The effect of vasopressor agents on pressure injury development in intensive care patients.

BACKGROUND: Vasopressors are life-saving agents that increase mean arterial pressure. The pharmacodynamic features of these agents and previous studies suggest that vasopressors may be an essential risk factor in developing pressure injuries. OBJECTIVE: This study aimed to examine the effect of vasopressors in medical-surgical intensive care patients on pressure injury development. DESIGN AND SETTINGS: This retrospective and correlational study was conducted between March 2021- May 2022. The electronic patient data were obtained from 148 surgical and medical patients exposed to vasopressor agents in the intensive care unit. Data on patients' demographic and clinical characteristics were evaluated using descriptive statistical methods (number, percentage, mean, standard deviation). Logistic regression modelling was used to assess independent relationships with pressure injury risk; results are reported as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: All patients were given norepinephrine agents, and dopamine infusion secondary to norepinephrine was found in only 28.3 % of patients (n = 42). Pressure injury incidence was 43.2 % (n = 64). Duration of norepinephrine infusion was recognized as an independent risk factor for ICU-acquired pressure injury development (OR 1.22, 95 % CI 1.11-1.35), while a medical admission diagnosis (instead of surgical) was protective against pressure injury risk (OR 0.24, 95 % CI 0.10-0.59). CONCLUSION: This study indicated that duration of norepinephrine infusion is a significant risk factor for pressure injury development. IMPLICATIONS FOR CLINICAL PRACTICE: Although norepinephrine use cannot be avoided entirely, its administration may be an early warning for nurses to increase pressure injury prevention strategies. Skin evaluation should be performed more frequently, and preventive strategies should be implemented meticulously. This study was registered on clincialtrials.gov (Identifier: NCT06163352).

Opinions and experiences of healthcare professionals regarding structured virtual patient visits in ICUs: A qualitative study.

OBJECTIVES: This study aimed to reveal the experiences of healthcare professionals regarding a structured Virtual Patient Visit (sVPV) program implemented in an ICU during the coronavirus disease 2019 (COVID-19) pandemic and to share the process of establishing the program. DESIGN: This qualitative, exploratory study was conducted using a semi-structured, in-depth interview method. SETTING: The study was conducted in a university hospital ICU in Turkey (where a sVPV program was implemented) and comprised one physician, eight nurses, and one clerk who volunteered to participate in the study. The data were evaluated with content analysis, and themes and sub-themes were determined. FINDINGS: Five themes and 13 subthemes were obtained: (1) an essential program during the pandemic, (2) contributing to patient's recovery, (3) family-centered care, (4) innovativeness, and (5) sustainability. CONCLUSION: The results show that the sVPV program is highly innovative and effective and contributed to positive patient outcomes and family-centered care practices during the COVID-19 pandemic. In addition, it was revealed that in order to conduct sVPVs effectively, organizational planning, such as legal processes, and the employment of experienced and competent healthcare professionals, should be well managed. CLINICAL RELEVANCE: A well-designed sVPV program specific to the setting alleviates anxiety among patients and family members, increases patient motivation and healing, and decreases the workloads of healthcare professionals. It is recommended that the sVPV program, which can be easily used during not only COVID-19 pandemics but also during other crises, be adopted in all ICUs and carried out by a dedicated nurse or healthcare provider.

Endotracheal Tube Cuff Pressure Management: An Observational Study Guided by the SEIPS Model.

INTRODUCTION: The aim of the rigorous endotracheal tube cuff pressure (ETTCP) management is to maintain cuff pressures within the recommended values during the mechanical ventilation period. However, hyperinflation or hypoinflation of cuff has been reported because of inconsistent clinical practices in intensive care unit (ICU) settings. Furthermore, there is no available best evidence for clinical decision-making regarding the ETTCP management provided by international institutes. PURPOSE: The aim of this study was to examine the ETTCP management work system in ICU settings in urban hospitals of Turkey and the United States using the Systems Engineering Initiative for Patient Safety model. METHODS: This was a direct observational, prospective field study, in which the COREQ (Consolidated Criteria for Reporting Qualitative Research) tool was used. The direct observations and follow-up interviews were conducted, and the results were reported using the Systems Engineering Initiative for Patient Safety model. RESULTS: We identified important characteristics of the ETTCP management work system in each of the 4 ICU and differences across the settings. CONCLUSION: Common use of the evidence-based and internationally used protocols may standardize the management of ETTCP, improve communication among ICU staff, and promote desired patient outcomes. RELEVANCE TO CLINICAL PRACTICE: There is a need for developing strategies to provide standardized ETTCP management and to improve patient's quality of care. To improve the patient outcomes and quality of care, ICU managers should consider clear expectations for ETTCP management in each job description, structured and evidence-based protocols, and effective communication among disciplines and provide teaching opportunities to encourage physicians, nurses, and respiratory therapists to meet their educational needs.

