Dissertations / Theses on the topic 'Intensive care units'

Nursing Care for Terminal Patients in Intensive Care Units by Pervell Dunbar Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University August 2015 Although the goal of the ICU has always been to save lives, ICU now additionally provides end-of life (EOL) care. The objective of this project was to provide ICU nurses with a comprehensive awareness of physical, emotional, and spiritual EOL care issues of patients and their families in order to be better equipped to handle EOL care. The framework used was Jean Watson's Caring model (10 Caritas). A literature review revealed a poster previously used by a major health organization as a conversation starter to facilitate decision-making among ICU nurses, EOL patients, and their families related to EOL issues. The purpose of this quality improvement initiative was to introduce and implement an educational EOL tool that would engage patients and family members in meaningful and useful conversations with ICU nurses. Twenty seven ICU nurses were selected by the unit's director to attend a PowerPoint presentation on the use of the EOL educational poster. Four ICU nurses were chosen by the director to be champions for this project. After the presentation, there was a period for questions and answers, and the ICU nurses were requested to give feedback on the presentation. The result from the feedback revealed that EOL care is outside previous practice and may require extra education and support. These comments substantiated similar conclusions from other researchers as described in this paper. With an increase in EOL training for ICU nurses and the implementation of EOL teaching tools like the poster used in this study, ICU nurses may be better able to have conversations with EOL patients and families, thus improving patient care.

PONTIFÍCIA UNIVERSIDADE CATÓLICA DO RIO DE JANEIRO
COORDENAÇÃO DE APERFEIÇOAMENTO DO PESSOAL DE ENSINO SUPERIOR
CONSELHO NACIONAL DE DESENVOLVIMENTO CIENTÍFICO E TECNOLÓGICO
PROGRAMA DE SUPORTE À PÓS-GRADUAÇÃO DE INSTS. DE ENSINO
A Unidade de Terapia Intensiva (UTI) é um departamento importante dentro do Hospital visto que lida majoritariamente com casos de alta complexidade e gera elevados custos administrativos, o que requer um controle adequado de seus processos. Inconformidades tais como erros em atividades de tratamento e falta de comunicação entre os funcionários são comumente responsáveis pelo baixo desempenho de UTIs e devem ser ajustados para reduzir possíveis danos ao tratamento do paciente. Para avaliar a eficiência de uma UTI, a literatura propõe que sejam estabelecidas métricas que considerem quatro perspectivas - médica ou clínica, econômica, social e institucional – que oferecem uma visão abrangente das atividades (administrativas ou de tratamento) dentro da unidade e seus impactos no pós-tratamento. Entretanto, a avaliação de desempenho em uma UTI não é uma tarefa simples, pois há diversas variáveis a serem consideradas e que podem ser potenciais causas de um mau desempenho. Além disso, não há uma métrica ou indicador padrão-ouro que consegue reter de forma adequadas as informações, sendo que diversas perspectivas devem ser consideradas. Os indicadores mais comuns são A Taxa de Mortalidade Padronizada (Standardized Mortality Ratio, SMR) e o Taxa de Uso de Rescursos Padronizada (Standardized Resource Use, SRU), que contabilizam desfechos de mortalidade (clínicos) e de uso de recursos (econômicos), junto de metodologias propostas para viabilizar a comparação entre diferentes UTIs, identificar de grupos de desempenho e analisar os riscos de mortalidade dos pacientes dentro da unidade, tais como os conceitos de Rankability e Perfis de Risco (Risk Profiles). Além disso, é necessário definir corretamente os desfechos a serem contabilizados em indicadores. Nesse contexto, recomenda-se a combinação de diferentes indicadores e metodologias de forma a complementar e elevar a confiabilidade da análise de desempenho e benchmarking. Com isso, este estudo tem como objetivo analisar um conjunto de UTIs em termos de desempenho quanto à mortalidade e uso de recursos, associando-os com as características das unidades e seus fatores institucionais, para identificar possíveis correlações. A análise foi feita em uma amostra composta por 12.100 pacientes que foram hospitalizados em 116 UTIs, considerando um desfecho em até 60 dias de interação. Este estudo teve como contribuição a combinação de diferentes técnicas e indicadores, e uma discussão a respeito da variabilidade do SMR em comparação à metodologia tradicional. Para este propósito, combinou-se as técnicas da Matriz de Eficiência, Rankability – índice de confiabilidade de um indicador de desfecho, e Perfis de Risco, de forma a obter e avaliar o desempenho de grupos de UTIs. Como resultados, verificou-se que UTIs cuja administração é de domínio Público e que destinam a maioria dos seus leitos ao Sistema Único de Saúde (SUS) brasileiro tiveram mortalidade significativamente alta em relação àquelas de dominínio privado (p-valor menor que 0.05). Além disso, realizou-se um agrupamento das UTIs utilizando quatro diferentes técnicas de clusterização de forma a garantir a máxima confiabilidade do indicador para comparação (Rankability), o que resultou na presença de clusters extremos contendo uma UTI cada, sendo elas a de maior e a de menor SMR, apesar de ambas apresentarem o mesmo conjunto de severidades. Para cada grupo, estimou-se o seu perfil de risco, e verificou-se que pacientes com menor gravidade apresentaram maior variabilidade nos riscos de morte, sendo estes maiores nos grupos com alto SMR e menores em grupos de menor mortalidade, sendo que a dispersão tendeu a ser menor quanto menor for o risco, o que poderia influenciar diretamente no cálculo do SMR. Com isso, por meio de equações matemáticas e simulação por meio de reamostragem, verificou-se que o SMR possui uma limitação em sua escala, que depende diretamente do espectro de gravidade dos pacientes em cada UTI ou grupo de desempenho analisado. O S
Intensive Care Unit (ICU) is an important department within a hospital since it deals mostly with complex cases and it generates the highest amount of costs, thus requiring adequate control on its care treatments. Nonconformities such as poor communication and treatment errors are commonly responsible for a bad performance in ICUs. However, evaluating the performance of an ICU is not an easy task and there are no gold-standard indicators. The most common metrics are the Standardized Mortality Ratio (SMR) and the Standardized Resource Use (SRU), which measure mortality and resource utilization, respectively. Hence, this study aims to analyze different ICUs in terms of mortality, resource use, and institutional factors, combining the methods Efficiency Chart, Rankability and Risk Profile. The analysis was performed considering a total of 12,100 patients in 116 ICUs provided by a clinical trial study. As results, it was verified that most ICUs were from hospitals with public administration (47.41 per cent), which had significantly high lethality rate compared to private hospitals. Four different clustering approaches were tested, which identified similar case-mixes between the best and lower performance groups of ICUs, and a high variability in expected risks for low severity patients. Using a resampling approach, it was evidenced that the mortality indicator varies strongly on low-risk groups of patients, while high-risk patients had a smaller range of SMR values, which may lead to biased conclusions when comparing ICUs with similar mortality and different case-mixes.

