Introducing palliative care into the intensive care unit: An interventional study.

BACKGROUND: Many Intensive Care Unit (ICU) deaths include patient and family suffering. While there is a need to include palliative care in the ICU, such care is often unavailable. OBJECTIVES: To determine whether a course in ICU Palliative Care was associated with changes in participants' palliative care knowledge, attitudes and practices. METHODS: Four cohorts of a national Israeli course in ICU palliative care (N = 122) were followed. Data were collected on the first and last day of a six-month course and 2-5 years later. RESULTS: Statistically significant differences were found in palliative care attitudes and practices, with knowledge levels and quality of death and dying stable after course completion. Participants reported obtaining knowledge and skills necessary to introduce palliative care but were thwarted by organizational barriers. CONCLUSIONS: The course was successful in building participants capacity to provide palliative care however; barriers made introduction of palliative care into the ICU difficult.

The quality of intensive care unit nurse handover related to end of life: a descriptive comparative international study.

BACKGROUND: Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it. OBJECTIVE: The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries. DESIGN: This was a descriptive comparative study. SETTINGS: The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units). PARTICIPANTS: A convenience sample of 157 handovers was studied. METHODS: Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors. RESULTS: The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154)=25.97, p=<.001; unit: F(6,150)=58.24, p=<.001), for the end of life subscale (country: F(2, 154)=28.23, p<.001; unit: F(6,150)=25.25, p=<.001), the family communication subscale (country: F(2,154)=15.04, p=<.001; unit: F(6,150)=27.38, p=<.001), the family needs subscale (F(2,154)=22.33, p=<.001; unit: F(6,150)=42.45, p=<.001) but only for units on the process subscale (F(6,150)=8.98, p=<.001. The total handover score was higher if the oncoming RN did not know the patient (F(1,155)=6.51, p=<.05), if the patient was expected to die during the shift (F(1,155)=89.67, p=<.01) and if the family were present (F(1,155)=25.81, p=<.01). CONCLUSIONS: Practices of end-of-life-handover communication vary greatly between units. However, room for improvement exists in all areas in all of the units studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool.

Translation of oral care practice guidelines into clinical practice by intensive care unit nurses.

PURPOSE: The purpose of this study was to determine whether there was a change in the oral care practices of intensive care unit (ICU) nurses for ventilated patients after a national effort to increase evidence-based oral care practices. DESIGN: Descriptive comparison of ICU nurses in 2004-2005 and 2012. METHOD: Two convenience national surveys of ICU nurses were collected in 2004-2005 (n = 218) and 2012 (n = 233). After the results of the initial survey were reported, a national effort to increase awareness of evidence-based oral care practices was conducted that included in-service presentations; publication of an evidence-based protocol in a national nursing journal; publication of the survey findings in an international nursing journal; and reports to the local press. A repeat survey was conducted 7 to 8 years later. The same survey instrument was used for both periods of data collection. This questionnaire included questions about demographic and personal characteristics and a checklist of oral care practices. Nurses rated their perceived priority level concerning oral care on a scale from 0 to 100. An evidence-based practice (EBP)[O4] score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with the evidence. The EBP score, priority score, and oral care practices were compared between the two samples. A regression model was built based on those variables that were associated with the EBP score in 2012. FINDINGS: There was a statistically significant increase in the use of EBPs as shown by the EBP score and in the perceived priority level of oral care. Increased EBPs were found in the areas of teeth brushing and oral assessment. Decreases were found in the use of non-evidence-based practices, such as the use of gauze pads, tongue depressors, lemon water, and sodium bicarbonate. No differences were found in the use of chlorhexidine, toothpaste, or the nursing documentation of oral care practices. A multiple regression model was found to be significant with the time of participation (2004-2005 vs. 2012) and priority level of oral care significantly contributing to the regression model. CONCLUSIONS: The national effort was partially successful in improving evidence-based oral care practices; however, increased awareness to EBP also might have come from other sources. Other strategies related to knowledge translation need to be attempted and researched in this clinical setting such as the use of opinion leaders, audits and feedback, small group consensus, provider reminder systems, incentives, clinical information systems, and computer decision support systems. CLINICAL RELEVANCE: This national effort to improve EBP did reap some rewards; however, other knowledge translation strategies should be used to further improve clinical practice.