Case study: An older COVID-19 patient in a Turkish intensive care unit with prolonged stay.

This paper reports the presentation and management of an older female patient who was diagnosed with Coronavirus disease (COVID-19) and discharged from an intensive care unit (ICU) after prolonged hospitalization. The patient's COVID-19 test was negative; therefore, she was monitored in the COVID-19 general clinic with normal levels of oxygen saturation (SpO2 ). The patient had been taking Plaquenil for rheumatoid arthritis for a long time. Azithromycin was administered first, and then, the treatment continued with favipiravir according to the national treatment protocol in Turkey. On the third day in the COVID-19 general clinic, she was transferred to the ICU because of decreased saturation levels. Owing to worsening respiratory status and SpO2 <70%, the patient was intubated on the sixth day in the ICU, and every day, she was nursed in a prone position for >16 hours. We believe that the treatment and care activities under qualified and effective nursing care, such as providing appropriate respiratory support at the right time, early initiation and maintenance of anticoagulant therapy, long-term prone positioning, maintaining sufficient fluid resuscitation, and early commencement of balanced enteral nutrition, contributed to the successful discharge of the patient from the ICU. The patient was finally extubated on the 23rd day. Respiratory support was continued with oxygen administered at 2 lt/min through a nasal canula with SpO2 at 94%. We believe that by combining all these factors, the patient's results improved. She was discharged from the ICU after 25 days without any organ dysfunction. During the 25 days of care in the ICU, infectious disease protection and isolation rules were strictly adhered to, and personal protective equipment was worn.

The effect of structured virtual patient visits (sVPVs) on COVID-19 patients and relatives' anxiety levels in intensive care unit.

AIM AND OBJECTIVES: To determine the effect of structured Virtual Patient Visits (sVPVs) on the anxiety, satisfaction, hospital anxiety and depression levels of intensive care unit (ICU) COVID-19 patients and their relatives. BACKGROUND: There is no evidence regarding the direct effect of virtual patient visits in the ICU. DESIGN: The STROBE statement guided this study. This investigator-initiated, prospective and single-centre study included COVID-19 patients and their relatives in an adult ICU between July and December 2020. We implemented daily sVPVs between all patients and their relatives. The study's primary outcome was the daily anxiety levels of patients and relatives immediately before and after sVPVs. The secondary outcomes were as follows: 1) hospital anxiety (HADS-A) and depression (HADS-D) levels during admission to and after discharge from the ICU and 2) satisfaction levels regarding the ICU and sVPVs of patients' relatives. RESULTS: A total number of 301 daily sVPVs were conducted between 50 patients and their relatives. There was a significant difference between daily anxiety levels before and after sVPVs in both patients (2.97 vs. 1.49) and their relatives (5.70 vs. 3.53; p > .05). Whereas the anxiety levels of patients with basic face or high flow nasal cannula and non-invasive mechanical ventilation decreased statistically significantly more than those with IMV after a sVPV (p < .001), there was not a significant difference in decreased anxiety levels of patients' relatives according to the type of respiratory support provided to the patient (p > .05). HADS-A levels of relatives decreased statistically significantly after discharge/death. There was no statistically significant difference in HADS-A and HADS-D levels after discharge/death between the relatives of patients who died or did not die (p > .05). Furthermore, the overall ICU satisfaction rates were statistically significantly lower in relatives of patients who died than those who did not die (p < .05). CONCLUSION: Regardless of whether the patients were intubated, sVPVs reduced the anxiety levels of all patients and relatives. The sVPV programme offered emotional support to patients and family members, with high levels of satisfaction, as well as provided regular informative updates and the opportunity for daily visits or final goodbyes. RELEVANCE FOR CLINICAL PRACTICE: The sVPV programme is essential for all ICUs during the COVID-19 pandemic.

"Noise Factory": A qualitative study exploring healthcare providers' perceptions of noise in the intensive care unit.

OBJECTIVES: This study aimed to explore healthcare providers' perceptions of noise in the intensive care unit. DESIGN: A qualitative exploratory study was conducted using group interviews. SETTING: The setting comprised a total of 15 participants (five physicians and ten registered nurses) working in an 18-bed medical surgical intensive care unit at a teaching hospital in Istanbul, Turkey. Semi-structured questions were formulated and used in focus group interviews, after which the recorded interviews were transcribed by the researchers. Thematic analysis was used to identify significant statements and initial codes. FINDINGS: Four themes were identified: the meaning of noise, sources of noise, effects of noise and prevention and management of noise. It was found that noise was an inevitable feature of the intensive care unit. The most common sources of noise were human-induced. It was also determined that device-induced noise, such as alarms, did not produce a lot of noise; however, when staff were late in responding, the sound transformed into noise. Furthermore, it was observed that efforts to decrease noise levels taken by staff had only a momentary effect, changing nothing in the long term because the entire team failed to implement any initiatives consistently. The majority of nurses stated that they were now becoming insensitive to the noise due to the constant exposure to device-induced noise. CONCLUSION: The data obtained from this study showed that especially human-induced noise threatened healthcare providers' cognitive task functions, concentration and job performance, impaired communication and negatively affected patient safety. In addition, it was determined that any precautions taken to reduce noise were not fully effective. A team approach should be used in managing noise in intensive care units with better awareness.