Background: Neonates who require specialized care and life-saving therapies in neonatal intensive care units (NICUs) and neonatal special care units (NSCUs) can be exposed to separation from their parents and families. Consequently, establishing a parental-neonate bond can be difficult. However, addressing this problem of separation through involving parents and families in neonatal care to improve parent-professional collaboration can result in positive outcomes for neonates and their families. Family-centred care (FCC) has developed over decades and is broadly recommended as an ideal model of care in daily clinical practice in NICUs. However, FCC implementation is challenging at individual, organizational, cultural, and healthcare system levels. In particular, developing countries are challenged by the lack of material resources, infrastructure, and staff shortages. In Thailand, the practical incorporation of FCC into daily clinical practice in neonatal care units is difficult, and it has not been sustainably achieved. Furthermore, there has been minimal research reporting on the development, implementation, and evaluation of FCC in the neonatal critical care context within Thailand. Aim and Objectives: The aim of this PhD study has been to develop, implement and evaluate innovation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU. It had three objectives, each representing a distinct phase in the study: (1) to identify perceptions, current practices and FCC strategies; (2) to develop and implement an innovation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU; and (3) to evaluate the FCC innovation developed in Phase 2. Methods and Results Design: The multistage, mixed-methods study design applied the Participatory Intervention Model (PIM) to guide the innovation’s development, implementation, and evaluation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU. Setting and context: This study was conducted in a tertiary care hospital in southern Thailand (February 2020-January 2021). Ethics approval was obtained from the Research Ethics Committee of Hatyai Hospital and Griffith University. Phase 1: Identification of perceptions, current practices, and FCC strategies Phase 1 was planned to include data collection over 3 months. Due to the COVID-19 pandemic, it was reduced to 2 months during the very early stages of the pandemic (February to March 2020). This phase consisted of two parts, including surveys and interviews with parents and the interdisciplinary professionals. Participants: Participants consisted of two groups: parents of neonates (all gestational ages with no life-threatening or life-limiting diagnosis) who had an expected NICU stay of at least 72 hours and visited the study NICU at least once, and interdisciplinary professionals with a permanent position for at least 1 year in the study unit. Part A: Survey of parents and interdisciplinary professionals Surveys of parents and interdisciplinary professionals were conducted using the validated Perceptions of Family Centred Care – Parent (PFCC-P) and Perceptions of Family Centred Care – Staff (PFCC-S) instruments which were translated into Thai. Sample size: Sample size was based on availability of parents and interdisciplinary professionals over the planned 3-month Phase 1 period. Recruiting parent participants in Phase 1 was prior/during the very early stages of the COVID-19 pandemic and needed to be stopped prior to pre-determined sample size of 100 parents due to visitor restriction (n = 85). Eighty-five parents and 20 interdisciplinary professionals completed the surveys. Data analysis: Demographic characteristics of parents, interdisciplinary professionals, and neonates are reported using descriptive statistics. The subscale scores for parents and interdisciplinary professionals were not normally distributed, so medians were calculated for each of the three sub-scales (respect, collaboration, and support). Parents’ and interdisciplinary professionals’ perceptions of FCC (PFCC-P & PFCC-S) were compared using the Mann-Whitney U test to examine differences in medians in the preimplementation phase because they were unpaired groups. Part B: Semi-structured interviews with parents and interdisciplinary professionals Face-to-face, semi-structured, individual interviews were planned to gain information from extended family members and parents and interdisciplinary professionals; however, given the visitation restrictions, only parents and interdisciplinary professionals were recruited to participate (during the first half of February 2020). Sample size: The sample size was determined when data saturation was identified. Eight interdisciplinary professionals and nine parents participated in face-to-face interviews. Data analysis: Thematic analysis was used to analyse the transcribed Thai language interviews. Results: The survey results across the median of three subscales demonstrated that parents and interdisciplinary professionals’ perceptions on the FCC strategies in current practice were 2-3/4 (Interquartile range [IQR] 1.7-3.8) and 3-4/4 (2.85-3.55), respectively. Considering the median subscale scores, the interdisciplinary professionals had significantly higher subscale scores for respect (median 3.00 (95% CI, 2.91-3.24) vs 2.50 (2.37-2.81)), collaboration (median 3.22 (3.10-3.37) vs 2.33 (1.9-2.62)), and support (median 3.20 (3.03-3.39) vs 2.60 (2.03-2.61)) (all p ≤ 0.001). The interview findings highlighted that the interdisciplinary professionals in this study accepted that the three critical elements of FCC (respect, collaboration, and support) were necessary to be implemented into clinical practice. However, they believed that in reality it was not easy in the Thai NICUs context. This finding identified that the challenge to promote parent-healthcare professional partnerships was associated with the structure and processes of the healthcare delivery system. In addition, the individuality of families' readiness and healthcare providers' perceptions of parents’ involvement as obstacles to providing care were found to be challenges to current practices of FCC. Phase 2: Development and implementation of innovation to facilitate FCC This phase was achieved by two different methods: strategy development working group and implementation of the FCC innovation. Strategy development working group: The development of FCC innovations by the strategy development working group (June to August 2020) was based on Phase 1 findings and the reported integrative literature review. In addition, the FCC innovations were considered within the policies and practices of the NICU in the context of COVID- 19 in Thailand. The development working group members were key and high-level stakeholders in the NICU. Educational activities for the healthcare professional team to incorporate the FCC innovations into their clinical practice in NICU were provided. Implementation of the FCC innovation: The FCC innovations were then implemented over 2 months (September to October 2020), during a period of restrictions on parents and staff arising from COVID-19. Results: The working group identified the gaps in the three key elements (respect, collaboration, and support) to providing FCC in a Thai NICU through the analysis of Phase 1’s results in consort with the findings from the integrative review. A preliminary protocol for the FCC innovations and implementation plan were developed consistent with the challenges associated with COVID-19 in Thailand. FCC practice innovations associated with improving communication were established, including changes and updates to the material within the parent booklet with specific material related to COVID- 19, neonatal updates at bedside or conducted via telephone calls, interdisciplinary family meeting for complex care situations, structured communication checklists, and documentation templates. In addition, although visiting restrictions were limiting, parents were provided with more flexibility as to when they could visit based on individual circumstances. The majority of the healthcare providers in this setting (80%) attended the educational activities to incorporate the FCC innovations into their clinical practice in the NICU. The FCC innovations were incorporated into daily NICU practice by nurses in cooperation with other healthcare providers and ancillary support staff during the pandemic. Phase 3: Evaluation of the FCC innovation Phase 3 (post-implementation) was conducted over 3 months (November 2020-January 2021), and it focused on evaluating the FCC innovations. This phase repeated the collection of data from the validated PFCC-P and PFCC-S surveys of parents and interdisciplinary professionals' perceptions, as per Phase 1, to assess respect, collaboration, and support changes after implementing the FCC innovations in the Thai NICU during the pandemic. Sample size: One hundred parents and 20 interdisciplinary professionals completed the surveys. Data analysis: As per Phase 1 for demographic characteristics. The Mann-Whitney U test was used to analyse parents' perceptions of the items of the PFCC-P pre- and postimplementation given they were two independent groups. Wilcoxon signed-rank test was used to compare the perceptions of the interdisciplinary professionals pre- and postimplementation using the PFCC-S given they were matched samples. Results: The participants consisted of 83 pairs of parents (i.e., mother and/or father of neonate participated) (35 pre; 48 post), which represented 102 neonates (50 pre; 52 post). There were 185 parents; 85 pre-implementation and 100 post-implementation. For the NICU health care team, 20 participated. The median scores of parents' perceptions post-implementation significantly improved for respect (2.50 to 3.50; 95%CI, 3.02-3.53), collaboration (2.33 to 3.33; 2.90- 3.40), support (2.60 to 3.60; 2.84-3.62), and the overall score (2.50 to 3.43) (p < 0.001, 95%CI 2.93-3.51). There was an absolute difference of at least 0.3 in the pre- and postimplementation scores for three subscales and overall score, where 0.3 corresponds to 10% of the rating scale. Comparatively, interdisciplinary professionals' perception of FCC did not significantly change pre- and post-implementation for respect ([median] 3.00 to 2.92; 95%CI, 2.87-3.16), collaboration (3.22 to 3.33; 3.16-3.47), support (3.20 to 3.20; 2.96-3.28) and overall (3.15 to 3.20; 95%CI, 3.10-3.25). Conclusions:Results from this study indicate that incorporating FCC innovations in the NICU appeared to be successful, despite the challenges of COVID-19. The key finding was that the innovations incorporated in the NICU were primarily based on communication strategies, a simple means to support, collaborate with, and respect parents that required low investment within the complex situation arising from COVID-19. These innovations were essential to engage collaborative working between parents and healthcare providers to promote parents as partners in a neonatal critical care team. To successfully implement FCC innovations in different settings, further innovations associated with communication methods need to target the specifics of individuals involved, healthcare settings, and available resources.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Nursing & Midwifery
Griffith Health
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Comparisons of the incidence of blood stream infection (BSI) between neonatal intensive care units (NICUs) can promote sharing of potentially better practices for infection control. Comparisons should take into account differences in babies’ vulnerability and the invasive procedures which can introduce infection. I carried out a systematic review of methods reported in the literature, or used by regional monitoring systems, for comparing the incidence of BSI among NICUs. I found substantial variation, especially in the risk factors used to adjust incidence estimates. The use of routinely recorded administrative data would minimize and accelerate staff workload for BSI monitoring. I investigated which risk factors recorded in routine data should be adjusted for when comparing BSI incidence between NICUs. I linked microbiology laboratory records with administrative records collected over four years for three London NICUs. I analysed rates of BSI using various methods, including Poisson regression and logistic regression assuming a matched case control design. With both approaches, National Health Service level of care was the strongest predictor for BSI incidence. Using Poisson regression models, the rate ratio for BSI, adjusted for birth weight, inborn/outborn status and postnatal age, was 3.15 (95% confidence interval (CI) 2.01, 4.94) for intensive care and 6.58 (95% CI 4.18, 10.36) for high dependency care, relative to special care. The case control study gave slightly larger estimates of effect than the Poisson regression models. Total parenteral nutrition was significantly associated with BSI incidence but explained less of the variance among babies than level of care. Using the results from the risk adjustment model, I demonstrated how routine data can be integrated into a method for prospective, risk adjusted monitoring. This method involved standardised infection ratios and a sequential probability ratio test. The method can evaluate changes in BSI rates over time and between NICUs. It could also be used to quantify improvements following infection control interventions.

Today’s intensive care units monitor patients through the use of various medical devices, which generate a high ratio of false positive alarms due to a low alarm specificity. The false alarms have resulted in a stressful working environment for healthcare professionals that are getting more desensitized to triggered alarms and causing alarm fatigue. The patient safety is also compromised by having high noise levels in the patient room, which disturbs their sleep. This thesis has developed an intelligent alarm system with an improved alarm management and the use of 23 intelligent algorithms to minimize the number of false positive alarms. The suggested system is capable of improving the alarm situation and increasing the patient safety in critical care. The algorithms were modeled with fuzzy logics consisting of delays and multi parameter validation. The results were iteratively developed by having focus groups with various experts.

Thesis (MCur (Nursing Science))--University of Stellenbosch, 2009.
ENGLISH ABSTRACT: The work environment in critical care units in South Africa is hampered by a profound shortage of nurses, heavy workloads, conflict, high levels of stress, lack of motivation and dissatisfaction among the staff. The task of managing a C.C.U. has therefore become a challenge. It is important that unit managers apply a leadership style that matches these challenges. The aim of this study was to investigate the ideal style of leadership. The objectives set for the study were to identify the ideal leadership style required in the following areas:  administrative functions  education functions  patient care  research An explorative, descriptive research design was applied, with a quantitative approach to determine the ideal leadership style for unit managers in critical care units of private health care institutions. The research sample consisted of all nurses working permanently in eleven private hospitals in the Cape Metropolitan area. A questionnaire consisting of predominantly closed questions was used for the collection of data, which was collected by the researcher in person. Ethical approval was obtained from the Committee of Human Science Research at Stellenbosch University. Permission to conduct the research was obtained from the institutions and informed consent from the participants. A pilot study was conducted to test the questionnaire at a private hospital which did not form part of the study. A 10% sample of the relevant staff, namely 27 participants were involved in this study. The validity and reliability was assured through the pilot study and the use of a statistician as well as experts in nursing and a research methodologist. Data was tabulated and presented in histograms and frequencies. Statistical significant associations were drawn between variables, using the Chi-square test. The Spearman rank (rho) order correlation was used to show the strength of the relationship between two continuous variables. Findings of the study show that participatory leadership style and transformational leadership approach were valued in all four (4) of the objectives. Emphasis was placed on consultation prior to any decisions. Nurses requested an opportunity to give feedback on a regular basis regarding the unit managers conduct (Chi-square test p = 0.025). They also agreed that unit managers should apply the necessary rules and procedures (Chi-square test p = 0.016). A huge request was made for integrity, trust, impartiality, openness, approachability and particularly honesty. The nurses also maintained that the nurse manager’s behaviour should be congruent. Furthermore, the results indicate that nurses would like to be empowered by:  being involved in the scheduling of off-duties  taking the lead in climate meetings  being granted opportunities (to all categories of nurses) to attend managerial meetings. N = 41 (48.2%) of nurses admitted that unit managers would instruct them to cope with insufficient staffing pertaining to ventilated patients, putting them under severe strain and at risk legally. N = 39 (47%) of nurses admitted that unit managers only consider qualifications and experience in the delegation of tasks if the workload in the unit justifies it. Safe patient care is not always a priority. N = 99 (96%) of nurses agreed that autocratic behaviour relating to task delegation exists. Recommendations included the application of transformational leadership and participatory management. The aim to create a healthier, more favourable work environment for critical care nurses will hopefully be attained through applying the ideal leadership style and leadership approach.
AFRIKAANSE OPSOMMING: Die werksverrigtinge in kritieke sorgeenhede in Suid-Afrika word deur ‘n ernstige tekort aan verpleegsters, hoë werklading, konflik, spanning, min motivering en baie ontevredenheid onder verpleeglui gekortwiek. Die leiding en bestuur van ‘n kritieke sorgeenheid is dus nie ‘n maklike taak nie. Dit is dus belangrik dat eenheidsbestuurders ‘n leierskapstyl aan die dag lê wat dié uitdagings doeltreffend aanspreek. Die doel van die studie is dus om ondersoek in te stel na die wenslike leierskapstyl vir kritieke sorgeenhede. Die doelwitte daargestel is dus om die ideale leierskapstyl in elk van die volgende funksies te bepaal:  administrasie  opleiding  pasiënte-sorg  navorsing Die ideale leierskapstyl vir eenheidbestuurders in kritieke sorgeenhede in privaathospitale is bepaal deur ‘n kwantitatiewe benadering met ‘n beskrywende ontwerp toe te pas. Die populasie het alle kritieke sorg verpleeglui ( permanent werksaam by een van elf privaathospitale in die Kaapse Metropool) ingesluit. Instrumentasie het ‘n vraelys behels (met oorwegend geslote vrae) en data is persoonlik deur die navorser ingevorder. Etiese toestemming is vanaf die Etiese Komitee van die Mediese Fakulteit te Universiteit Stellenbosch verkry asook die hoofde van die verskillende privaathospitale waar navorsing plaasgevind het. Ingeligte toestemming is ook van elkeen van die deelnemers verkry. Ten einde die vraelys te toets, is ‘n loodstudie by ‘n privaathospitaal ( wat nie by die studie ingesluit was nie) gedoen. Die loodstudie het N = 27 (10%) van die totale populasie behels. Die betroubaarheid en geldigheid van die studie is deur die loodstudie, die gebruik van ‘n statistikus, verpleegdeskundiges en die navorser-metodoloog versterk. Data is getabuleer en in histogramme en frekwensies voorgestel. Deur die Chi-square- toets te gebruik, is statisties betekenisvolle assosiasies tussen veranderlikes bepaal. Ten einde sterkte van verhoudings tussen twee opeenvolgende veranderlikes te bepaal, is die Spearman rangordekorrelasie (rho) aangewend. Die bevindings van die studie het getoon dat ‘n deelnemende bestuurstyl en transformasie-leierskapbenadering die mees aangewese keuse vir al vier doelwitte is. Die toepassing van veral ‘n deelnemende besluitnemingsproses het groot voorrang geniet, Verpleegkundiges wil daarbenewens ook op ‘n gereelde basis geleentheid hê om terugvoering oor die leierskapgedrag van die eenheidsbestuurder te gee (Chi-square toets p = 0.025). Ook verlang die deelnemers dat eenheidsbestuurders nie reëls en regulasies moet verontagsaam nie (Chi-square toets p = 0.016). ‘n Ernstige versoek is gerig ten opsigte van integriteit met pertinente verwysing na eerlikheid, vertroue, onpartydigheid, deursigtigheid, toeganklikheid en dat die leier se woorde en dade moet ooreenstem. Die resultate het verder getoon dat verpleegsters graag bemagtig wil word deur:  betrokkenheid in die skedulering van afdienste,  leiding in klimaatsvergaderings te wil neem,  geleentheid te hê om bestuurvergaderings by te woon (alle kategorieë van verpleegkundiges).. N = 39 (48.2%) van verpleegkundiges het erken dat hulle gedwonge personeeltekorte ten opsigte van geventileerde pasiënte ervaar en dus aan mediese geregtelike risiko’s en onnodige druk blootgestel word. N 39 (47%) van verpleegkundiges het erken dat eenheidsbestuuders kwalifikasies en ondervinding slegs in ag neem indien die werklading in die eenheid dit toelaat..Veilige pasiëntesorg kry dus nie altyd voorkeur nie. N = 99 (96%) van verpleegkundiges het erken dat outokratiese gedrag ( wat met werkstoewysing verband hou) wel voorkom. ‘n Transformasie leierskapsbenadering en deelnemende bestuurstyl is dus aanbeveel. Die hoop word dus uitgespreek dat deur aan die verpleegkundiges se versoeke ten opsigte van die ideale bestuursbenadering en bestuurstyl te voldoen, die werksatmosfeer binne kritieke sorgeenhede toenemend gesonder en dus aangenamer sal word.

