhanced quality care (Rogers-Clark, Pearce, & Cameron, 2009; Rosenstein & O'Daniel, 2008; Stagg & Sheridan, 2010). The purpose of this evidence-based practice (EBP) project was to design, implement, and evaluate a multiphase intervention to build a HWE in the intensive care unit (ICU) and determine its effect over a 3 month period on (a) lateral violence (LV), (b) moral courage (MC), (c) communication, (d) collaboration, and (e) job satisfaction. The Knowledge to Action EBP model (Graham & Tetroe, 2007) and Parse's (2008) leading-following model were used to facilitate the actions towards implementing a change and understand the connections and patterns during the change process. After conducting an exhaustive literature search, a multiphase intervention was determined to be the best practice recommendation for creating a HWE. ICU nurses attending a mandatory education day in the fall of 2014 were recruited to participate. Eighty-three nurses signed informed consent forms and agreed to participate in the project. Phase I of the project was the initiation of an ICU mission and vision statement created by the shared governance council. Phase II was a didactic session for nurses. Phase III consisted of the dissemination of the hospital's harassment and intimidating behavior policy. Phase IV was the initiation of an annual web-based competency on HWEs. A modified HWE assessment survey was administered to participants pre-didactic, post-didactic, and one month following didactic. Descriptive analysis was used to describe sample characteristics. To determine the effect of the intervention, analysis of the data was conducted using a one-way repeated-measure ANOVA. Five outcomes were evaluated: (a) LV, (b) MC, (c) communication, (d) collaboration, and (e) job satisfaction. While 83 nurses participated in the project, only 78 nurses completed all three surveys (94%). The project demonstrated a significant effect for LV (p < .001), communication (p < .05) and job satisfaction (p < .05). Although no significant effect was found for MC (p > .05) or collaboration (p >.05), scores did improve and were maintained over time. In the increasingly volatile healthcare system, it is essential to illuminate the true art of nursing by creating and maintaining a HWE. The findings from this EBP project support a multiphase approach for creating a HWE.

The purpose of this research was to explore the relationships of family functioning, social support, appraisal of illness/caregiving, uncertainty, and coping on psychological distress among family members of loved ones undergoing adult cardiac surgery. A descriptive correlational design with instruments to measure the six variables of interest and demographics was used to collect data at three points in a planned adult cardiac surgery experience. A convenience sample of 81 family members was recruited and completed all three data collection points. The sample was primarily Caucasian (92.8%), female (70%), spouses (63%) and highly educated (100% had completed high school or more). There were no statistically significant differences in any of the predictor variables by age, gender or race. Psychological distress, as measured on the Distress Thermometer, during the ICU stay was 5.791 (S.D. 2.587) and 5.220 (S.D. 2.615) prior to discharge. While both psychological distress scores indicate significant effect on the family members, the decrease was statistically significant. The results of the regression analysis showed that the model, along with three demographic variables (age, relationship, and gender) accounted for 36.3% of the variance; both overall active coping and avoidant coping predicted psychological distress. Path analysis showed that the only significant predictors of psychological distress were overall active coping and overall avoidant coping at similar levels of influence. The most frequently used coping strategies reported by the sample were active coping strategies of acceptance, use of emotional support, positive reframing, active coping and planning. Avoidant coping strategies, such as venting, self-blame, and substance use, were reported less frequently, although some subjects did report using these strategies. Nurses should be mindful of the psychological distress these family members experience throughout the hospital stay and further research should determine what interventions may assist with decreasing it.

