The Relationship Between Nursing Workload, Quality of Care, and Nursing Payment in Intensive Care Units.

BACKGROUND: Nursing workload is highly associated with patient safety. It has been argued that the imbalance between nursing payment and nursing workload in Taiwan National Health Insurance (NHI)-covered intensive care units (ICUs) has resulted in the inadequate allocation of nursing manpower. However, limited empirical data are currently available to support this argument. PURPOSE: The aim of this study was to investigate the correlation between nursing workload, quality of care, and NHI-covered nursing payments in ICU settings. METHODS: This macrodata analysis study retrieved data from the existing ICU patient classification system, nursing quality monitoring system, and infection control monitoring system of a medical center in central Taiwan. Data on the Therapeutic Intervention Scoring System-28 (TISS-28) and non-TISS-28 scores, nursing hours, and nursing labor utilization rate were retrieved for the 23-month period beginning in January 2013 and ending in November 2014. The indices of care quality used in this study included incidence of falls, pressure sore density, incidence of restraint use, incidence of tube self-extraction, and infection density. RESULTS: A total of 92,442 data sets were collected from eight ICUs, with 61% of the direct ICU nursing hours categorized as TISS-28 and 39% categorized as non-TISS-28. Mean nursing hours totaled 12.5 hours. The direct nursing hours, the total nursing hours, the bed occupancy rate, the nursing hours calculated by patient classification system, and the nursing hours calculated by nurse-patient ratio were statistically, significantly correlated respectively with all of the care quality indices except for incidence of falls. The number of items of patient care in the patient classification records was greater than that of NHI-covered nursing payments. The NHI-covered nursing payment for every patient accounted for only 4.77% of the total medical expenses in the ICU. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Data from the patient classification database, quality monitoring database, and medical cost database indicate excessive nursing workload and underpayment from the Taiwan NHI program. Current nursing workload was significantly associated with care quality. This study provides empirical data for administrators to consider when revising nursing staffing and NHI payment policies.

Effectiveness of coffee for postoperative ileus in patients following abdominal surgery: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The purpose of this systematic review is to critically appraise, synthesize and present the best available evidence concerning the effects of coffee on postoperative ileus following abdominal surgery. The review will consider the effect of coffee and decaffeinated coffee on recovering gastrointestinal function, time to first bowel movement, time to first flatus, time to tolerance of solid food, postoperative complications and length of hospital stay.

The Effects of Aromatherapy Massage on Sleep Quality of Nurses on Monthly Rotating Night Shifts.

The goal of this study is to examine the effects of aromatherapy massage on sleep quality of nurses with monthly rotating night shifts. Subjects were enrolled at a medical center in central Taiwan with overall score ≥ 5 of Pittsburgh Sleep Quality Index (PSQI) and randomly assigned to the treatment or control groups. They were validated by pretests during their first graveyard shift in the trial period and the sleep quality information was collected by using the PSQI and sleep detectors. During the second graveyard shift, the treatment group received aromatherapy massage and the control group rested in the same aromatherapy room after work. All subjects filled out the PSQI surveys and the sleep quality information was collected during massage or resting and the following night. We found that the total PSQI was significantly decreased in the treatment group following the aromatherapy massage. Specifically, the components such as subjective sleep quality, sleep disturbance, and daytime dysfunction were significantly decreased. However, there were no significant changes of average PSQI scores between the two groups before and after intervention. Taken together, our study suggested that aromatherapy massage could improve sleep quality of nurses with monthly rotating night shift.

The Relationship Between Nursing Workload, Quality of Care and Nursing Payment in Intensive Care Units.

Nursing workload adversely affects patient safety in intensive care units, the higher nursing care hours were lower incidence rate of bedsores.

The Efficacy of an In-Service Education Program Designed to Enhance the Effectiveness of Physical Restraints.