Patient satisfaction is an outcome of care that represents the patient's judgment on the quality of care. An important aspect of quality affecting patient's judgment can be attributed to patients' expectations and experiences regarding nursing care according to type of unit. The purpose of this study was to examine differences between patients' perceptions of satisfaction with nursing care in critical care units and medical units in one Midwestern hospital.The conceptual framework was "A Framework of Expectation" developed by Oberst in 1984, which asserted that patients have expectations of hospitals and health care professionals regarding satisfaction and dissatisfaction with care. The instrument used to measure patient satisfaction was Risser's Patient Satisfaction Scale, with three dimensions of patient satisfaction: (a) Technical-Professional, (b) Interpersonal-Educational, (c) Interpersonal-Trusting. The convenience sample included 99 patients50 from critical care units and 49 from medical wards. Participation was voluntary. The study design was comparative descriptive and data was analyzed using a t-test.The demographic data showed that the majority of patients had five or more admission. About one-third of the patients were 45-55, 56-65, 66-75, respectively. Findings related to the research questions were that: (a) 84 percent of the respondents rated overall satisfaction in the satisfactory to excellent range, (b) results of a t-test showed significant differences in overall patient satisfaction with patients being more satisfied with care in critical care units. Significant differences were found in three subscales with critical care being more satisfied. No relationship was found between patient satisfaction and age/and/or type of unit.Conclusions were that in both medical and critical care units patients were more satisfied with Technical-Professional and Interpersonal-Trusting than with Interpersonal-Educational. Also noted was that patients in the units where nurse-to-patient ratio was higher participants perceived that nurses had more time, energy and ability to meet patient expectation. Implications call for analysis of nurse/patient ratio in relation to patient satisfaction and nurses in relation to patient education as well as patient's perceptions of getting their needs met.
School of Nursing

Background and aims Untreated stress-induced hyperglycaemia in critically ill patients has been associated with harmful effects, which can even be fatal. Current evidence about the optimal glycaemic targets, and the most effective and safest methods of glycaemic control (GC) in intensive care units (ICU), is contradictory. GlyCon study aimed to investigate the effectiveness, efficiency and safety of the monitoring and insulin treatment methods for GC implemented in the seven ICUs of an NHS ICU network in the UK. In addition, GlyCon study also aimed to explore the contents of the local protocols for GC of these ICUs, as well as the views of ICU professionals about several aspects of GC. Methodology A multi-method study was undertaken, comprising three sub‑studies: (1) a document review of the protocols for GC designed by and implemented at each of the participating ICUs, using techniques of inductive content analysis and descriptive statistics; (2) an online survey to ICU medical and nursing staff, on their opinion about effective GC, and deviations from protocol instructions, which was analysed using descriptive statistics and logistic regression; (3) A retrospective study about the methods and outcomes of GC, based on a review of electronic and manual medical records of a stratified random sample of 146 patients admitted to the seven participating ICUs during 2012 and 2013. The main analyses of association between the exposures and the primary outcome measure (percentage of time with glycaemic levels of 4‑10mmol/L, or TIR, which was transformed into the odds of being within that range at any time, or odds of IR), were mainly based on generalised estimating equations using the logit link, and autoregressive correlation structure. Secondary outcome measures of time‑efficiency and safety were also investigated, and analysed using univariate statistics and multiple log‑linear regression. Results The protocols for GC implemented in the seven ICUs differed greatly in their target patients, target glycaemic levels, recommended methods for monitoring, and insulin titration algorithms, among others. Most of the 40 respondents to the survey agreed that TIR≥75% constitutes good GC and TIR < 50% constitutes poor GC. Opinions were divided on intermediate levels of TIR, with professionals having more experience in intensive care tending to rate such intermediate TIR as poor GC more often than their less experienced colleagues. Most of the proposed protocol deviations were considered as major by at least two thirds of the respondents. Professionals’ role (nurse vs. physician) and their number of years of experience were significantly associated with different views. The blood glucose (BG) monitoring frequencies and insulin hourly dosages, at each glycaemic status, differed by ICU, and between patients with and without diabetes. Non‑adherence to protocol instructions regarding BG monitoring and insulin infusion rates occurred more often than not. The median (IQR) TIR was 91% (81‑96%) and 56% (34‑71%) among patients without and with diabetes, respectively. A number of time-dependent and time-constant factors were associated with higher odds of IR at any time. Time-constant protective factors included: having spent more than 20% of admission time receiving insulin during hyperglycaemia, certain ICU protocols, and lower levels of severity on admission. Time-dependent protective factors were: the number of hours from admission, and the dobutamine and insulin hourly dosages. Time-dependent detrimental factors were: non‑adherence to protocol insulin instructions, the hourly nutritional energy administered, and the hourly dosage of certain drugs, including adrenaline and hydrocortisone. Conclusions Protocols for GC, practice of GC, and outcomes of GC, all differed significantly across hospitals. Some protocols seemed more effective, time‑efficient or safe than others, but there was a high incidence of non‑adherence to protocol instructions in all ICUs. This contrasts with professionals rating deviations from protocols as major, more often than not. Certain monitoring and insulin treatment methods for GC were more effective, and some were more time‑efficient than others, particularly among patients without diabetes. There is a clear need for protocols to include different recommendations for patients with diabetes, as well as to formally emphasise the importance of GC also in patients without diabetes. ICU multidisciplinary teams should be involved in the development of these protocols, and their views should be accounted for in research studies about the effectiveness of GC in the ICU.

Thesis (S.M.)--Massachusetts Institute of Technology, Sloan School of Management, Operations Research Center, 2010.
Cataloged from PDF version of thesis.
Includes bibliographical references (p. 135-143).
Poor management of the patient flow in intensive care units (ICUs) causes service rejections and presents significant challenges from the standpoint of capacity planning and management in ICUs. This thesis reports on the development of a simulation framework to study admission control polices that aim to decrease the rejection rate in the ICU at Children's Hospital Boston (CHB), and to provide predictions for the future state of the ICU system. To understand the patient flow process, we extensively analyze the arrival and length of stay (LOS) data from the ICU census. The simulation model for the ICU is developed based on the results from this statistical analysis as well as the currently-practiced scheduling and admission policies of the ICU at CHB. The model is validated to provide accurate estimates for important performance metrics such as rejection rates in the ICU. The simulation model is used to study the performance of many admission control policies. The policies of our interest exploit "caps" to control the number of scheduled patients who are allowed to enter the ICU on a single day. In particular, we consider two cap-based policies: the uniform cap policy (UCP), which is the existing policy in CHB, and the service-specific cap policy (SSCP), which is originally proposed in this thesis. While the UCP implements caps on the total census of surgical patients, the SSCP utilizes the service-oriented heterogeneity of surgical patients' LOS and enforces caps on separate groups of surgical patients based on their average LOS. We show that the UCP can reduce the rejection rate in the ICU at the expense of extra waiting time of scheduled patients. The SSCP is shown to further decrease the rejection rate while increasing the waiting time compared to the UCP. We also demonstrate that the performance of both policies depends on the level of system utilization. In order to validate our results theoretically, a discrete-time queueing model for the ICU is developed and verified to provide estimates for performance measures that are consistent with the results from simulation. Finally, we introduce the notion of state-dependent prediction, which aims to identify the likelihood of the future state of the ICU conditional on the information of a current state. Several experiments are conducted by simulation to study the impact of a current state on a state in the future. According to our results, current state information can be useful in predicting the state of the ICU in the near future, but its impact gradually diminishes as the time difference between the present and future grows. Our major finding is that the probability of unit saturation at a certain future time can be determined almost entirely by the number of current patients who will leave the ICU after that time, regardless of the total number of patients who are currently staying in the unit. These results imply the potential development of adaptive cap-based policies that dynamically adjust caps according to the outcomes of state-dependent predictions.
by Wongsakorn Chaiwanon.
S.M.