This dissertation aims to study cardiovascular physiology from the cellular level to the whole heart level to the body level using numerical approaches. A mathematical model was developed to describe electromechanical interaction in the heart. The model integrates cardio-electrophysiology and cardiac mechanics through excitation-induced contraction and deformation-induced currents. A finite element based parallel simulation scheme was developed to investigate coupled electrical and mechanical functions. The developed model and numerical scheme were utilized to study cardiovascular dynamics at cellular, tissue and organ levels. The influence of ion channel blockade on cardiac alternans was investigated. It was found that the channel blocker may significantly change the critical pacing period corresponding to the onset of alternans as well as the alternans’ amplitude. The influence of electro-mechanical coupling on cardiac alternans was also investigated. The study supported the earlier assumptions that discordant alternans is induced by the interaction of conduction velocity and action potential duration restitution at high pacing rates. However, mechanical contraction may influence the spatial pattern and onset of discordant alternans. Computer algorithms were developed for analysis of human physiology. The 12-lead electrocardiography (ECG) is the gold standard for diagnosis of various cardiac abnormalities. However, disturbances and mistakes may modify physiological waves in ECG and lead to wrong diagnoses. This dissertation developed advanced signal analysis techniques and computer software to detect and suppress artifacts and errors in ECG. These algorithms can help to improve the quality of health care when integrated into medical devices or services. Moreover, computer algorithms were developed to predict patient mortality in intensive care units using various physiological measures. Models and analysis techniques developed here may help to improve the quality of health care.

Delirium is a pervasive complication of critical illness that increases patient morbidity and mortality. This exploratory study examined associations between delirium, thiamine blood levels, genes associated with thiamine metabolism and other genes identified as having an association with delirium in critically ill patients.Fifty mechanically ventilated ICU patients were enrolled in this prospective observational study between June 2009 and June 2010. Blood thiamine levels and delirium status were assessed daily. A blood sample for genotyping was obtained at baseline.Thiamine blood levels are highly variable in critical illness; 56% of the variance in thiamine levels derives from differences between individuals. The remaining 44% of the variance comes from differences in the within-patient trajectory over days.Whole blood thiamine levels were not asociated with delirium in critical illness. There was evidence of a genetic association with delirium. This study warrants replication with a larger number of pateints to validate this finding.

Globally, nursing shortage is affecting all components of patient care process, especially in the developing countries due to their lack of resources. Literature identified nurses’ dissatisfaction with work environment and turnover as causes for the shortage, and the ambiguity of nurses’ role as a cause for dissatisfaction. So, exploring nurses’ role, as a part of their work environment, from nurses’ perspectives is believed to formulate a compatible environment that is more appealing to nurses to stay.Using the person-environment fit theory, this study tried (a) to describe role discrepancy, depressive symptoms, and turnover intention among the Jordanian ICU RNs; and (b) to examine the relationship of role discrepancy with nurses' depressive symptoms and turnover intention. Using a descriptive correlational cross-sectional design, a convenience sample of 114 RNs from 8 ICU units, at the JUH, who were recruited and surveyed through interviews and self-administered questionnaires. Analysis included descriptive statistics, correlations, paired and independent t-tests and polynomial regression analyses.Amongst the sample, 63.2% were females, 56.1% singles, and 93.9% holding the BSN degree, with average age 27.1 years, average period of nursing experience 4.7 years, and 3.9 years in current ICU. Nurses rated their satisfaction with their salary, work, and work environment as 5.6, 5.4, and 4.2, out of 10, respectively.Nurses’ ideal role conception was higher than their actual role (4.26 vs. 3.14, respectively, p < .05). Their reported level of depressive symptoms was 26.68, out of 60. Participants’ average turnover intention was reported to be 3.59, with their professional turnover intention higher than their organizational turnover intention (3.71 vs. 3.4, respectively, p < .05).Nurses’ perception of role discrepancy was not found to have a statistically significant relationship with nurses’ level of depressive symptoms or turnover intention. So, the hypothesized curvilinear relationship was not found useful to explain the relationship between the components of the role discrepancy with depressive symptoms or turnover intention. However, the low reliability and validity results of the NRCS and the modified WCS caused the results to be cautiously taken, and limited the generalizability of the findings. Further examination of those two instruments is recommended.

