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There are many challenges in caring for the postsurgical patient in the intensive care unit. When the postsurgical patient has an active malignancy, this can make the intensive care unit care more challenging. Nutrition, infection, and the need for postoperative mechanical ventilatory support for the patient with cancer present challenges that may increase the patient’s length of stay in the intensive care unit. Critical care nurses must be aware of these challenges as they provide care to this patient population.

Extracorporeal membrane oxygenation is emerging as a vital resource for survival of patients with acute respiratory distress syndrome related to COVID-19. Although recent research provides much insight into the advantages of extracorporeal membrane oxygenation in this patient population, little has been published on its use in pregnancy. This case study describes the use of venovenous extracorporeal membrane oxygenation in a young pregnant woman with acute respiratory distress syndrome due to COVID-19. It illustrates the benefits of a multidisciplinary approach to this treatment modality, allowing time for a fetus to become viable while preserving the life of the mother. In this case, the mother was able to return home after receiving this therapy and resume normal activities of daily living independently.

Background With telemedicine technology, off-site expert clinicians can consult in real time with bedside nurses and providers. The success of telemedicine may depend on its acceptance by bedside nurses and providers. Objectives To compare nurses’ perceptions of telemedicine in 2 intensive care units (ICUs) at Emory University Hospital, an academic medical center, and to determine the relation between nurses’ years of ICU experience and their perceptions of telemedicine in the hospital’s ICUs (Emory e-ICU Center). Methods This study used a descriptive correlational design. Nurses in the 2 units completed a demographic form and a questionnaire about their perceptions of the Emory e-ICU Center. Results A total of 60 participants completed the study (30 nurses from each unit). Among the entire sample, the perception scores ranged from 2.4 to 5.0, with a mean score of 3.8 (SD, 0.6). Perception scores were significantly higher for nurses in the acute respiratory ICU than for those in the cardiovascular ICU; nurses in the acute respiratory ICU had spent less time working in an ICU. No statistically significant correlation was found between nurses’ years of experience in an ICU and their perception scores. This correlation was also not significant within each unit. Nurses’ experience with telemedicine in the ICU also did not correlate significantly with perception scores. Conclusions Despite differences in nurses’ years of experience, the perceptions of the Emory e-ICU Center did not differ significantly among nurses.

In March 2020, in response to the coronavirus disease 2019 (COVID-19) pandemic, the executive leadership of an academic medical center in Atlanta tasked an interprofessional quality improvement (QI) team with identifying ways to improve staff and patient safety while caring for patients with suspected or confirmed COVID-19 infection. Additional goals of the initiative were to improve workflow efficiency by reducing the amount of time spent donning and doffing personal protective equipment (PPE) and to conserve PPE, which could be in short supply in a prolonged pandemic. The QI team developed a "warm zone model" that allowed staff members to wear the same mask, eye protection, and gown while moving between the rooms of patients who had tested positive for COVID-19. The risk of self-contamination while doffing PPE is well documented. Staff members were trained to conserve PPE and to properly change gloves and perform hand hygiene between exiting and entering patients' rooms. The warm zone model allowed multidisciplinary team members to reduce the times they donned and doffed PPE per shift while maintaining or increasing the times they entered and exited patients' rooms. Staff members believed that the model improved workflow and teamwork while maintaining staff members' personal safety. Daily gown use decreased on the acute care unit where the model was employed, helping to preserve PPE supplies. Once the model was proven successful in acute care, it was modified and instituted on several critical care COVID-19 cohort units.

Objectives To provide an overview of tumor lysis syndrome, which is one of the metabolic oncologic emergencies. Data Sources A review and synthesis of empirical articles. Conclusion One of the metabolic oncologic emergencies identified by the Oncology Nursing Society is tumor lysis syndrome. This condition is life-threatening and is characterized by metabolic derangements that can lead to acute kidney injury and multiple organ dysfunction. Normal intracellular components (potassium, phosphorus, and nucleic acids) spill into the bloodstream when cancer cells die. If the tumor is large and highly responsive to chemotherapy, the resulting cascade of dead tumor cells may overwhelm normal homeostatic mechanisms. The cells enter the bloodstream faster than they can be cleared by the kidneys. This results in hyperkalemia and hyperphosphatemia. Nucleic acids convert to uric acid in the liver with a resultant hyperuricemia. Excess uric acid in the kidneys can lead to uric acid nephropathy and renal insufficiency. Phosphorus binds with calcium, leading to hypocalcemia from the formation of calcium phosphate precipitate or crystals. These crystals can also lead to renal insufficiency or acute kidney injury, which can lead to a metabolic acidosis and exacerbation of the hyperkalemic state. These metabolic derangements define presence of tumor lysis syndrome. Implications for Nursing Practice Multidisciplinary collaboration and communication is essential to identifying patients at risk prior to treatment. Meticulous nursing care in terms of prevention and treatment is critical to patient survival.

