DNP FINAL REPORT: SEDATION PROTOCOL COMPLIANCE FOR IMPROVED OUTCOMES IN INTENSIVE CARE

Background: Current evidence-based practice guidelines show that lighter sedation reduces mechanical ventilator days (MVD) and intensive care (ICU) length of stay (LOS). Guidelines (2018) for the management of pain, agitation, delirium, immobility, and sleep were released to direct appropriate high-quality care to achieve positive outcomes. However, studies demonstrated there were barriers to compliance of these guidelines. Objective: To improve compliance with an existing evidence-based sedation protocol in an intensive care, and, thereby, improve patient outcomes (MVD and ICU LOS). Methods: The three-month quality improvement (QI) project evaluated processes leading to compliance with the guideline. First, nurses were surveyed to determine knowledge and comfort with the guideline. Based on the guideline and data from nurses, education was provided on sedation medications, mechanical ventilation, the EBP sedation protocol, and focused on spontaneous awakening and breathing trials. Protocol comfort and compliance was evaluated. Results: Primary compliance issues were lack of experience and education. Despite education, MVD increased by 23% and ICU LOS by 7%. Implications for Practice: Staff education concerning sedation guidelines is key to achieving compliance and optimal MVD and ICU LOS

An Exploratory Study Of Physiologic Responses To A Passive Exercise Intervention In Mechanically-ventilated Critically Ill Adults

Muscle weakness is the most common and persistent problem after a critical illness. Early mobilization of the critically ill patient, beginning with passive exercise and progressing to ambulation, may mitigate muscle effects of the critical illness. However, mobilization may produce adverse effects, especially early in the illness when risk for physiologic deterioration is common. If safe, introducing a mobility intervention early in the illness may facilitate ventilator weaning, shorten intensive care unit and hospitals stays, and improve functional status and quality of life for mechanically ventilated critically ill patients. The aim of this study was assess the cardiopulmonary and inflammatory responses to an early standardized passive exercise protocol (PEP) in mechanically ventilated critically ill patients. Using a quasi-experimental within-subjects repeated measures design, mechanically ventilated critically ill adults who were physiologically stable received a single standardized PEP within 72 hours of intubation. The PEP consisted of 20 minutes of bilateral passive leg movement delivered by continuous passive motion machines at a rate of 20 repetitions per minute, from 5-75 degrees, to simulate very slow walking. Physiologic parameters evaluated included heart rate (HR), mean blood pressure (MBP), oxygen saturation, and cytokine levels (IL-6 and IL-10), obtained before, during, and after the intervention. The Behavioral Pain Scale (BPS), administered before, during and after the intervention was used as a measure of participant comfort. The study sample was comprised of 18 (60%) males and 12 (40%) females, with a mean age of 56.5 years (SD 16.9 years), who were primarily Caucasian (N=18, 64%). Mean APACHE II scores for the sample were 23.8 (SD 6.2) with a mean predicted death rate of 48.8 (SD 19.8), indicating moderate mortality risk related to illness severity. Number of comorbidities ranged iv from 1-10 (X=4). All participants completed the intervention with no adverse events. Using repeated measures analysis of variance (rmANOVA), no significant differences were found in HR, MBP, or oxygen saturation at any of the four time points in comparison to baseline. BPS scores were significantly reduced (F(2.43, 70.42)=4.08, p=.02) at 5 and 10 minutes after the PEP was started, and were sustained at 20 minutes and for one hour after the PEP was completed. IL-6 was significantly reduced (F(1.60, 43.1)=4.351, p=.03) at the end of the intervention but not at the end of the final rest period. IL-10 values were not significantly different at any of the three time points, but IL-6 to IL-10 ratios did decrease significantly (F(1.61, 43.38)=3.42, p=.05) at the end of the PEP and again after a 60 minute rest period. Passive leg exercise was well tolerated by study participants. HR, MBP, and oxygen saturation were maintained within order set-specified ranges during and for one hour after activity, and patient comfort improved during and after the intervention. A downward trend in HR was noted in participants, which is contrary to usual HR response during exercise, and may represent clinical improvement in this population related to reduction in pain. Reduction of mean IL-6 values at the end of the PEP, but not after the rest period, suggests that the PEP was responsible for the initial IL-6 improvement. Improvement of IL-6 to IL-10 ratios from the end of the PEP to the end of the final rest period suggests that IL-10, although non-significant, may have had some effect, indicating that IL-10 increases may occur later than the time period of study. Passive exercise can be used as an approach to facilitating mobilization in mechanically ventilated critically ill adults until they are ready to participate in more active exercise. It could be that more frequent and aggressive exercise, such as passive cycling at faster rates, four times daily, will be tolerated in this population. While the understanding of clinical significance of cytokine profiles in critically ill patients is still evolving, cytokine levels may be useful in v explaining benefits of mobilization in this population. Further study is required to replicate the impact of passive exercise on pain, and it may represent a novel approach to pain management in critically ill patients