BACKGROUND: Physical restraints are used to enhance the safety of patients and to avoid injury. However, physical restraints may cause injuries if improperly used or if they are used in the absence of continuous monitoring. Nursing staff who use physical restraints often lack sufficient related knowledge, which may increase the risk to patient safety. PURPOSE: This study investigates the impact of an in-service education program for nursing staff that is designed to improve physical-restraint-related knowledge, attitudes, behaviors, and techniques. METHODS: A pretest-posttest design and a quasi-experimental method were employed to evaluate the effectiveness of the in-service education program. One hundred thirty-six nursing staff from four adult intensive care units (ICUs), including two medical ICUs and two surgical ICUs, in a medical center in central Taiwan were enrolled as participants. The experimental group (EG) and the control group (CG) were composed of patients from one randomly assigned medical ICU and one randomly assigned surgical ICU each. The pretest data on physical-restraint-related knowledge, attitudes, behaviors, and techniques were collected before the in-service education program. The EG received 2 hours of classroom education on guidelines and techniques related to physical restraints. The posttest data for the two groups were collected a month after implementation of the in-service education program. General Estimation Equation was used to measure and analyze the data repeatedly. RESULTS: The posttest scores of the EG for knowledge and technique were significantly higher than the pretest scores (p < .0001). However, the posttest scores of the EG for attitudes and behaviors did not significantly differ from the pretest scores. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: In-service education for physical restraints enhances relevant knowledge and techniques but does not significantly affect attitudes or behaviors. Correct implementation of physical restraints not only promotes the quality of nursing care for patients in the ICU but also reduces the risk of physical-restraint-related complications. This study highlights the importance of changing the thoughts and concepts related to the use of physical restraints within the overall caring strategy of hospitals.

[Review and analysis of the review results of Taiwan nurses association nursing projects (2011~2013)].

BACKGROUND: Nursing projects are a key part of N4 professional competency training for nursing personnel. Low passage rates for these projects have been shown to negatively affect the intent of nursing personnel to advance further in the nursing ladder system. PURPOSE: This study analyzes the scores for nursing projects between 2011 and 2013, the passage rate for these projects, and the differences in passage rates between different types of projects. METHOD: This retrospective and descriptive study collected data on nursing projects conducted under the auspices of the Taiwan Nurses Association between 2011 and 2013. Furthermore, the comments of reviewers on 100 nursing projects were randomly selected and subjected to content analysis. RESULTS: A total of 3,359 nursing projects were examined. Eliminating unqualified nursing projects left a total of 3,246 projects for the dataset. A total of 1,099 projects were scored with passing grades, giving a passing rate of 33.9%. The authors of these passing projects worked primarily in northern Taiwan, worked in medical centers, and worked in intensive care departments. The projects submitted by authors in central Taiwan had the highest average score and passing rate, while those living in offshore islands had the lowest average score and passing rate. Most of the project topics belonged to the category: "improvement of nursing service skills or quality" (77.3%). Items with the lowest scores were: validation of questions, analysis of the current situation, and evaluation of results. The topics of nursing projects did not relate significantly to passing rate. However, years of experience, geographic location of hospital, level of institution, and department each had a statistically significant impact on the passage rate. A content analysis of reviewer comments was used to extract common problems. Most of the positive comments were related to the category of "literature review and reference", while most of the negative comments were related to the categories of "literature review and reference", "analysis of current situation", "problem result and process", "evaluation of results", and "validation of questions". CONCLUSIONS / IMPLICATIONS FOR PRACTICE: This study analyzed the types of nursing projects, the trends in submission, and the comments of project reviewers. The results indicate that the validation of problems in project writing and current situation analysis and the evaluation of results should be improved. These findings may be referenced by nursing personnel for executing projects in the future and for developing improved criteria / methodologies for the clinical ladder system for nursing personnel.

Chair-sitting exercise intervention does not improve respiratory muscle function in mechanically ventilated intensive care unit patients.