Background Sudden cardiac arrest is a major cause of death worldwide. Performance of prompt, high-quality cardiopulmonary resuscitation improves patient outcomes. Objectives To evaluate the association between patient survival of in-hospital cardiac arrest and 2 independent variables: adherence to resuscitation guidelines and patient severity of illness, as indicated by the number of organ supportive therapies in use before cardiac arrest. Methods An observational study was conducted using prospectively collected data from a convenience sample. Cardiopulmonary arrest forms and medical records were evaluated at an academic medical center. Adherence to resuscitation guidelines was measured with the ZOLL R Series monitor/defibrillator using RescueNet Code Review software. The primary outcome was patient survival. Results Of 200 cases, 37% of compressions were in the recommended range for rate (100-120/min) and 63.9% were in range for depth. The average rate was above target 55.7% of the time. The average depth was above and below target 1.4% and 34.7% of the time, respectively. Of the 200 patients, 125 (62.5%) attained return of spontaneous circulation. Of those, 94 (47%) were alive 24 hours after resuscitation. Fifty patients (25%) were discharged from the intensive care unit alive and 47 (23.5%) were discharged from the hospital alive. Conclusions These exploratory data reveal overall survival rates similar to those found in previous studies. The number of pauses greater than 10 seconds during resuscitation was the one consistent factor that impacted survival. Despite availability of an audiovisual feedback system, rescuers continue to perform compressions that are not at optimal rate and depth.

Objectives Code status specifies the action that healthcare providers should take in the event of cardiac arrest. Studies have shown, however, that patients with do-not-resuscitate/do-not-intubate (DNR/DNI) orders have worse outcomes and do not consistently receive the standard of care. Several studies have demonstrated that physicians behave differently toward patients with DNR/DNI orders, but little research exists into whether DNR/DNI status affects the practice of other members of the care team. Our objective was to determine whether code status affects decision making by nursing staff. Methods This was an anonymous, self-administered survey of nurses between April 2018 and March 2019 using SurveyMonkey. The survey contained four previously published clinical vignettes followed by a series of questions regarding specific interventions tailored to reflect nursing escalation of care. Our focus was two local hospitals: one large academic quaternary-referral center and one large community hospital. Registered nurses on medical-surgical units identified based on available unit-specific e-mail listservs from both hospitals were the participants. Nurses in higher-acuity units were excluded. Results Nurses are significantly less likely to call rapid response or a physician when a patient undergoes certain changes in clinical status if the patient is labeled as DNR/DNI rather than full code. For all of the vignettes, respondents were less likely to say they would call rapid response or a physician for patients with a DNR/DNI status who developed tachycardia (P 0.05). Nurses with >3 years of experience were less likely to escalate care throughout the vignettes (odds ratio Conclusions This study is the first to demonstrate that code status affects decision making by nursing staff. It highlights the limitations that code status designations create with regard to patient care. By acknowledging that patients with DNR/DNI orders receive different care, we can create systems in which patients are treated equally, regardless of their code status.