The Computer for Charting and Monitoring

book chapterBiomedical Informatic

Monitoring and regulation of supported breathing in Intensive Care

This thesis describes several chapters related to monitoring and regulation of breathing. The main goal is to provide better insight in the interaction between spontaneous breathing and mechanical ventilatory support. In chapter 2 we investigated the effect of metabolic alkalosis on the ventilatory response. To analyze whether speckle tracking ultrasound can be used to noninvasively quantify diaphragm contractility, in chapter 3 this technique is used in healthy subjects undergoing a randomized stepwise threshold loading protocol. Chapters 4, 5 and 6 of this thesis focus on the interaction between the two parallel systems involved in providing adequate ventilation: the patient and more specific its upper airway, and the ventilator. We studied this interaction in patients with an acute exacerbation of COPD during noninvasive ventilation

Ventilatory ratio : a simple bedside index to monitor ventilatory efficiency

A lack of a simple index that monitors ventilatory efficiency at the bedside has meant that oxygenation has been the predominant variable that is used to monitor adequacy of ventilatory strategies and disease severity in mechanically ventilated patients. Due to complexities in its measurement, deadspace ventilation, the traditional method to track ventilatory failure, has failed to become integral in the management of mechanically ventilated patients. Ventilatory ratio (VR) is an easy to calculate index that uses variables measured at the bedside: [Mathematical equation appears here. To view, please open pdf attachment] where [Symbols appears here. To view, please open pdf attachment] is taken to be 100 ml.kg-1.min-1 based on predicted body weight and [Symbols appears here. To view, please open pdf attachment] is taken to be 5 kPa. Physiological analysis of VR dictates that it is influenced by deadspace fraction and CO2 production. Physiological analysis of VR was validated in a benchside lung model and a high fidelity computational cardiopulmonary physiology model. The impact of CO2 production on VR was investigated in patients undergoing laparoscopic surgery who received exogenous intraperitoneal CO2. This showed that delta values of the 2 variables were linear. The variability of CO2 production was examined in ICU patients and results of the study showed that variability of CO2 production was small. In an ICU population correlation of VR was stronger with deadspace in comparison to CO2 production. Of these two variables, deadspace had the greater effect on VR. The clinical uses of VR were examined in 4 databases of ICU patients. VR was significantly higher in non-survivors compared to survivors. Higher values of VR were associated with increased mortality and more ventilator days. A rising values of VR over time was also associated with worse outcome. VR is a simple bedside index that provides clinicians with useful information regarding ventilatory efficiency and is associated with outcome

Identifying ICU patient safety priorities within a Northern Ontario setting : a delphi study

The purpose of this study was to explore patient safety priorities as perceived by clinical experts working in a northern Ontario adult ICU. A modified Delphi was used to elicit consensus regarding patient safety priorities from the perspective of an expert panel of registered nurses and intensivists. At the onset of the study, the consensus level was set at 70%. Data was collected through serials rounds with researcher-developed questionnaires. Descriptive statistical analysis was completed. No consensus was reached at Round 1. Three points of consensus regarding patient safety priorities were reached at Round 2: improving pain and agitation management; incorporating a checklist into the bullet round reporting tool; and implementing use of visual cues for high-risk lines. These strategies support the need for anticipation, recognition, and management of at risk situations. The results have the potential to guide the advancement of the patient safety mandate within an ICU setting.Master of Science (MSc) in Nursin

Towards respiratory muscle-protective mechanical ventilation in the critically ill: technology to monitor and assist physiology