BACKGROUND: Chair-sitting may allow for more readily activated scalene, sternocleidomastoid, and parasternal intercostal muscles, and may raise and enlarge the upper thoracic cage, thereby allowing the thoracic cage to be more easily compressed. OBJECTIVE: To evaluate the effect of chair-sitting during exercise training on respiratory muscle function in mechanically ventilated patients. METHODS: We randomized 16 patients to a control group and 18 patients to a chair-sitting group. The patients in the chair-sitting group were transferred by 2 intensive care unit nurses from bed to armchair and rested for at least 30 min, based on the individual patient's tolerance. We measured heart rate, blood pressure, S(pO(2)), and respiratory rate. In the treatment group, before transferring the patient from bed to armchair, and 30 min after the completion of chair-sitting we measured respiratory muscle function variables, including the ratio of respiratory rate (f) to tidal volume (V(T)), S(pO(2)), maximum inspiratory pressure (P(Imax)) and maximum expiratory pressure (P(Emax)). In the control patients we took those same measurements while the patient was in semirecumbent position, before and after treatments, for at least 6 days or until the patient was discharged from the intensive care unit or died. RESULTS: The 2 groups did not significantly differ in age, sex, or clinical outcomes. Respiratory rate, V(T), f/V(T), S(pO(2)), P(Imax), and P(Emax) were not significantly better in the chair-sitting group. The study period significantly improved respiratory rate, V(T), P(Imax), and P(Emax) (all P < .001), but not f/V(T). CONCLUSIONS: Six days of chair-sitting exercise training did not significantly improve respiratory muscle function in mechanically ventilated patients.

Influence of physical restraint on unplanned extubation of adult intensive care patients: a case-control study.

BACKGROUND: Unplanned extubation commonly occurs in intensive care units. Various physical restraints have been used to prevent patients from removing their endotracheal tubes. However, physical restraint not only does not consistently prevent injury but also may be a safety hazard to patients. OBJECTIVES: To evaluate the effect of physical restraint on unplanned extubation in adult intensive care patients. METHODS: A total of 100 patients with unplanned extubations and 200 age-, sex-, and diagnosis-matched controls with no record of unplanned extubation were included in this case-control study. The 300 participants were selected from a population of 1455 patients receiving mechanical ventilation during a 21-month period in an adult intensive care unit at a medical center in Taiwan. Data were collected by reviewing medical records and incident reports of unplanned extubation. RESULTS: The incidence rate of unplanned extubation was 8.7%. Factors associated with increased risk for unplanned extubation included use of physical restraints (increased risk, 3.11 times), nosocomial infection (increased risk, 2.02 times), and a score of 9 or greater on the Glasgow Coma Scale on admission to the unit (increased risk, 1.98 times). Episodes of unplanned extubation also were associated with longer stays in the unit. CONCLUSIONS: An impaired level of consciousness on admission to the intensive care unit and the presence of nosocomial infection intensify the risk for unplanned extubation, even when physical restraints are used. To minimize the risk of unplanned extubation, nurses must establish better standards for using restraints.

Effects of prone position on inflammatory markers in patients with ARDS due to community-acquired pneumonia.

BACKGROUND/PURPOSE: Acute respiratory distress syndrome (ARDS) is a serious disorder of intensive care unit patients. We evaluated the safety of continuous prone position ventilation (PRONE) and its effects on oxygenation and plasma cytokine concentrations in patients with ARDS caused by severe community-acquired pneumonia (CAP). METHODS: This was a prospective observational clinical study conducted in a respiratory intensive care unit of a 1200-bed medical center in central Taiwan. Twenty-two patients with severe CAP and ARDS were included. They were treated by traditional supine ventilation (SUPINE, n = 11) or PRONE (n = 11) if they met the criteria for ARDS. Patients in the PRONE group were ventilated in prone position continuously for at least 72 hours. Plasma cytokines were collected and analyzed at baseline, 24 hours and 72 hours after enrolment. Serial PaO2/FiO2 and complications were evaluated. RESULTS: Complications associated with PRONE were minor and self-limited. PRONE had higher PaO2/FiO2 ratio than SUPINE did at 48 hours after enrolment. The levels of plasma IL-6 concentration declined significantly with time in the PRONE group (p = 0.011). The levels of plasma IL-6 concentration at enrolment, 24 hours and 72 hours after enrolment also predicted the 14th day mortality of all patients. CONCLUSION: PRONE was a safe and effective maneuver for improving oxygenation in patients with severe CAP and ARDS. PRONE also influenced IL-6 expression in patients with severe CAP.