Introduction - Maximising efficient and effective use of resources without compromising quality of care is essential in the current healthcare climate. Intensive care unit services are one of the most resource intensive and therefore expensive services within a hospital. Because intensive care unit services comprise a significant portion of hospital costs and resources, appropriate utilisation of intensive care units is imperative. The occurrence of delayed discharges and the reason for the delays is important as they impact on the efficiency and effectiveness of intensive care unit services. Patients who no longer need intensive care unit care block beds for impending admissions, unnecessarily utilise the costly and often scarce resources and by remaining in a stressful environment may experience negative psychological and social effects detrimental to their well being. Study objectives - To determine to what extent delayed discharge from the intensive care unit occurs and ascertain the reasons for these delays. Design - A prospective cross sectional design to determine the number of delayed discharges from the intensive care unit and reasons causing the delay. A discharge was considered to be delayed if the patient was not discharged from the intensive care unit within 8 hours of being deemed suitable for discharge by intensive care unit medical staff. Setting - A level III intensive care unit with 22 beds (12 general and 10 surgical beds in 2 adjacent areas) in a metropolitan tertiary teaching hospital of 955 beds located across two campuses. Sample - A prospective convenience sample of consecutive patients admitted over a 6-month period from September 2000 to March 2001. Exclusions were patients who died whilst in the intensive care unit and those patients who could be discharged prior to commencement of the study. Method. - Intensive care unit medical staff informed nursing shift coordinators when patients could be discharged. The nursing shift coordinators completed the data collection tool on all patients discharged from intensive care unit. Admission and discharge times and APACHE-11 data (a predictive scoring system for ICU patient outcome) were recorded from intensive care unit records. Results - There were 652 discharges, 468 patients were not delayed (71.8%), 176 were delayed (27.0%, 95% CI 23,9%-30.7%) and 8 (1.2%) patients had no delay information available. There were substantial delays in discharging patients from the intensive care unit; for every 5 discharges that were not delayed, 2 patients would be delayed. Unavailable ward beds (81 %) were cited as the main reason for delay in discharge. Delay time from the intensive care unit ranged from 0.2 hours (1 0 minutes) to 617.5 hours (3 weeks, 4 days, 17.5 hours). Mean delay time was 42 hours (I day, 18 hours) and median delay time 21.3 hours. There was a statistical significance difference between-non delayed and delayed patients for APACHE II score on admission (Ɩ = -3.824 {642), p <0.0001) and worst APACHE 11 score in first 24 hours e (Ɩ = -5.123 (642), p <0.0001 ). There was also a statistically significant difference between delay from the intensive care unit and non delayed discharge by admitting diagnosis (Chi sq (12) = 43.235, p < 0.0001); primary organ system failure (chi sq (6) = 14.231, p = 0.027); ward destination (chi sq (7) = -51.486, p < 0.0001 ); specialty (chi sq (23) = -43.371, p = 0.006) and day of eligible discharge (chi sq (6) = 34.008; p < 0.0001 ). Conclusion - Discharge from the intensive care unit is delayed on average by 27% in the study hospital. These delays can be related to how sick the patient was, principle admitting diagnosis, discharge destination and weekend discharge. Reducing these delays would free up beds for other admissions, may result in a cost saving for the health care facility through more efficient resource utilisation and ultimately benefit patients by better managing the discharge process.

Thesis: M. Eng., Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science, 2017
Cataloged from PDF version of thesis.
Includes bibliographical references (pages 63-64).
Telemedicine is an exciting development at the intersection of technology and medicine, which promises to improve health care systems and alleviate the workload on doctors and nurses alike at hospital intensive care units. While much work has been done on assessing the benefits of telemedicine compared to traditional approaches, we do not know which are the characteristics of patients that will benefit most from the introduction of tele-ICU systems in hospitals. In this thesis, we analyzed two large databases that contain plethora of deidentified health records about patients treated in traditional and tele-ICU hospitals, named MIMIC and eICU-CRD, respectively. By comparing key patient outcomes such as length of stay and mortality, and running sophisticated statistical methods, we identified certain traits of admitted patients that constantly benefit more from the presence of eICU than other patients. We hope that this work will help hospitals around the country and the world as they are preparing their facilites for the new generation of technologies.
by Narek Dshkhunyan.
M. Eng.
M.Eng. Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science

Professional nurses working in an intensive care unit (ICU) are faced with the death of critically ill patients frequently. Modern day medicine and technology have made it possible for advanced life-sustaining measures to be implemented on patients who, without medical intervention, would otherwise not have survived. The question is raised: is modern technology preserving life and prolonging the dying process, or is it in the best interest of the patient for treatment to be withdrawn? Nurses, caring for these patients and their families, are practicing at the bedside of these dying patients and are thus often faced with end-of-life issues, particularly withdrawal of treatment. The primary functions of critical care nurses are toward their patients. Physicians are responsible for making decisions regarding withdrawal of treatment. However, the nurses in the ICU are responsible for implementing the decisions made; sometimes contradicting what they believe in. The experience of end-of-life issues, namely withdrawal of treatment, is a cause of distress for the professional nurse. Little research has been done on how the ICU nurses deal with end-of-life issues and what support structures are required to assist nurses in dealing with end-of-life issues (Hov, Hedelin & Athlin, 2006:204) The objectives of the study were to explore and describe the professional nurses‟ lived experiences of end-of-life issues in the intensive care unit. The study aimed to make recommendations regarding support strategies to assist professional nurses in dealing with end-of-life issues in the intensive care unit. The researcher has selected a qualitative research approach with an explorative, descriptive and contextual design in order to conduct the study. Data was collected by means of semi-structured interviews. Data was analysed using the steps as illustrated by Tesch‟s method. Ethical principles were maintained throughout the research study. The findings of this study are to be presented in a journal publication.

Hospital-acquired, or nosocomial infections (HAIs) are the major source of mortality and morbidity for hospitalized patients. It is estimated that 7-10% patients developed HAIs during their hospital stays, with most patients got infected from intensive care units (ICU) [1,2]. Hand hygiene (HH) is recognized as the most easy and effective way to prevent HAIs. However, the observed hand hygiene compliance rates among healthcare workers (HCWs) have been regarded as unacceptably low, especially in ICU [3]. This literature review is to discuss the factors influencing the hand hygiene compliance among HCWs in ICU, in both the individual and institutional level, and suggest which factor was important in both levels. Recommendations in comprehensive approach on hand hygiene practices will also be included.
published_or_final_version
Public Health
Master
Master of Public Health

Central line-associated bloodstream infections (CLABSI) figure as one of the most important healthcare-associated infections (HAI), particularly in intensive care units (ICU). Despite their clinical and public health importance, little is known about CLABSI in Canadian ICUs. Thus, the first objective of this thesis was to describe the epidemiology of CLABSI in Quebec ICUs, using data from the Surveillance Provinciale des Infections Nosocomiales – Bactériémies Associées aux Cathéters Centraux (SPIN-BACC) program. We showed that CLABSIs are an important problem in Quebec ICUs, but CLABSI incidence rates have decreased since 2007. Moreover, the proportion of methicillin-resistant Staphylococcus aureus has declined to <40% since 2006 (chapter 6). Surveillance programs are essential to establish benchmarks. In the last years, several regional and national CLABSI surveillance programs have decided to eliminate continuous participation requirements from hospitals. This might have jeopardized the validity of these programs' results because the minimal number of months hospitals should participate in such programs to generate valid annual benchmarks for CLABSI incidence rates have yet to be determined. Our second objective was to determine, through simulation, the impact of different participation requirements on the ability of national and provincial/regional surveillance programs to yield valid estimates of the true annual ICU CLABSI pooled incidence rates. We demonstrated that shortening participation requirements might be suitable for national ICU CLABSI surveillance programs if data are randomly collected. Nevertheless, regional/provincial programs should opt for continuous participation to avoid biased benchmarks (chapter 7). Furthermore, surveillance programs can also be used as a tool to reduce CLABSI incidence rates in ICUs. However, the magnitude of this effect has not been definitely determined as earlier studies presented a wide range of effect estimates. We hypothesized that the effect of surveillance on CLABSI rates differs depending on the characteristics of participating ICUs. Our third objective was to determine the effect of SPIN-BACC on the CLABSI incidence rates in Quebec ICUs, and identify ICU-level variables associated with higher CLABSI incidence rates. There were important reductions in the CLABSI incidence rates of "surveillance-naïve" (31%) and of non-university affiliated ICUs (27%) that participated in SPIN-BACC for 3 years. However, due to our small sample size, these results were not statistically significant. Neonatal and "surveillance-naïve" units were associated with higher CLABSI incidence rates (chapter 8). In conclusion, our first study described the CLABSI burden on ICU patients in Quebec. Our simulation study suggested that small and medium sizes surveillance programs should perform continuous surveillance to avoid biased benchmarks. Finally, we suggested that reductions in ICU CLABSI incidence rates associated with targeted surveillance may be more pronounced among "surveillance-naïve" and non-university affiliated ICUs. All the different applications of CLABSI surveillance data demonstrated in this thesis have the ultimate goal of improving patient care and safety.
Parmi les infections associées aux soins de santé, les bactériémies associées aux cathéters centraux (BACC) occupent une place prédominante, particulièrement dans les unités de soins intensifs. Toutefois, l'épidémiologie des BACC au niveau canadien est peu connue. Dès lors, le premier objectif de cette thèse était de décrire l'épidémiologie des BACC dans les unités de soins intensifs du Québec en utilisant les données du programme de Surveillance Provinciale des Infections Nosocomiales – Bactériémies Associées aux Cathéters Centraux (SPIN-BACC). Nous démontrons que les BACC sont un problème majeur dans les unités de soins intensifs du Québec. Néanmoins, les taux d'incidence de BACC ont progressivement baissé depuis 2007 et la proportion de Staphylococcus aureus résistants à la méthicilline se maintient <40% depuis 2006 (chapitre 6). Les programmes de surveillance sont essentiels pour générer des étalons externes. Toutefois, au cours des dernières années, plusieurs programmes régionaux et nationaux ont aboli la participation continue comme préalable. Cette décision pourrait avoir compromis la validité de leurs résultats car le nombre minimal de mois lesquels les établissements doivent soumettre des données à ces programmes afin d'obtenir des taux d'incidence régionaux/provinciaux ou nationaux valides est inconnu. Notre deuxième objectif était de déterminer, à l'aide de simulations, l'impact de différents seuils minimum de participation sur la capacité des programmes de surveillance régionaux/provinciaux et nationaux à fournir des estimations valides du vrai taux d'incidence des BACC dans les unités de soins intensifs. Nous démontrons que la réduction des seuils de participation peut être appropriée pour les programmes nationaux si les données sont soumises de façon aléatoire. Toutefois, les programmes régionaux/provinciaux, ainsi que les petits sous-ensembles des unités de soins intensifs, devraient opter pour une participation continue afin d'éviter le risque de générer des étalons externes biaisés (chapitre 7). Par ailleurs, les programmes de surveillance peuvent aussi être utilisés comme outils pour réduire le taux d'incidence des BACC dans les unités de soins intensifs. Toutefois, l'importance de cet effet n'a pas encore été déterminée de façon définitive, car les études antérieures ont presenté une vaste gamme d'effets de tailles différentes. Dès lors, notre troisième objectif était de déterminer l'effet de SPIN-BACC sur les BACC dans les unités de soins intensifs du Québec et d'identifier les variables associées à un taux d'incidence des BACC plus élevé. Nous observons des réductions importantes des taux d'incidence des BACC parmi les unités de soins intensifs qui n'avaient jamais été exposées à la surveillance (31%), ainsi que parmi les unités de soins intensifs non-universitaires (27%) qui ont participé à SPIN-BACC pendant 3 années. Toutefois, ces résultats n'étaient pas statistiquement significatifs à cause de notre petite taille d'échantillon. Les unités de soins intensifs néonatales et les unités qui n'avaient jamais été exposées à la surveillance étaient associées à un taux d'incidence des BACC plus élevé (chapitre 8). En bref, nous avons démontré que les BACC constituent un lourd fardeau au sein de la population de patients admis aux unités de soins intensifs dans la province de Québec. Notre deuxième étude a suggéré que les programmes de surveillance de petite et moyenne tailles devraient effectuer leur surveillance de façon continue. Enfin, l'effet d'un programme de surveillance ciblé sur les taux d'incidence des BACC semble être plus prononcé au sein des unités de soins intensifs n'ayant jamais exposées à la surveillance et les unités de soins intensifs qui ne sont pas affiliées à des universités.