Objectives To determine mortality rates among adults with critical illness from coronavirus disease 2019. Design Observational cohort study of patients admitted from March 6, 2020, to April 17, 2020. Setting Six coronavirus disease 2019 designated ICUs at three hospitals within an academic health center network in Atlanta, Georgia, United States. Patients Adults greater than or equal to 18 years old with confirmed severe acute respiratory syndrome-CoV-2 disease who were admitted to an ICU during the study period. Interventions None. Measurements and main results Among 217 critically ill patients, mortality for those who required mechanical ventilation was 35.7% (59/165), with 4.8% of patients (8/165) still on the ventilator at the time of this report. Overall mortality to date in this critically ill cohort is 30.9% (67/217) and 60.4% (131/217) patients have survived to hospital discharge. Mortality was significantly associated with older age, lower body mass index, chronic renal disease, higher Sequential Organ Failure Assessment score, lower PaO2/FIO2 ratio, higher D-dimer, higher C-reactive protein, and receipt of mechanical ventilation, vasopressors, renal replacement therapy, or vasodilator therapy. Conclusions Despite multiple reports of mortality rates exceeding 50% among critically ill adults with coronavirus disease 2019, particularly among those requiring mechanical ventilation, our early experience indicates that many patients survive their critical illness.

SummaryWe report preliminary data from a cohort of adults admitted to COVID-designated intensive care units from March 6 through April 17, 2020 across an academic healthcare system. Among 217 critically ill patients, mortality for those who required mechanical ventilation was 29.7% (49/165), with 8.5% (14/165) of patients still on the ventilator at the time of this report. Overall mortality to date in this critically ill cohort is 25.8% (56/217), and 40.1% (87/217) patients have survived to hospital discharge. Despite multiple reports of mortality rates exceeding 50% among critically ill adults with COVID-19, particularly among those requiring mechanical ventilation, our early experience indicates that many patients survive their critical illness.

CARDIAC TAMPONADE, a structural oncologic emergency identified by the Oncology Nursing Society, can occur at any time during the cancer trajectory.1 Cardiac tamponade is the compression of the heart due to the abnormal accumulation of fluid in the pericardial space (pericardial effusion), which exce

Background: Hospital-acquired methicillin-resistant Staphylococcus aureus bloodstream infections (MRSA BSIs) are associated with serious morbidity and mortality in immunocompromised patients. Of all MRSA BSIs at our academic medical center, 63% occurred in the oncology units. A multidisciplinary team was formed to address the improvement opportunity: the clinical nurse specialist, hospital epidemiologist, unit leaders, nurse champions and representatives from infection prevention, pharmacy and information technology. The goal was to decrease the incidence of hospital-onset MRSA BSI in the oncology wards by 10 infections in 2016 by implementing daily chlorohexidine (CHG) bathing and weekly nasal povidone-iodine antisepsis in July 2016. Methods: The strategically targeting oncology with povidone-iodine nasal antisepsis and bathing with CHG Staph reduction initiative (STOP-BSI) was a quality improvement project consisting of daily CHG baths for all oncology patients and nasal povidone-iodine on admission and weekly thereafter. Nurses and patient care technicians were trained on how to administer CHG treatments. Education was also provided to patients on how to use CHG bath wipes to self-administer the nasal antisepsis. Education resources were created to help answer concerns of the staff, patient, or family, and an escalation process was developed for treatment refusal. CHG bath audits were performed to measure compliance and to identify barriers to the process. Results: By the end of 2016, the number of infections decreased by 5 on the oncology units. The number of infections continued to decrease each year. The bone marrow transplant (BMT) unit decreased from 8 infections in 2015 to 3 in 2018. The hematology oncology unit infections decreased from 5 infections in 2015 to 0 in 2018. The medical oncology unit infections decreased from 2 infections in 2015 to 0 in 2018. The CLABSI rates per 1,000 line days trended downward after some time. Conclusions: Implementing daily CHG baths and weekly povidone-iodine nasal antisepsis reduced the number of MRSA BSI infections in the oncology population. The CLABSI rates decreased after barriers to the process were removed.Funding: NoneDisclosures: None

The objective of this study was to determine if patient and family advisors' (PFAs) collaboration in an educational program could increase the empathy levels of intensive care unit (ICU) nurses.Data suggest that nurse empathy is on the decline. Ensuring that nurses consistently empathize with patients and families helps create positive patient experiences.Thirty nurses participated in a PFA-designed educational intervention using simulation-based role playing. The Toronto Empathy Questionnaire (TEQ) was used to measure empathy before and after the intervention.The TEQ empathy scores increased significantly after nurses completed the PFA-designed educational program. Younger nurses (30 years) improved on average 3.03 ± 3.6 points compared with older nurses (30 years), who improved, on average, only 0.43 ± 2.06 points (t24.4 = 2.46, P = .021). For the changes in TEQ scores from preintervention to postintervention, age was significantly associated with improvements in TEQ scores.Patient and family advisors can positively impact empathy among ICU nurses.