Inadequate delivery of ventilatory assist and unphysiological respiratory drive may severely worsen respiratory muscle function in mechanically ventilated critically ill patients. Diaphragm weakness in these patients is exceedingly common (>60% of patients) and associated with poor clinical outcomes, including difficult ventilator liberation, increased risks of intensive care unit (ICU) and hospital readmission, and mortality. The underlying mechanisms of diaphragm dysfunction were extensively discussed in this thesis. Pathways primarily include the development of diaphragm disuse atrophy due to muscle inactivity or low respiratory drive (strong clinical evidence), and diaphragm injury as a result of excessive breathing effort due to insufficient ventilator assist or excessive respiratory drive (moderate evidence, mostly from experimental work). Excessive breathing effort may also worsen lung injury through pathways that include high lung stress and strain, pendelluft, increased lung perfusion, and patient-ventilator dyssynchrony. Relatively little attention has been paid to the effects of critical illness and mechanical ventilation on the expiratory muscles; however, dysfunction of these muscles has been linked to inadequate central airway clearance and extubation failure. The motivation for performing the work presented in this thesis was the hypothesis that maintaining physiological levels of respiratory muscle activity under mechanical ventilation could prevent or attenuate the development respiratory muscle weakness, and hence, improve patient outcomes. This strategy, integrated with lung-protective ventilation, was recently proposed by international experts from different professional societies (this thesis), and is referred to as a combined lung and diaphragm-protective ventilation approach. Today, an important barrier for implementing and evaluating such an approach is the lack of feasible, reliable and well-understood modalities to assess breathing effort at the bedside, as well as strategies for assisting and restoring respiratory muscle function during mechanical ventilation. Furthermore, monitoring breathing effort is crucial to identify potential relationships between patient management and detrimental respiratory (muscle) function that can be targeted to improve clinical outcomes. In this thesis we identified and improved monitoring modalities for the diaphragm (Part I), we investigated the impact of mechanical ventilation on the respiratory pump, especially the diaphragm (Part II), and we evaluated a novel strategy for maintaining expiratory muscle activity under mechanical ventilation (Part III)

The development of a nursing technology: making visible the nursing contribution to the development of critical care

In the context of one Intensive Care Unit (ICU) and one High Dependency Unit (HDU), this thesis explores and analyses the nursing contribution to the development of critical care. This comprises over more than half a century, focussing on nurses' relationship with, and perceptions of one 'technology', weaning from mechanical ventilation, as part of everyday nursing practice in the new millennium. My findings suggest that nurses take a task-focussed approach to weaning, treating it as a `medical' technology transferred to them from doctors, rather than seeing its potential to become a ‘nursing technology' in which the nurse is enabled to transform weaning into a way of implementing care in order to improve patient outcomes. Analysis demonstrates when nurses work in this way weaning is delayed and as a result patients will be exposed to greater morbidity and mortality. Theoretically, my argument builds in particular on Sandelowski's (1996, 1997,1998,2000,2000a, 2000b) work on the nursing – technology relation in which she describes how technology has shaped nursing practice and was shaped by nursing practice. I build on Sandelowski's ideas to develop two concepts that are central to my argument: technology transferred and technology transformed. I have used an ethnographic approach to study nurses using technology in the work place. The empirical data were obtained through fieldwork on one critical care unit in a large teaching hospital in the Midlands over a six-month period. The methods include participant observation, interviews with twelve nurses and the collection of over two–hundred and fifty hours of field notes. My study of the nursing role in critical care contributes new knowledge to two fields: first, the history of intensive care as a specialism within the wider development of the National Health Service (NHS). My work adds to this literature by making visible the nursing contribution to that development and, in the process, raising a question about the extent to which previous histories may have been misleading: these (see for example Lassen 1953, Hamilton 1963, Ibsen 1966, Hilberman 1975, Pontoppidan, Wilson, Rie & Schneider 1977, Cule 1989, Crocket and Mercer 1995, Gilbertson 1995, Le Fanu 1999, Kesecioglu 2000) have tended to assume that its development was a result of new medical technology. Second, is the literature on 'technology' as it relates, to nursing. I believe that my definition of a 'nursing technology' makes it possible for the first time to put structures in place which will transform nurses' contribution to patient care, improving patient outcomes. I conclude that rather than extending and expanding their roles through the transfer of technology, nurses transform those technologies that preserve the nursing role and can contribute to positive outcomes for patients. Only in this way will the nursing contribution to the development of critical care be recognised and valued

The development of a nursing technology: making visible the nursing contribution to the development of critical care