Mechanical ventilation is a life-saving therapy for patient treatments in Intensive Care Units (ICUs). The management of mechanical ventilation is a very challenging task. It has long been recognised that a computer-based bedside decision support system is r desirable for optimal ventilator management in ICUs. In this thesis, a closed-loop adaptive model-based ventilator management decision support system is developed. A previously developed ventilated patient mathematical model is further improved and extended with respect to the model parameter estimation and the simulation of the patients as their clinical states evolve. A hybrid modelling strategy is implemented by combining mathematical modelling and data-driven modelling techniques. With the availability of rich data in ICU and the improvements made in the model parameter estimation, the model is able to represent patient state evolution and provide accurate blood gas and tidal volume predictions. An adaptive decision support system is, thereafter developed based on the patient model using an optimisation approach and the system is evaluated via a series of closed-loop simulations. Results show that the srstem can generate good ventilator setting advice subject to the patient state changes and competing ventilator management targets. In addition, a future ventilator management tool, named Electrical Impedance Tomography CElT), is investigated in this thesis in relation to its data processing and feature extraction. The integration of EIT into the current decision support system represents a very promising research direction for the optimal ventilator management decision support.

A neonatologia é uma subespecialidade da pediatria relativamente nova iniciando-se como uma área altamente tecnológica e que tende a ser cada vez menos invasiva. Foram vários os avanços que permitiram uma redução da mortalidade do recém-nascido prematuro: o transporte in utero, os corticóides prenatais, o "milagre" do surfactante, cuidados regionalizados (de que Portugal é um bom exemplo), ... Com a evolução dos tempos a preocupação dos neonatologistas "transferiu-se" da mortalidade para a morbilidade, os cuidados passaram de centrados no doente a centrados na família, a ventilação tornou-se não invasiva, a maior importância da nutrição, sono, redução da infecção, luz, ruído e dor, variáveis conjuntas influenciando o neurodesenvolvimento.

This study had three purposes: (1) to examine the differences and similarities between intensive care and medical-surgical RNs' self-reports of professional nursing practice and job satisfaction. (2 & 3) to explore the influence of professional nursing practice on nurse satisfaction in intensive care RNs and medical-surgical RNs, respectively. A two-group, cross-sectional descriptive design with a sample of 340 RNs was utilized to perform a secondary analysis of baseline data from the Differentiated Group Professional Practice project. Self-reports of RNs evidenced significantly higher levels of autonomy and control over nursing practice among intensive care subjects as opposed to medical-surgical subjects. The concepts of organizational commitment, autonomy, control over nursing practice, and group cohesion had a positive influence on total job satisfaction for the medical-surgical subjects. The above concepts with the exception of autonomy had a positive influence on total job satisfaction for the intensive care subjects.

In the United States, adult ICU patient care consumes $90 billion annually, or 1% of the gross national product. In the ICU, about 40% of the patients are mechanically ventilated resulting in an 11% greater length of stay (LOS) that requires 35% more resources. And, an estimated 60% of these patients are adversely impacted for as long as five years following discharge. Patient immobility while ventilated contributes to poor quality and financial outcomes. The Institute of Healthcare Improvement (IHI) reports on average early patient mobility (EPM) reduces a 4.5-day LOS by as much as 1.3 days; and reduces the risk for complications such as ventilator associated pneumonia, thromboembolisms, and pressure ulcers. The purpose of this evidence-based practice (EBP) quality improvement project was to evaluate an EPM program based to improve interdisciplinary collaboration and care coordination. The introduction, development, and evaluation of this project were guided by the Iowa Model and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility (ABCDE) bundle. The EPM program was implemented in a 20-bed ICU in a 400-bed hospital as the Mobilization Criteria / Algorithm for Critical Care Patients (MCACCP). Retrospective data was collected for six months from the electronic health record and evaluated with a web-based analytics tool. The project resulted in a 1.2-day decrease in ICU LOS and a 6.7% reduction in ventilator days. The average daily census decreased from 16.2 in 2015 to 14.7 through 2016. EBP research supports the benefit of early mobility of ICU patients to reduce complications, ventilator days, LOS, and the overall cost for care. This project demonstrates standardizing clinical practice based on EBP guidelines and protocols translates into improved teamwork, patient outcomes, and organization metrics.

Communication among patients and nurses m the Intensive Care Unit (ICU) has received extensive attention in the nursing research literature. These studies have identified numerous factors both enhancing and impeding effective nurse client communication. Despite the extensive research attention paid to nurse client communication in an ICU setting, no studies can be located that take a multidimensional approach to exploring the factors serving to enhance or impede such nurse "client communications. The literature review searched from 1980 when the landmark study by Ashworth ( 1980) reported on nurse-patient communication in the ICU. Many studies followed on nursing communication

Long-term outcomes for patients admitted to intensive care units (ICUs) are recognised to be of increasing importance. Published studies indicate that ICU survivors have significant physical impairment, impaired quality of life, and excess mortality during the post-ICU period. The period of excess mortality has been variously estimated as lasting from one to 16 years after ICU discharge. Remarkably little information about long-term mortality and healthcare resource use exists for critical care populations, and outcomes relative to a non-ICU control population are unknown. The aims of the studies presented in the thesis were (i) to describe long-term (five year) mortality and identify factors associated with mortality for patients admitted to ICUs in Scotland (ICU admission cohort) and those surviving to be discharged from hospital alive (ICU survivor cohort); (ii) to compare mortality rates with control populations after adjustment for relevant confounders; (iii) to evaluate the extent of, and factors associated with, long-term (five year) major healthcare resource use of survivors of critical illness (ICU survivor cohort); and (iv)to compare major healthcare resource use with a control hospital inpatient population. I undertook a detailed systematic review of the international literature relating to healthcare resource use in ICU survivors to inform the design of the part of the study relating to resource use. This revealed a paucity of high quality studies but led to recommendations for improving the conduct and reporting of future research in this field. Using both retrospective cohort and matched cohort study designs, I analysed data relating to all patients admitted to Scottish ICUs in 2005 from the Scottish Intensive Care Society Audit Group (SICSAG) database. Two cohorts were defined: an ICU admission cohort, representing all ICU admissions, and a subcohort of those who survived to hospital discharge (ICU survivor cohort). Matched control cohorts of non-ICU hospital inpatients were selected from national datasets. The main outcomes were five-year mortality and major healthcare resource use obtained from linkage to national datasets. Major healthcare use was measured by number of hospital readmissions, number of days spent in hospital and hospital costs during the five years after hospital discharge. Five year mortality was 53% in the ICU cohort compared with 27% for the matched control hospital cohort and 16% for an age/sex-standardised general population. Among hospital survivors, ICU patients had higher five year mortality after adjustment for confounders (HR 1.3, 95%CI 1.2 to 1.4, p<0.001). Age, comorbidity, ICU admission diagnosis and deprivation quintile were independently associated with five-year mortality. The ICU diagnosis with greatest five year mortality (relative to self-poisoning) was variceal bleeding (HR 3.9, 95%CI 2.2 to 6.7, p<0.001). The readmission rate for the 5259 ICU patients surviving to hospital discharge declined from 1.7 readmissions per person in the first year to 0.9 in the fifth year of follow-up. Overall, ICU survivors spent a mean of 29 days in hospital over the five year follow up period, at a cost of £14593 per person. Previous number of admissions was the factor most strongly associated with resource use. ICU patients had a significant increased rate of hospital admission compared with the control cohort throughout the five year follow up period (admission rate ratio 1.21 (95%CI 1.14 to 1.29, p<0.001)). In the programme of work presented in this thesis, I have systematically reviewed evidence for resource use following critical illness, and have demonstrated that ICU patients are more likely to die compared with other hospital inpatients over a five-year horizon, even when only hospital survivor cohorts are considered. Furthermore, I have demonstrated that ICU survivors utilise a significant amount of excess acute hospital resource, which is relevant to health service planning and economic evaluations.

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Introdução: O traumatismo cranioencefálico constitui um dos principais problemas de saúde pública e está entre as principais causas de morte, incapacidade ou invalidez. As suas características variam de acordo com a população envolvida, sendo de expressiva importância o conhecimento das características das internações de modo a elaborar diretrizes básicas para programas de prevenção e também intervenções específicas na área assistencial. Objetivos: Caracterizar o perfil epidemiológico do traumatismo cranioencefálico (TCE) na Unidade de Terapia Intensiva do Hospital de Base de Bauru e elaborar um Guia de orientações pós-alta hospitalar para o cuidador. Métodos: Estudo quantitativo, retrospectivo e de natureza documental, baseado na análise de prontuários eletrônicos de pacientes vítimas de traumatismo cranioencefálico internados no período de janeiro a julho de 2016. Resultados: Foram admitidos 156 pacientes (29,65%) com traumatismo cranioencefálico; 139 prontuários atendiam os critérios de inclusão e foram analisados. Houve predomínio de idosos e adultos (idade 41 anos ou mais), representando 58,28% da amostra; prevalência do sexo masculino (82%) e traumatismos causados por quedas (39,57%), seguidos de espancamentos (15,11%) e acidentes motociclísticos (14,39%). Desses pacientes, 24 evoluíram a óbito; 19 pacientes receberam alta com algum déficit (neurológico, motor ou visual) e com 27 dispositivos invasivos. Conclusão: Apesar das altas taxas de prevalência de traumatismo cranioencefálico no Brasil e do seu significativo impacto econômico e social, o número de estudos com dados epidemiológicos consistentes permanece escasso. Este estudo pode contribuir para direcionar ações de saúde e políticas públicas na região de Bauru em relação ao cuidado com as vítimas de TCE, assim como do agente causador. Pode também ajudar na efetivação do processo de cuidar da população vulnerável e investir em programas de prevenção, reduzindo sequelas e minimizando os custos ao Sistema Único de Saúde. Produto da dissertação: O Guia “Orientações pós-alta hospitalar para o cuidador de pacientes acamados” foi elaborado para orientar os cuidadores e apoiar as principais ações no domicílio, proporcionando assistência de qualidade.
Cranioencephalic trauma is a major public health problem and is among the main causes of death, incapacity or disability. Its characteristics vary according to the population involved, and the knowledge of the characteristics of hospitalizations is of significant importance in order to elaborate basic guidelines for prevention programs and also specific interventions in the care area. Objectives: To characterize the epidemiological profile of Traumatic Brain Injury (TBI) in the Intensive Care Unit of Bauru Base Hospital and to prepare a post-discharge guidebook with orientations to caregivers. Methods: Quantitative, retrospective and documental study based on the analysis of the electronic records of patients with traumatic brain injury hospitalized from January to July, 2016. Results: A total of 156 patients (29.65%) were admitted with traumatic brain injury; 139 medical records met the inclusion criteria and were analyzed. There was a predominance of elderly and adults (age 41 years or older), representing 58.28% of the sample; male prevalence (82%) and injuries caused by falls (39.57%), followed by beatings (15.11%) and motorcycle accidents (14.39%). Of these patients, 24 evolved to death; 19 patients were discharged with some neurological, motor or visual deficit, and another 27 with invasive devices. Conclusion: Despite the high rates of prevalence of cranioencephalic trauma in Brazil, and its significant economic and social impact, the number of studies with consistent epidemiological data remains scarce. This study may contribute to orientate health actions and public policies in the region of Bauru related to the care for the victims of TBI, as well as those regarding the causative agent. It can also help with the effectiveness of the process of caring among segments of the population considerd vulnerable, as well as in investiments in prevention programs, reducing sequelae and minimizing costs to the Unified Health System. Outcome of the dissertation: The guidebook Post-discharge guidelines for the caregiver of bedridden patients was developed to guide caregivers and support main actions at home, helping to provide quality care.