SPINAL CORD COMPRESSION (SCC) is a life-threatening complication of primary and metastatic cancer that can significantly impact a patient's quality of life. Prompt diagnosis and treatment are critically important. Identified by the Oncology Nursing Society as a structural oncologic emergency, SC

Sleep disturbances are common in the intensive care unit setting. This article describes the causal factors associated with alterations in sleep in the intensive care setting, effects of sleep disturbances for patients, and strategies to mitigate sleep disturbances. A review of normal sleep architecture is provided, as is a discussion of the methods of measuring sleep in the critical care setting.

Neutropenia is the most common dose-limiting toxicity of chemotherapy. It is considered an unpreventable side effect of many types of cancer treatment. It may be a side effect of therapy or a planned aspect of a conditioning regimen for bone marrow or hematopoietic stem cell transplantation (HSCT). The definition of neutropenia differs among institutions, ranging from an absolute neutrophil count (ANC) of less than 500 cells/mm to less than 1500 cells/mm. Neutropenia can lead to infection, increased length of stay (LOS), delay, reduction, or discontinuation of cancer treatment, and increased morbidity and mortality. More than 60,000 patients with cancer are hospitalized annually in the United States for chemotherapyinduced neutropenia (CIN). Older patients with cancer may be more vulnerable for infection and death than their younger counterparts. The typical duration of neutropenia is 7-10 days but will vary based on the patient’s age, chemotherapy agent(s) received, comorbidities, and bone marrow reserve. Although patients cannot prevent CIN from occurring, there are a number of actions nurses and patients can take in order to help mitigate developing an infection while neutropenic.

The Institute of Medicine (IOM) affirmed that the employment of temporary or per diem nurses augments risk to patient safety. The IOM recommends health care facilities avoid hiring nurses working from a temporary external agency. The IOM recognizes the need for health care facilities to have a plan in place for situations when confronted with short staffing, higher acuity, and increased patient census. Based on recommendations from the IOM, an internal agency was developed in a university-based health care system. Cost savings were realized because of the collaborative efforts of human resources to fill vacancies, unit management managing their respective budgets by flexing staff based on patient census, and the development and implementation of the Enterprise Staffing Pool.

Sleep is an important factor related to health and quality of life for all individuals. For people with cancer, sleep disturbances are common and are a source of distress. This article summarizes the problems and reviews the types, prevalence, etiology, risk factors, clinical sequelae, and management of sleep disturbances experienced by cancer patients. A comprehensive review of the literature is presented, along with direction for nursing practice and research.

Cancer is a complex group of diseases. Many of the current treatment modalities available provide limited effectiveness and significant side effects. This circumstance creates a challenge for health care providers. There is great need for the development of innovative therapies that increase efficacy and decrease morbidity. In general, chemotherapeutic agents are unable to distinguish cancer cells from normal cells. As a result of therapy, patients may develop significant myelosuppression. Patients who are undergoing chemotherapy need to be observed for signs of hematologic and nonhematologic toxicities. Patients should be advised that periodic blood tests are indicated to monitor for anemia, neutropenia, and thrombocytopenia. If myelosuppression develops, measures to prevent complications such as bleeding and infection are indicated. Strategies to combat fatigue should also be discussed. Understanding of the biology of cancer has increased significantly in recent years. As knowledge of the science grows, new therapies are developed and clinical trials are initiated to investigate feasibility and efficacy of agents. Many of these trials involve agents that target specific biologic processes of cancer. While the complexities of cancer treatment are prolonging the life expectancy of patients who have the disease, patients are presenting with increasing numbers and types of morbidities. Nurses need to be aware of the rationale for treatment, mechanism of action of the agents administered, and expected toxicities of therapies. With this knowledge, symptoms can be identified earlier, life-threatening sequela can possibly be averted, and patients and families can be educated about what to expect and how to make knowledgeable decisions about treatment options. Enhancing patients' knowledge base may also increase their adherence to challenging therapies.