In the context of one Intensive Care Unit (ICU) and one High Dependency Unit (HDU), this thesis explores and analyses the nursing contribution to the development of critical care. This comprises over more than half a century, focussing on nurses' relationship with, and perceptions of one 'technology', weaning from mechanical ventilation, as part of everyday nursing practice in the new millennium. My findings suggest that nurses take a task-focussed approach to weaning, treating it as a `medical' technology transferred to them from doctors, rather than seeing its potential to become a ‘nursing technology' in which the nurse is enabled to transform weaning into a way of implementing care in order to improve patient outcomes. Analysis demonstrates when nurses work in this way weaning is delayed and as a result patients will be exposed to greater morbidity and mortality. Theoretically, my argument builds in particular on Sandelowski's (1996, 1997,1998,2000,2000a, 2000b) work on the nursing – technology relation in which she describes how technology has shaped nursing practice and was shaped by nursing practice. I build on Sandelowski's ideas to develop two concepts that are central to my argument: technology transferred and technology transformed. I have used an ethnographic approach to study nurses using technology in the work place. The empirical data were obtained through fieldwork on one critical care unit in a large teaching hospital in the Midlands over a six-month period. The methods include participant observation, interviews with twelve nurses and the collection of over two–hundred and fifty hours of field notes. My study of the nursing role in critical care contributes new knowledge to two fields: first, the history of intensive care as a specialism within the wider development of the National Health Service (NHS). My work adds to this literature by making visible the nursing contribution to that development and, in the process, raising a question about the extent to which previous histories may have been misleading: these (see for example Lassen 1953, Hamilton 1963, Ibsen 1966, Hilberman 1975, Pontoppidan, Wilson, Rie & Schneider 1977, Cule 1989, Crocket and Mercer 1995, Gilbertson 1995, Le Fanu 1999, Kesecioglu 2000) have tended to assume that its development was a result of new medical technology. Second, is the literature on 'technology' as it relates, to nursing. I believe that my definition of a 'nursing technology' makes it possible for the first time to put structures in place which will transform nurses' contribution to patient care, improving patient outcomes. I conclude that rather than extending and expanding their roles through the transfer of technology, nurses transform those technologies that preserve the nursing role and can contribute to positive outcomes for patients. Only in this way will the nursing contribution to the development of critical care be recognised and valued

The development of a nursing technology: making visible the nursing contribution to the development of critical care

In the context of one Intensive Care Unit (ICU) and one High Dependency Unit (HDU), this thesis explores and analyses the nursing contribution to the development of critical care. This comprises over more than half a century, focussing on nurses' relationship with, and perceptions of one 'technology', weaning from mechanical ventilation, as part of everyday nursing practice in the new millennium. My findings suggest that nurses take a task-focussed approach to weaning, treating it as a `medical' technology transferred to them from doctors, rather than seeing its potential to become a ‘nursing technology' in which the nurse is enabled to transform weaning into a way of implementing care in order to improve patient outcomes. Analysis demonstrates when nurses work in this way weaning is delayed and as a result patients will be exposed to greater morbidity and mortality. Theoretically, my argument builds in particular on Sandelowski's (1996, 1997,1998,2000,2000a, 2000b) work on the nursing – technology relation in which she describes how technology has shaped nursing practice and was shaped by nursing practice. I build on Sandelowski's ideas to develop two concepts that are central to my argument: technology transferred and technology transformed. I have used an ethnographic approach to study nurses using technology in the work place. The empirical data were obtained through fieldwork on one critical care unit in a large teaching hospital in the Midlands over a six-month period. The methods include participant observation, interviews with twelve nurses and the collection of over two–hundred and fifty hours of field notes. My study of the nursing role in critical care contributes new knowledge to two fields: first, the history of intensive care as a specialism within the wider development of the National Health Service (NHS). My work adds to this literature by making visible the nursing contribution to that development and, in the process, raising a question about the extent to which previous histories may have been misleading: these (see for example Lassen 1953, Hamilton 1963, Ibsen 1966, Hilberman 1975, Pontoppidan, Wilson, Rie & Schneider 1977, Cule 1989, Crocket and Mercer 1995, Gilbertson 1995, Le Fanu 1999, Kesecioglu 2000) have tended to assume that its development was a result of new medical technology. Second, is the literature on 'technology' as it relates, to nursing. I believe that my definition of a 'nursing technology' makes it possible for the first time to put structures in place which will transform nurses' contribution to patient care, improving patient outcomes. I conclude that rather than extending and expanding their roles through the transfer of technology, nurses transform those technologies that preserve the nursing role and can contribute to positive outcomes for patients. Only in this way will the nursing contribution to the development of critical care be recognised and valued