Objective: To determine the risk factors for extubation failure in the intensive care unit. Methods: The present case-control study was conducted in an intensive care unit. Failed extubations were used as cases, while successful extubations were used as controls. Extubation failure was defined as reintubation being required within the first 48 hours of extubation. Results: Out of a total of 956 patients who were admitted to the intensive care unit, 826 were subjected to mechanical ventilation (86%). There were 30 failed extubations and 120 successful extubations. The proportion of failed extubations was 5.32%. The risk factors found for failed extubations were a prolonged length of mechanical ventilation of greater than 7 days (OR = 3.84, 95%CI = 1.01 - 14.56, p = 0.04), time in the intensive care unit (OR = 1.04, 95%CI = 1.00 - 1.09, p = 0.03) and the use of sedatives for longer than 5 days (OR = 4.81, 95%CI = 1.28 - 18.02; p = 0.02). Conclusion: Pediatric patients on mechanical ventilation were at greater risk of failed extubation if they spent more time in the intensive care unit and if they were subjected to prolonged mechanical ventilation (longer than 7 days) or greater amounts of sedative use.
Revisión por pares
Revisión por pares

Kangaroo Mother Care (KMC) is an alternative model of care that prevents parent-infant separation when preterm infants need neonatal intensive care by skin-to-skin contact between infants and their parents. KMC is also a strategy that involves parents in their infants’ care and enables them to assume the responsibility for the care. Furthermore, KMC promotes parent-infant bonding and attachment. The overall aim of this thesis was to gain a deeper understanding and knowledge about parents’ capacity, willingness, and experiences of KMC and to which extent parents choose to use KMC throughout their infants' hospital stay. These studies were conducted in the NICUs at two Swedish university hospitals (NICU A and NICU B). Mothers of infants cared for at NICU A (n=17) answered a questionnaire about their experiences of KMC (Paper I). Twenty parents of infants cared for at NICU A recorded the duration of each KMC session during a period of 24 hours and the identity the KMC provider (Paper II). Seven fathers were interviewed about their experiences of KMC (Paper III) and 76 mothers and 74 fathers completed a questionnaire about what facilitated or rendered it difficult to perform KMC (Paper IV). The time of initiation of KMC and duration in minutes, and the identity of the KMC providers was recorded continuously during the infants’ (n=104) hospital stay: 83 mothers and 80 fathers also completed a questionnaire during their infants’ hospital stay (Paper V). This thesis provides new knowledge about parents’ practice of KMC, also continuously day and night, in a high tech NICU in an affluent society, with good resources for infant care in an incubator by trained staff. The accuracy of parents’ records of KMC were comparable to nurses’ records. The results indicate that parents want to be together with their infant in the NICU and be actively involved in the infants’ care. Although parents may experience KMC as exhausting and uncomfortable, they still prefer KMC to conventional neonatal intensive care as it supports their parental role. Early initiation of KMC after birth appears to result in a longer total duration of KMC during the infants’ hospital stay.

The purpose of the study was to identify NANDA - I diagnoses, NOC outcomes, and NIC interventions used in nursing care plans for ICU patient care and determine the factors which influenced the change of the NOC outcome scores. This study was a retrospective and descriptive study using clinical data extracted from the electronic patient records of a large acute care hospital in the Midwest. Frequency analysis, one-way ANOVA analysis, and multinomial logistic regression analysis were used to analyze the data. A total of 578 ICU patient records between March 25, 2010 and May 31, 2010 were used for the analysis. Eighty - one NANDA - I diagnoses, 79 NOC outcomes, and 90 NIC interventions were identified in the nursing care plans. Acute Pain - Pain Level - Pain Management was the most frequently used NNN linkage. The examined differences in each ICU provide knowledge about care plan sets that may be useful. When the NIC interventions and NOC outcomes used in the actual ICU nursing care plans were compared with core interventions and outcomes for critical care nursing suggested by experts, the core lists could be expanded. Several factors contributing to the change in the five common NOC outcome scores were identified: the number of NANDA - I diagnoses, ICU length of stay, gender, and ICU type. The results of this study provided valuable information for the knowledge development in ICU patient care. This study also demonstrated the usefulness of NANDA - I, NOC, and NIC used in nursing care plans of the EHR. The study shows that the use of these three terminologies encourages interoperability, and reuse of the data for quality improvement or effectiveness studies.

BACKGROUND: Physical therapists (PTs) may care for full-term or premature newborns in all levels of hospital nurseries. There is some endorsement in the published physical therapy literature for restricting practice in the nursery setting to only those PTs with specialized training.1-4 PURPOSE: The purpose of this study was to understand the experiences of becoming and being a physical therapist in a special care nursery (SCN) or neonatal intensive care unit (NICU) from the therapists’ perspective. METHODS: The participants were physical therapists who have practiced in a SCN or NICU in the United States. A phenomenological approach was used and data was collected through interviews. The constant comparative method was used to analyze the data and identify common themes to describe therapists’ beliefs about becoming and being a physical therapist in a hospital nursery. RESULTS: These four themes include: 1) Never Alone, which reflects the unique collaborative culture of the NICU; 2) Families First, which speaks to the need to focus on the family, avoid judgment, and facilitate their involvement in the care of their child; 3) Take a Deep Breath, which reflects the need to be mindful and cautious because of the potential to do harm due to the extreme fragility of the infant; and 4) Know What You Don’t Know, which reflects the depth and breadth of knowledge necessary to work in the NICU/SCN. CONCLUSIONS: This project was the first to systematically research practicing therapist’s beliefs and perspectives regarding PT practice in the SCN and NICU. It is evident that current practice does not align with the adopted statements from APTA and APPT, as well as other professional associations. Much evidence draws attention to the fragility of premature neonates, yet our PT practice and education does not appropriately address these concerns.

Quality care in intensive care units is expected by patients and is mandatory for nurses and other health professionals to provide. In Saudi Arabia, the demand for intensive care units (ICUs) is growing rapidly, partly due to the high levels of road trauma and a population increase. In response to these issues, the government has increased the number of ICU beds in some public tertiary regional hospitals. A corresponding increase in patients and a shortage of specialized nurses has major implications for nurses’ ability to provide quality care. In the Western world there is comprehensive literature related to research and factors that influence nursing care. To date, however, no such study has been conducted in an ICU in Saudi Arabia. The purpose of this study was, therefore, to explore and describe factors that influence nursing care in a Saudi Arabian ICU. Additionally, since clinical governance has been described as a structured system for promoting quality care and health service planning, a further aim was to describe the findings within this framework.This study employed a single exploratory descriptive case study using a qualitative approach. Data were collected from various sources with thematic analysis being used to establish themes that emerged from the data. The proposition taken in this case study was that multiple factors influence the quality care registered nurses provide in an ICU setting. It was an assumption that these factors would be both internal and external to the ICU. Findings from this study concurred with this assumption uncovering multiple, complex and interrelated factors that influenced the quality of nursing care in the ICU. It also uncovered factors which were located in the conduit between the internal and external environment: namely intermediate factors. The environment was seen as: direct factors that immediately affected nurses and their ability to provide quality care; intermediate factors were those that encapsulated regular, but intermittent elements; and indirect factors related to elements external to the ICU. Within each of these categories themes and sub-themes emerged. Themes in the direct factors were Continuance: with sub themes of Shift work arrangement, Workload, Collegiality, and Unit management. Burden of responsibility: with sub themes of Educational preparation and Availability of Resources. Proximity: emerged as a theme which related to being close contact with patients.Themes in the intermediate factors were: Relationships with superiors, as well as Policies and protocols. Themes in the indirect factors were: Leadership and bureaucracy, Quality management, and Ongoing education. Together these factors had a profound influence on the quality of nursing care in the ICU. Some had distinctive characteristics whilst others overlapped and were interrelated clarifying and explaining aspects of the complex open system in which nursing care was provided. It is anticipated that these findings will not only have relevance to the ICU in the setting, but also to other hospitals in the Saudi Arabian health care system.

Patients who are critically ill get often admitted to intensive care units (ICUs). The majority of these patients require support with their breathing and are thus connected to a mechanical ventilator. One aspect to consider in the mechanically ventilated patient is endotracheal tube cuff pressure (ETT) management. The management of ETT cuff pressure entails that nurses working in ICUs have the responsibility of ensuring that ETT cuff pressure is kept within normal range of 20-30 cmH20 for the safety of the patients in order to avoid complication of over and under inflation. Poor management of ETT cuff pressure places the mechanically ventilated patients under risk of tracheal injury. Tracheal injury may also be caused by over or under inflation of the ETT cuff. Over inflation of the ETT cuff can lead to the occlusion of capillaries lining the trachea at the cuff site, tracheal stenosis, and can also lead to the death of mucus membranes around the area, just to mention a few. On the other hand, under inflation of the ETT cuff, can lead to air leaks as well as aspiration of gastric contents into the tracheal tree. Therefore, in order to maintain ETT cuff pressure within normal ranges, evidence-based guidelines related to the management of ETT cuff pressure should be used. However, in Malawi the management of endotracheal tube cuff pressure in mechanically ventilated adult patients by nurses in ICUs is not well explored and it is not clear whether this practice is based on evidence-based guidelines. Furthermore, strategies on how to implement evidence-based guidelines in the ICU might not be known and poorly defined because of the complexity of the context. The study is therefore aimed at implementing and evaluating the effect of an evidence-based guideline on the management of ETT cuff pressure in mechanically ventilated adult patients by nurses in ICUs in Malawi using active (printed educational materials and monitoring visits) and passive (printed educational materials only) implementation strategies. The research study used a quantitative approach with multi-designs. Four phases were used in order to achieve the four objectives that were set. Phase one was the pre-test and used a survey design, two was the expert panel review of the evidence-based guideline, three was the implementation of the reviewed evidence-based guideline using a randomised controlled trial design and phase four was the post-test which used a survey design. The RCT included 25 participants from the control and 27 from the intervention group. Each group had three ICUs of which one in each group was from a private hospital and the other were government. Data collection in phases one and four was by a hand delivered pre-and post-questionnaire. In phase two the expert panel members with experience in critical care used the AGREE II Instrument to review the evidence-based guideline that was implemented. In order to gather data during the monitoring visits, the researcher recorded field notes. The applications that were developed by the University statistician consultant using visual basic applications in excel were used to analyse data. Two different implementation strategies were used to implement the evidence-based guideline. The control group used passive implementation strategy which was printed educational materials thus the evidence-based guideline and algorithm. The intervention group used both active and passive implementation strategies which was the printed educational materials thus the evidence-based guideline and algorithm plus monitoring visits by the researcher. In order to establish the effect of the implemented evidence-based guideline on the nursing care practice for the management of endotracheal tube cuff pressure an evaluative posttest survey was conducted in phase four of the research study. The results revealed that the majority of participants had gaps in both groups regarding nursing care practice for the management of endotracheal tube cuff pressure for the mechanically ventilated adult patients in the pretest but improved in the posttest. In the control group 52% had very low knowledge score, 16% had low score, 28% average, and 4% high score while in the category of very high score there was nobody. However, in the posttest those in the very low score were only 44% while the percentage in the low score remained 16%. There was an improvement in the average scores in the posttest such that only 44% were in this category. There was no one in the high and very high score in the pretest. On the other hand, in the intervention group, 78% had a very low score, 9% low score, and 13% were in the category of average score, while in the high and very high score category there was zero percent in the pretest. However, there was also an improvement in the posttest such that only 44% a very low knowledge score. But 19% had a low score, there were 37% in the average category and no one was in the high and very high score. Statistical analysis revealed that the results were not significantly different between and within groups. Improvements were observed in the two groups regarding the scientific knowledge scores for the nursing care practices in the posttest. Upon qualitative analysis of the data from the open-ended question, two main themes emerged thus the need for documentation of endotracheal tube cuff and the process of implementation the evidence-based guidelines. Sub themes such as lack of documentation; no part of routine care and monitoring not done at all were identified under the main theme of the need for documentation of ETT cuff pressure. The Guideline itself need to be clear; implementation strategies; follow up; incentives; supervision; incentives; time factor; resources or equipment required for successful implementation; nurses buy-in critical for the implementation; training detrimental to EBP implementation; nurses attitude crucial to implementation of EBGs and knowledge of nurses for guideline essential for the implementation were the sub themes identified under the main theme of the process of implementing the evidence-based guideline. All appropriate ethical considerations such as principles of autonomy and self-determination, confidentiality and anonymity, voluntary participation, right to receive treatment, informed consent, were adhered to throughout the research study. The research study was unique in nature because it was the first of its kind in Malawi and it contributed to the awareness of the recommended practice for management of endotracheal tube cuff pressure in the ICUs in the country by implementing an evidence-based guideline. The unique contribution of the study is that it is a challenge to implement evidence-based guideline in poor and resource constraint countries like Malawi.