Modern technology and advances in antineoplastic therapy have led to longer survival of patients with cancer. Therapies for neoplastic disease also may result in several distressing and potentially life-threatening toxicities. Management of symptoms related to cancer and its treatments can be complex, pose challenges for the critical care team, and require ongoing comprehensive assessment and anticipation of problems. Interventions may include pharmaceutic interventions, nonpharmacologic interventions, and psychosocial support. Physical and psychologic care is vital if patients are to survive a life-threatening critical event and continue to battle their neoplastic disease. One of the challenges unique to caring for patients in an oncology ICU is staff dichotomy. Depending on the policies governing the ICU, a patient's care may be directed by the oncologist, the surgeon, the intensivist, or in some cases, all of these specialists. Under usual circumstances, regardless of who is directing the care, there is collaboration among the services and the multidisciplinary team. Conflict can arise when there are differences of opinion as to treatment priorities, perception of potential treatment effectiveness, or prognosis of the patient or when care decisions are made unilaterally. 2 The oncologist and intensivist bring different perspectives to a clinical situation. 29 These differences can make care objectives unclear and result in confusion for the ICU staff and family members. The nursing staff must struggle sometimes to integrate two differing opinions. One of the primary responsibilities of caring for families in the ICU is providing current information about the patient's clinical status. 23 Providing accurate information may be challenging given the multiplicity of physicians involved in the care of the patient. In a recent study, 17% of families of patients who died in the ICU felt they had received insufficient or unclear information. 21 Under ideal circumstances, the objectives and limits of care are addressed by the services, the family, and, if feasible, the patient at the time of ICU admission. 9 A systematic approach to clinical decision-making regarding care must be used. The use of treatments may be difficult to predict on ICU admission. Goals of treatment must be agreed on and shared. Which therapies are to be used, and to what end, can then become part of the plan of care. Ongoing evaluation of the patient's status and collaboration between the oncologist and intensivist should be inherent within the plan. The ICU has been described as an emotionally charged, intense work setting. 18 Several nurses in one study felt that family members "look to the nurse for the `real' answer" 18 for information regarding prognosis and evaluation of quality of life. Families often express concerns about the plan of care. If conflicting messages are sent by the various services, confusion and dissatisfaction can result. Avoiding staff dichotomy through ongoing collaboration and family and staff updates can help promote optimal patient outcomes. Critical care medicine has two distinct purposes. The first is the use of technology to restore critically ill patients with potentially reversible illness to the best possible quality of life. The second is to provide patients who are hopelessly ill and their families with humane care and accurate information during the dying process. 32 Few patients or families are willing to continue the discomfort of life-support systems after a reasonable trial has demonstrated that their benefit has come to the point of diminished returns. 5 New technologies, new drugs, and the use of combinations of therapies for the management of neoplastic diseases have improved life expectancy. This aggressive management, however, is not without consequence. In addition to multiple-organ dysfunction and the consequences of myelosuppression, patients with neoplastic disorders are admitted to the ICU for a variety of life-threatening diagnosis- and treatment-related comorbidities. Data from a recent investigation revealed that acute respiratory failure, hypotension, septic shock, dehydration, pneumonia, fevers, bleeding, congestive heart failure, fluid overload, and pericardial effusion accounted for most admissions in one oncology ICU. 15 In addition to these comorbidities, patients with cancer experience numerous physiologic and psychologic symptoms. Nausea, vomiting, fatigue, mucositis, anorexia and cachexia, and constipation are some of the more common symptoms that result from cancer and cancer treatment. Therapies associated with the development of these symptoms include single and combination chemotherapeutic agents, radiation therapy, monoclonal antibodies, biologic-response modifiers, and bone marrow transplantation (BMT). 9 The development of the symptoms is related partially to the inability of antineoplastic agents to distinguish rapidly dividing normal cells from cancer cells and partially to organ toxicities. 4 These symptoms can complicate the clinical situation, increase morbidity in the ICU, and add additional measures in the management of the critical care patient. The symptoms may be intermittent or continuous and can cause varying levels of distress. 2 An understanding of these symptoms, their causes, and their associated implications for care are essential to meet the multidimensional needs of the patient. Critical care management of the oncology patient requires an understanding of how these symptoms affect a patient's quality of life and recovery from life-threatening complications. Adequate assessment and prompt recognition and management of the symptoms are essential 25 but may pose a challenge for those caring for the patient, because the symptoms are not always observable. Symptom distress is defined as the "degree or amount of physical or mental upset, anguish, or suffering experienced from a specific symptom, e.g., nausea, fatigue, insomnia." 26 Failure to recognize and treat symptom distress can result in enhanced distress and additional problems for the patient. Aggressive use of high-dose chemotherapy and radiation therapy is common in the treatment of solid and hematologic malignancies. Myelosuppression is a common and anticipated treatment-related toxicity. The resultant thrombocytopenia and neutropenia create unique problems for these patients. Associated high levels of morbidity and mortality may be reduced with meticulous nursing care.