Internationally and nationally it is recognised that there is a shortage of Registered Nurses (RNs), which is occurring within a context of increasing costs of health care and limited funding. The specialist area of the Intensive Care Unit (ICU) is one area that requires numerous resources. The patients admitted to ICU need advanced specialist care involving significant human resources (nursing, medical, allied health) and equipment. One method that is utilised to manage the ICU nurse resource is workload tools. Workload tools guide manager’s decisions related to the allocation of ICU nurses. In order to develop workload tools that are applicable to the Australian context, it is important to first understand what the Australian ICU nurse does as they work. The aim of this study was to describe and analyse ICU nurses’ activities during the day shift. A non participant time and motion observation method was utilised. Ten ICU nurses were observed for their day shift in a private hospital in South East Queensland. First, the number of activities undertaken was analysed to determine the frequency of undertaking multiple activities at one time. Next, the data were categorised into four major and 25 minor work activity categories. The major categories were direct patient care, indirect patient care, unit related activities and personal activities. Finally, the observed nurses’ activities were classified according to a schema of six work activities. This schema included ‘routineness’, ‘discretion’, ‘intensity’, ‘multiplicity’, ‘complexity’ and ‘accessibility’. Data analysis was performed using Microsoft Excel and Statistical Package for Social Sciences. The ten ICU nurses were observed for 76 hours 26 minutes. In total 3,081 activities were observed. The ICU nurses were observed performing two simultaneous activities for 43% of their time. The major work activity categories data indicated that the ICU nurses’ time was divided up into direct nursing care activities (60.3%), indirect nursing activities (32%), personal activities (4.5%) and unit-related activities (3.2%). The schema of work activity findings indicated that the ICU nurses’ activities were predominantly ‘routine’ (94.2%), versus ‘non-routine’, requiring ‘discretion’ for 95.8% of their work activities. The ‘discretion’ category indicating the autonomy of the ICU nurse as they worked. In total, 95.6% of activities were ‘not intense’, and 41.2% of them required multiple activities (‘multiplicity’). A total of 25.2% of the work activities that were ‘complex’ and 94.9% required nurses to use their knowledge as they worked (‘accessibility’). This study identified that the ICU nurses spent approximately two thirds of their time involved in direct nursing care and almost a third of their time involved in indirect nursing care. The simultaneous activities that ICU nurses performed equated to greater than 40% of their time. The actions of the ICU nurses were predominantly routine, autonomous and not intense. The work activities were principally regular, however there were complicating factors for this group of ICU nurses, such as multiple and complex activities. This level of analysis of ICU nurses’ work is not commonly undertaken, yet it provides valuable information that can be used to inform workforce planning. It is recommended that the development of workload tools in the Australian context should consider the broad complex nature of providing care for the ICU patient to capture potential workload for the ICU nurses. Research into the frequency with which ICU nurses undertake simultaneous activities suggest that without adequate concentration, errors may occur. Future research exploring the work undertaken during all shifts utilising time and motion observations and the schema of work activities would provide a broader contextual view of their work. The schema of work activities has been adapted and employed for the first time in the ICU environment. Future studies utilising the schema of work activities will provide a comparison and critique of the categorisation of the ICU nurse work activities. Allocation of time for specific direct nursing activities alone does not consider other activities that nurses undertake nor does it consider the complexity of these activities.

Background: While many studies have documented the importance of providing nutrition support in the critical care setting within 48 hours of Intensive Care Unit (ICU) admission in order to minimize undesirable clinical outcomes and malnutrition, few studies have reviewed how to achieve those recommendations. The present study will provide evidence on whether or not the implementation of a voluntary Nutrition Support Protocol across a healthcare system will shorten time to nutrition initiation and increase the number of patients who received nutrition within 48 hours.Methods: The Nutrition Support Protocol was developed in support of evidence-based recommendations under the leadership of a critical care Registered Dietitian (RD). Data was collected via medical chart review over a near three year time period. Changes in the time of nutrition initiation were compared between the pre-and post-protocol implementation periods. In the post-protocol implementation period, different methods of administering nutrition (enteral, parenteral or oral) were compared along with the time to the initiation of nutrition, total percent of patients who received nutrition within 48 hours, and whether or not the nutrition was managed by the physician or utilizing the Nutrition Support Protocol (RD leadership). Differences between groups (pre-protocol versus post-protocol implementation periods and physician managed versus Nutrition Support Protocol managed) were tested using analysis of variance (ANOVA) and Wald's Chi Square. Results: The time to nutrition initiation significantly decreased from the pre-protocol to the post-protocol period, 36.3 ± 31.5 hours versus 28.9 ± 25.3, pConclusions: The use of a nutrition management protocol for the initiation of nutrition support to critically ill patients significantly improved the number of patients receiving nutrition support within 48 hours and should be considered as part of standard practice in the ICU setting.