Thesis (MCurr)--Stellenbosch University, 2013.
ENGLISH ABSTRACT: The shortage of nurses in the intensive care units (ICU) affects both the nurse and the patient with regard to quality care and the quality of work life. Job satisfaction as well as factors within the organisation and work environment predisposes dissatisfaction. Identifying these factors may improve the quality of life at work and reduce staff shortages. The aim of this study is to evaluate the contextual factors influencing the turnover of intensive care nurses in specified hospitals in the Cape Metropole. The objectives were: • To determine the factors influencing the turnover of intensive care nurses in specified hospitals in the Cape Metropole. • To compare the findings of the data in the specified hospitals. An explorative, descriptive design with a quantitative approach has been applied. The research sample consists of all nurses working in the intensive care units in the specified hospitals at the time of the study. A convenience sampling was applied. A structured questionnaire containing predominantly closed-ended questions was used and data collection was conducted by the researcher herself. A pilot study consisting of 10% (N=21) of the sample was done in one of the hospitals to validate the reliability of the questionnaire. The 21 participants who completed the pilot test did not participate in the actual study. The reliability and validity of the findings was assured by the utilization of the statistician and experts in the nursing department. The data is presented in tables and histograms. A Chi -square test is used to test the statistical significance association between variables. Spearman’s ranks (rho) order correlation is used to show the strength of the relationship between two continuous variables. The findings of the study show that discontent with salaries, inferior working environments, organisational factors, physical as well as emotional stress and the lack of career development opportunities, were major determinants in the poor quality of life at work with regard to the two set objectives. Recommendations include those for better remuneration, improved career opportunities and the creation of a safe as well as a friendly work environment. The aim is to create a positive work environment and improve the quality of life at work.
AFRIKAANSE OPSOMMING: ’n Tekort aan verpleegsters in die intensiewesorgeenheid beïnvloed beide die verpleegster en die pasient sovêr dit die gehalte van sorg lewering en die kwaliteit van arbeidservarings in die werkplek betref. Werkstevredenheid, sowel as faktore binne die organisasie en omgewingsfaktore in die werkplek, is aanleidend tot ontevredenheid binne die organisasie. Deur hierdie faktore te identifiseer, mag die kwaliteit van werkslewe verbeter word en die verlies aan personeel verminder word. Die doel van hierdie studie is om die kontekstuele faktore wat die personeel omset van intensiewesorgverpleegsters in spesifieke hospitale in die Kaapse Metropool beïnvloed, te evalueer. Die doelwitte was: • Om die faktore wat die omset van intensiewesorgverpleegsters in spesifieke hospitale in die Kaapse metropool beinvloed, te bepaal • Om die bevindinge van die studie binne verskeiehospitale te vergelyk Om hierdie navorsingsvrae te beantwoord, is ’n verkennende en beskrywende ontwerp met ’n kwantitatiewe benadering aangewend. Die steekproef het bestaan uit alle verpleegspersoneel werksaam in die intensiewesorg-eenhede in die gespesifiseerde hospitale binne die studie vermeld . ’n Gerieflikheids-steekproef is uitgevoer. ‘n Goedgestruktueerde vraelys met hoofsaaklik geslote vrae is gebruik vir datainsameling en vraelyste was persoonlik deur die navorser ingeneem. ’n Loodsstudie wat 10% van die steekproef beslaan, (N= 21), is in een van die hospitale onderneem om sodoende die betroubaarheid van die vraelys te bevestig. Die 21 deelnemers was nie deel van die werklike studie nie. Die betroubaarheid en geldigheid van die betrokke studie is bevestig deur die statistikus en kenners in die verplegingsdepartement van sodanige inrigting. Data is voorgelê in die vorm van tabelle en histogramme. ’n Chi-vierkanttoets is gebruik om die statistiese-beduidends verwantskap tussen veranderlikes te toets. Spearman se rangorde (rho) korrelasie is gebruik om die sterkte van die verhouding tussen twee aaneenlopende veranderlikes aan te dui. Die bevindinge dui aan dat ontevredenheid oor salarisse, ‘n swak werksomgewing en organisatoriese faktore, sowel as fisiese en emosionele stres, asook ’n gebrek aan loopbaanontwikkeling, groot bepalers was van swak werkskwaliteit in terme van die twee voorgestelde doelwitte. Aanbevelings bestaan uit voorstelle vir beter salarisse, die skepping van loopbaangeleenthede en die daarstelling van ’n veilige, vriendelike, werksomgewing. Die doel is om ’n positiewe werksomgewing te skep en om die kwaliteit van werkslewe te verbeter.

Background: Critical care nurses (CCNs) frequently provide end-of-life care for critically ill patients. CCNs may face many obstacles while trying to provide quality EOL care. Some research focusing on obstacles CCNs face while trying to provide quality EOL care has been published; however, research focusing on family behavior obstacles is limited. Research focusing on family behavior as an EOL care obstacle may provide additional insight and improvement in care. Objective: What are the predominant themes noted when CCNs share their experiences of common obstacles, relating to families in providing EOL care? Methods: A random geographically dispersed sample of 2,000 members of the American Association of Critical-Care Nurses was surveyed. Responses from a qualitative question on the questionnaire were analyzed. Results: Sixty-seven EOL obstacle experiences surrounding issues with families' behavior were analyzed for this study. Experiences were categorized into 8 themes. Top three common obstacle experiences included families in denial, families going against patient wishes and advance directives, and families directing care which negatively impacted patients. Conclusions: In overcoming EOL obstacles, it may be beneficial to have proactive family meetings to align treatment goals and to involve palliative care earlier in the ICU stay.

Magister Curationis - MCur
Parents undergo negative experiences that include parental anxiety, depression, and posttraumatic stress when their new-born babies are hospitalised in neonatal intensive care unit. During this stressful period, parents need assistance from staff in order to cope. A quantitative, descriptive survey design was used to describe parents’ perception of nursing support during their baby’s admission in neonatal intensive care units (NICU) at three selected private hospitals in the city of Cape Town in the Western Cape Province. A structured existing 21- item Likert type questionnaire, the Nurse-Parent Support Tool (NPST) was used to collect data from an all-inclusive sample of 85 parents with a response rate of 78.8% (n=67). The purpose of the questionnaire was to determine their perception of information giving and communication by nurses; emotionally supportive behaviours by nurses; care given support or instrumental support and to identify parents’ perception of esteem or appraisal support while in the NICU environment. The data was analysed using Statistical Package for Social Sciences (SPSS) version 24. The findings of this study suggested that the overall mean score for parents’ perception of nursing support was high 4.6 (±0.5) out of a possible of 5. There was no significant difference in the overall mean perceived support score between the different facilities. No significant differences were found in terms of all the demographics characteristics with regard to perceptions of the support that was received, thus indicating that there was no relationship between the demographic variables and perception of support. The findings suggested that though high parental support was reported, the area of involving parents in the care of their babies i.e. letting them decide whether to stay or leave during procedures need improvement.

BACKGROUND. Intensive care units (ICUs) are "hot" areas for antibiotic consumption, infection and antibiotic resistance. Resistance affects patient outcomes, resource utilization and determines whether treatments are adequate. Within Europe, Italy has among the highest rates of antibiotic consumption but resistances - particularly in ICUs - are largely unexplored, both nationally and regionally. OBJECTIVES. To assess variation in antibiotic prescribing, consumption, resistance, and treatment outcomes and to identify critical points for improvement in antimicrobial practice across 5 ICUs in the Veneto region, North-east Italy. RESULTS. From 2002 to 2010, 911 patients were reviewed. Median K'U stay (17 days; IQR, 8-29) and ICU mortality (mean, 24.9%) were similar across sites. Empirical antibiotics were given to 853 patients (83.1%), with penicillin/β-lactamase inhibitor combinations (26%), cephalosporins (20.7%), fluoroquinolones (10.9%), and carbapenems (9.8%) frequently used. Laboratory investigation was often long delayed (median 7 days IQR = 3-14) after treatment initiation, and there were few (37.2%) microbiological-based shifts; 30.9% of empirical regimens were inadequate. Treatment inadequacy (AOR=13.99) and septic shock (AOR=3.29) were the main independent predictors for hospital mortality. Amongst 1908 isolates tested - predominantly, Pseudomonas aeruginosa (22%) and MRSA (14.8%) - 53.7% were multiresistant, with significant inter-hospital differences in resistance rates of Enterobacteriaceae to fluoroquinolones, and for P. aeruginosa to fluoroquinolones and carbapenems) (p < 0.001). The relationship between resistance and use of fluoroquinolones and 3rd_ generation cephalosporins was clear for Enterobacteriaceae (p < 0.001), but weaker for P. aeruginosa. The susceptibility of Escherichia coli to fluoroquinolones decreased over time (X2 = 0.009). Antibiotic use was inflated, especially at one ICU with excess of fluoroquinolone (94.4 DDD/100 bed-days vs. 26.1-35.9 elsewhere) use. CONCLUSIONS. Considerable inter-hospital variation III prescribing affected antibiotic consumption and resistance prevalence. Poor and delayed use of laboratory microbiology was prominent, as was the uncontrolled use of antibiotics. Urgent interventions are needed and improvement strategies are discussed.