BACKGROUND: Little is known about the level of comfort experienced by cancer patients with do-not-resuscitate orders and how use of nursing resources affects their comfort. OBJECTIVE: To explore the relationship between use of nursing resources and comfort in cancer patients with and without do-not-resuscitate orders in the intensive care unit. METHODS: The sample consisted of 30 adult patients who had do-not-resuscitate orders and 30 randomly selected patients who did not. Pairs consisting of 1 patient from each group were admitted to the study simultaneously and were evaluated during the same observation period. Level of comfort was assessed by using the PACU Behavioral Pain Rating Scale. Data on use of nursing resources, determined with the Therapeutic Intervention Scoring System, and on demographics and severity of illness were abstracted from the medical records. RESULTS: Chi-square analyses revealed no significant relationship between comfort and use of nursing resources. Differences between the 2 types of patients in comfort and in use of resources were not significant. Evaluation of the multivariate relationship between comfort and use of resources, with do-not-resuscitate status added as a further predictor variable, revealed no significant relationships. Severity of illness and a patient's number of visitors were predictors of use of nursing resources. CONCLUSIONS: Despite high use of nursing resources, nurses continue to focus on comfort as an outcome of care irrespective of patients' do-not-resuscitate status.

This article describes the pathophysiologic changes that occur with aging as they relate to cancer and cytotoxic therapies, implications related to drug therapy, and complications of treatment modalities as they relate to older persons with cancer who may potentially be admitted to the intensive care unit. Knowledge of these issues is essential for health care providers, so that they can face the complex challenges and optimize the outcomes of critically ill older persons with cancer.

Maintaining quality while being financial stewards is essential in today's health care climate. One strategy considered effective for keeping patients safe is the use of sitters. However, research supporting the effectiveness of this intervention for reducing certain patient safety outcomes is limited. A sitter-reduction program in one hospital resulted in $1.2 million in annual savings without negatively impacting fall rates. The intentional presence of the nursing staff was pivotal to the successful reduction in sitter use.

Certification is defined in the nursing literature in several ways; no one consistent definition of certification exists. Nursing specialty certification programs are intended for consumer protection. Certification protects the public by enabling consumers to identify competent people more readily. However, benefits for stakeholders other than patients and families are also described in the literature. This article describes the value of specialty certification from the perspective of the patient and family, nurse, and employer.

One of the 14 Forces of Magnetism requires a health care organization to have a professional model of care. The eligibility requirements stipulate that this model must be utilized throughout the health care system and that the same philosophy must be used throughout the system. The American Association of Critical-Care Nurses Synergy Model for Patient Care describes nursing practice based on eight patient characteristics, and also describes eight nurse competencies. The core concept of the model is that the needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses. Synergy results when the needs and characteristics of a patient, clinical unit, or system are matched with a nurse's competencies. The synergy model is an excellent framework to organize the work of patient care throughout the health care system. It can be used and applied in various ways and provides a comprehensive framework for assuring success in building a philosophy that supports the Forces of Magnetism.

Objectives: To provide a review of the patho-hysiology and corresponding signs and symptoms of tumor lysis syndrome (TLS); to review clinical and laboratory monitoring parameters. Data sources: Primary and tertiary literature and clinical experience. Conclusions: An understanding of the pathophysiology of TLS, meticulous assessment for signs tend symptoms and monitoring of laboratory data, as well as curly recognition of problems are essential for optimul patient outcomes. Implications for Nursing Practice: Knowledge of the pathophysiology of TLS will assist the oncology nurse in better understanding the overall syndrome and allow improved patient cure mana gement through close clinical and laboratory monitoring of signs and symptoms, and, ideally, promote a proactive approach to managing TLS.