Advances in treatment of critically ill patients have enabled life to be sustained well beyond the point when patients are able to participate in treatment decisions. Family members have been accepted as surrogate decision-makers for these patients, but the environment of the ICU, and the nature of decision-making regarding the use of life-sustaining treatment presents unique challenges. Bioethics offers normative prescriptions about how such decisions should be made, but little is known about how they actually are made, and how the experience impacts the decision-maker in the long term. The purpose of this study was to describe and explain the experiences of family members who were involved in treatment decisions on behalf of their loved ones, in order to promote understanding of such experiences and to suggest areas for effective, supportive intervention. In-depth interviews were conducted with 17 individuals who had been involved in decisions on behalf of their loved ones, most within the past year. Grounded theory was used as the method of analysis, and three major themes, conceptualized as arriving at a judgment, moving in concert vs. dis-harmony and looking back and going on emerged. Arriving at a judgment was essentially an intrapersonal process based on the evaluation of cues related to the patient's condition, treatment desires, and other salient considerations. It was profoundly affected by the contextually based interpersonal process of moving in concert vs. dis-harmony. Looking back and going on after the decision-making experience included questioning, regretting, assigning meaning, fantasizing, grieving, accepting, and planning. Overall respondents felt that the experience was an emotionally difficult one, but no respondent expressed the wish that they hadn't been involved in the decision. Tentative theoretical generalizations and propositions developed in this study can be used as guidelines for clinicians seeking to intervene in a supportive manner with family decision-makers. The concepts and categories can be further developed, substantiated, or reconstructed through further research. The study also provides descriptive data to bioethicists who are interested in decision-making for incompetent patients.

คุณภาพการนอนหลับ เป็นปัจจัยสำคัญต่อการฟื้นฟูของผู้ป่วยวิกฤต ดังนั้นพยาบาลต้องให้ความสำคัญในการประเมินคุณภาพการนอนหลับของผู้ป่วยวิกฤต และให้การพยาบาลเพื่อเพิ่มคุณภาพการนอนของผู้ป่วยวิกฤตในไอซียู วิธีการประเมินคุณภาพการนอนหลับได้แม่นยำ เที่ยงตรงมากที่สุด คือ เครื่องมือวัดการนอนหลับ polysomnography (PSG) ซึ่งเป็นเครื่องมือมาตรฐานในการวัดการนอนหลับ แต่เครื่องมือนี้มีวิธีการและการแปรผลซัลซ้อน ยุ่งยากและราคาแพง จึงไม่เหมาะกับการใช้ในงานประจำในหอผู้ป่วยหรือไอซียู การประเมินการนอนหลับ โดยพยาบาลสังเกต หรือให้ผู้ป่วยประเมินตนเอง สามารถใช้ในงานประจำได้สะดวกง่ายและไม่มีค่าใช้จ่ายด้านอุปกรณ์ งานวิจัยเชิงบรรยายครั้งนี้ ต้องศึกษาการใช้แบบประเมินคุณภาพการนอนและแบบสังเกตการนอนของผู้ป่วยหลังผ่าตัดหัวใจในไอซียูกลุ่มตัวอย่างแบบเฉพาะเจาะจง ตามคุณสมบัติที่กำหนด จำนวน 36 คน เก็บข้อมูลโดย 1) พยาบาลสัมภาษณ์ตามแบบประเมินคุณภาพการนอนที่บ้าน วันผ่าตัด และวันที่ 1 หลังผ่าตัด 2) พยาบาลสังเกตการนอนวันที่ 1 หลังผ่าตัด ผลการศึกษาคุณภาพการนอนของผู้ป่วยที่บ้านอยู่ในเกณฑ์ดีมาก คุณภาพการนอนมีแนวโน้มลดลงหลังผ่าตัด การสังเกตคุณภาพการนอนโดยพยาบาลทุกชั่วโมงได้ผลใกล้เคียงกับแบบประเมินคุณภาพการนอนที่ผู้ป่วยประเมินตนเอง