Thesis: S.M., Massachusetts Institute of Technology, Department of Mechanical Engineering, 2015. In conjunction with the Leaders for Global Operations Program at MIT.
Thesis: M.B.A., Massachusetts Institute of Technology, Sloan School of Management, 2015. In conjunction with the Leaders for Global Operations Program at MIT.
Cataloged from PDF version of thesis.
Includes bibliographical references (pages 101-107).
This thesis provides a new framework for understanding how conditions, people, and environments of the Intensive Care Unit (ICU) effect the likelihood the preventable harm will happen to a patient in the ICU. Two years of electronic medical records from seven adult ICUs totalling 77 beds at Beth Israel Deaconess Medical Center (BIDMC) were analysed. Our approach is based on several new ideas. First, instead of measuring safety through frequency measurement of a few relatively rare harms, we leverage electronic databases in the hospital to measure Total Burden of Harm, which is an aggregated measure of a broad range of harms. We believe that this measure better reflects the true level of harm occurring in Intensive Care Units and also provides hope for more statistical power to understand underlying contributors to harm. Second, instead of analysing root causes of specific harms or risk factors of individual patients, we focus on what we call Risk Drivers, which are conditions of the ICU system, people (staff, patients, families) and environments that affect the likelihood of harms to occur, and potentially their outcomes. The underlying premise is that there is a relatively small number of risk drivers which are common to many harms. Moreover, our hope is that the analysis will lead to system level interventions that are not necessarily aiming at a specific harm, but change the quality and safety of the system. Third, using two years of data that includes measurements of harms and drivers values of each shift and each of seven ICUs at BIDMC, we develop an innovative statistical approach that identifies important drivers and High and Low Risky States. Risky States are defined through specific combinations of values of Risk Drivers. They define environmental characteristics of ICUs and shifts that are correlated with higher or lower risk level of harms. To develop a measurable set of Risk Drivers, a survey of current ICU quality metrics was conducted and augmented with the clinical experience of senior critical care providers at BIDMC. A robust machine learning algorithm with a series of validation techniques was developed to determine the importance of and interactions between multiple quality metrics. We believe that the method is adaptable to different hospital environments. Sixteen statistically significant Risky States (p < .02) where identified at BIDMC. The harm rates in the Risky States range over a factor of 10, with high risk states comprising more that 13.9% of the total operational time in the ICU, and low risk states comprise 38% of total operating shifts. The new methodology and validation technique was developed with the goal of providing a basic tools which are adaptable to different hospitals. The algorithm described within serves as the foundation for software under development by Aptima Human Engineering and the VA Hospital network with the goal of validation and implementation in over 150 hospitals. In the second part of this thesis, a new heuristic is developed to facilitate the optimal design of stochastic manufacturing systems. The heuristic converges to optimal, or near optimal results in all test cases in a reasonable length of time. The heuristic allows production system designers to better understand the balance between operating costs, inventory costs, and reliability.
by J Adam Traina.
S.M.
M.B.A.

Clinical social workers have roles in providing end-of-life care in the United States. Although clinical social workers are present in the intensive care unit (ICU) setting and have expertise to address end-of-life care dynamics, social workers are not consistently included in end-of-life discussions in the ICU setting. The purpose of this action research study was to explore the barriers that prevent clinical social workers from being included in end-of-life discussions in the ICU and how clinical social workers perceive their roles in end-of-life discussions in the adult ICU setting. Open-ended questions were used to gather data by facilitating 4 focus groups with 17 clinical social workers employed at a Florida hospital. This study was guided by complexity theory, which is concerned with complex systems and how systems can produce order while simultaneously creating unpredictable system behavior. A thematic analysis coding technique was used to analyze the data collected. Three themes emerged from data analysis: the ICU setting as chaotic, complex, and unpredictable; role ambiguity; and lack of confidence of social workers to perform expected roles in end-of-life discussions. The implications of this study for social work practice and social change relate to closing the gap between the patient, family members, social workers, and the medical team by developing protocols that consistently include social workers in end-of-life discussions, including education for the multidisciplinary team in the ICU on the skill set and role of clinical social workers in end-of-life discussions and formal training and education for clinical social workers regarding end-of-life care.

A critical care unit is a dynamic and highly technological environment. Professional nurses who have been working in the critical care unit for a period of time are passionate about the environment in which they work. They find their on duty time challenging and stimulating. The critical care environment is slowly changing. Due to the fact that there are fewer professional nurses with an additional qualification in critical care available to work in the critical care units. The utilisation of an increasing number of agency nurses leads to an increase in sub-standard nursing care as well as dissatisfied doctors and patients. The shortage of critical care staff has resulted in the need to find an alternative human resources framework and still provide cost effective, safe quality patient care. This leads to the design and implementation of a team nursing care framework for critical care. The research objectives for this study were: - To explore and describe the experiences of professional nurses with regard to a team nursing care framework in private critical care units. - Develop guidelines to optimize the team nursing care framework in critical care units in a private hospital group. The research is based on a qualitative, explorative, descriptive and contextual research design. The study is based on a phenomenological approach to inquiry. Eleven in-depth semi structured face-to-face phenomenological interviews were utilized as the main means of collecting data. A purposive, criterion based, sampling method was used. Specific inclusion criteria were met and consent was obtained from the participants and from the management of the private clinic where the research was conducted. Two central themes were identified:- Theme One: The professional nurses experienced the team nursing care framework in the critical care unit as a burden. Six sub-themes were identified. - Theme Two: Professional nurses made recommendations for improvement of the team nursing care framework in the critical care unit. By describing the lived experiences of the professional nurses in the critical care units, based on research interviews, the researcher painted a clear picture of the team nursing care framework in the critical care unit. Guidelines were developed based on the identified themes. The broad guidelines are aimed at ensuring that the nurses are competent to care for critical care patients prior to them commencing work in the critical care unit. The researcher concludes this study by making recommendations for Nursing practice, education and research.

A segurança do paciente grave é uma meta da qualidade do atendimento em Unidade de Terapia Intensiva (UTI), daí a necessidade de se investigar os fatores relacionados à ocorrência de eventos adversos nesse contexto. Trata-se este estudo de uma pesquisa quantitativa, retrospectiva, analítico-transversal que teve como objetivo analisar os fatores associados aos incidentes e/ou eventos adversos (INC/EA) no preparo e administração de medicamentos, nos cuidados com tubo endotraqueal/traqueostomia, sondas, drenos, cateteres e queda em UTI segundo as características demográficas e clínicas do paciente e recursos estruturais da Unidade. Os dados foram coletados por meio dos registros de INC/EA dos prontuários dos pacientes que tiveram notificado algum tipo de INC/EA no período de 2003 e 2006, inclusive, em cinco UTI de cinco hospitais do Município de São Paulo. No tratamento estatístico, foi utilizada a análise de regressão logística multivariada para a identificação dos fatores independentes de INC/EA e condições de saída da Unidade. Para a identificação dos fatores independentes do tempo de permanência nas UTI, utilizou-se a análise de regressão linear múltipla. As variáveis que entraram nos modelos foram aquelas que apresentaram na regressão logística univariada um valor de teste Wald<0,20; em todas as análises realizadas foi utilizado o nível de significância de 5%. Do total de 21.230 admissões nas UTI, 377 (1,78%) pacientes sofreram algum tipo de INC/EA. Foram notificadas 461 ocorrências, a maioria relacionada ao preparo e administração de medicamentos (196-42,51%), seguidas aos cateteres periféricos e arteriais (105-22,77%) e às sondas nasogástricas (73-15,83%). Quanto aos fatores associados aos INC/EA e recursos materiais/equipamentos e ambiente físico das unidades, o baixo número de ocorrências (16-2,82%) inviabilizou a análise dessas variáveis. Da mesma forma, nenhum hospital dispunha das escalas diárias de enfermagem com dados retrospectivos sobre os recursos humanos existentes no período do estudo. Verificou-se que o número de dias de permanência dos artefatos terapêuticos foi um dos principais fatores independentes associados aos INC/EA quer no preparo e administração de medicamentos (número de dias de TE/Traq.), quer nos cuidados com cateter periférico, sonda nasogástrica e cateter central (número de dias de artefatos terapêuticos), seguidos da gravidade e da não sobrevivência dos pacientes. Referente ao tempo de permanência na UTI, os fatores associados foram número de dias de sondas, drenos e cateteres, número de itens da prescrição medicamentosa, não sobrevivência e INC/EA com cateteres periféricos e medicamentos. Finalizando, constatou-se que pacientes não sobreviventes tiveram maior número de dias com TE/Traq., eram mais graves e apresentaram, aproximadamente, cinco vezes mais chance de sofrer um INC/EA com TE/Traq.. Considerando que o enfoque da segurança do paciente é de responsabilidade compartilhada de todos os profissionais, da área de saúde ou não, julga-se que os resultados dessa investigação contribuam para a melhoria da assistência ao paciente crítico, por abrir perspectivas para o estabelecimento de protocolos de prevenção dessas ocorrências
The safety of serious patients is a goal of the quality of service in Intensive Care Units (ICUs), therefore, the need to investigate the factors related to the occurrence of adverse events in this context. This study reports a quantitative, retrospective, analytic-transversal research that aimed to analyze the factors associated with the incidents and/or adverse events (INC/AE) in the preparation and administration of medication, in the care of endotracheal/tracheostomy tubes, probes, drains, catheters and fall in ICUs according to the demographic and clinical characteristics of patients and structural resources of the Units. Data was collected from the registry of INC/AE made in the charts of patients that were notified with some type of INC/AE in five ICUs of five hospitals of the City of Sao Paulo from 2003 to 2006. The statistical treatment consisted of an analysis of multivariate logistic regression to identify the independent factors of INC/AE and exit conditions of the Units. The author also ran the multiple linear regression analysis to identify the independent factors of the length of stay in the ICUs. Variables that presented a Wald test rate <0,20 in the univariate logistic regression entered in the models. All analysis adopted a 5% significance level. From 21.230 total admissions in the ICUs, 377 (1,78%) patients suffered some type of INC/AE. A total of 461 occurrences were notified. Most of these occurrences were related to the preparation and administration of medication (196-42,51%), followed by the peripheral catheters and A- lines (105-22,77%), and the nasograstic tubes (73-15,83%). The low number of occurrences (16-2,82%) of factors associated with INC/AE, material/equipment resources and physical settings of the units made the analysis of these variables unfeasible. The same way, no hospital made available daily nursing schedules that contained retrospective data about the existing human resources at the time of the study. The author verified that the number of days of use of therapeutic artifacts was one of the main independent factors associated with INC/AE. These related to the preparation and administration of medication (number of days of TE/Traq.), as well as to the care of peripheral catheters, nasograstic tubes and central catheters (number of days of therapeutic artifacts), followed by seriousness and non-survival of the patients. The factors associated with the length of stay in the ICU were number of days with probes, drains and catheters, number of items of the prescribed medication, non-survival and INC/AE with peripheral catheters and medication. At last, the author established that non-survival patients spent a greater number of days with TE/Traq. They were also more serious and were about five times more likely to suffer INC/AE with TE/Traq. Considering that the focus of a patient safety is shared responsibility of all professionals, from the health field or not, the author considers that the results of this investigation contribute to the improvement of the assistance to critical patients, as it opens perspectives for the establishment of protocols for the prevention of such occurrences