Interobserver Reliability of Glasgow Coma Scale Scores for Intensive Care Unit Patients.

BACKGROUND: Intensive care units frequently use the Glasgow Coma Scale to objectively assess patients' levels of consciousness. Interobserver reliability of Glasgow Coma Scale scores is critical in determining the degree of impairment. OBJECTIVE: To evaluate interobserver reliability of intensive care unit patients' Glasgow Coma Scale scores. Methods This prospective observational study evaluated Glasgow Coma Scale scoring agreement among 21 intensive care unit nurses and 2 independent researchers who assessed 202 patients with neurosurgical or neurological diseases. Each assessment was completed independently and within 1 minute. Participants had no knowledge of the others' assessments. RESULTS: Agreement between Glasgow Coma Scale component and sum scores recorded by the 2 researchers ranged from 89.5% to 95.9% (P = .001). Significant agreement among nurses and the 2 researchers was found for eye response (73.8%), motor response (75.0%), verbal response (68.1%), and sum scores (62.4%) (all P = .001). Significant agreement among nurses and the 2 researchers (55.2%) was also found for sum scores of patients with sum scores of 10 or less (P = .03). CONCLUSIONS: Although the study showed near-perfect agreement between the 2 researchers' Glasgow Coma Scale scores, agreement among nurses and the 2 researchers was moderate (not near perfect) for subcomponent and sum scores. Accurate Glasgow Coma Scale evaluation requires that intensive care unit nurses have adequate knowledge and skills. Educational strategies such as simulations or orientation practice with a preceptor nurse can help develop such skills.

Interrater reliability in pupillary assessment among intensive care nurses.

BACKGROUND: Pupillary abnormalities are a common and reliable finding of brain herniation, ischaemia, and acute brain injury in critically ill patients. Reliable pupil assessment is a vital evaluation in diagnostic and therapeutic procedures for neurocritical patients. AIM: To evaluate inter-rater reliability of pupillary assessment among intensive care. METHODS: In this prospective, blind observational study, intensive care nurses and two researchers evaluated the pupil size, reactivity and symmetry of 200 patients with neurosurgery or neurological diseases. A total of 200 pupillary measurement sets were completed independently and blindly. RESULTS: Three observers -two researchers and the nurse- found fair-to-good and excellent agreements in initial pupil size evaluations of right and left pupils, respectively (ICC = 0.70, 95%; ICC = 0.75, 95%). In patients with pupil size ≥4 mm, the observers found fair-to-good agreements in both right and left pupil initial size measurements (ICC = 0.52; ICC = 0.65). Agreement in pupil symmetry was moderated (K = 0.58), and reactivity was near perfect (K = 0.89) between the three observers. CONCLUSION: Although the two researchers found near perfect agreement in pupil size, symmetry and reactivity assessment, two researchers and the nurse found moderate agreement in pupil symmetry and fair-to-good agreement in pre- and post-light stimulation pupil size.

Effects of eHealth-Based Interventions on Adherence to Components of Cardiac Rehabilitation: A Systematic Review.

OBJECTIVE: The aim of this study was to determine the effects of eHealth-based interventions on patient adherence to components of cardiac rehabilitation (CR). METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided this review. Medline, CINAHL, Embase, and Cochrane Library databases were searched for studies published from January 1996 to December 2017. All studies were included in which eHealth-based components of CR and its effects on patient adherence were measured. Because this review included a heterogeneous group of study designs, the authors qualitatively described the effect of eHealth on adherence into a narrative approach. RESULTS: A total of 1520 studies were identified, with 1415 excluded after screening. Of the remaining 105 studies, 90 were excluded after full text assessment, leaving 15 studies for analysis. Most (11) of the 15 studies reported on medication adherence. Other studies focused on adherence to diet, physical activity, vital signs, weight, step counts, smoking, and fluid restriction. The type of eHealth used also varied, ranging from telemonitoring and web-based applications to telephone calls. Of the 15 studies, 7 reported significant improvements with eHealth-based components of CR on adherence. DISCUSSION AND CONCLUSION: This review summarizes the effects of eHealth on components of CR and revealed variations in measurement and evaluation methods. The telemonitoring and web-based applications for self-care behaviors were most effective in promoting adherence. The measurement of adherence should be based on an explicit definition of adherence and should be measured with validated scales tested in the CR population.

Significance of the detection of influenza and other respiratory viruses for antibiotic stewardship: Lessons from the post-pandemic period.

OBJECTIVE: The aim was to describe the factors associated with antibiotic use in upper respiratory tract infections (URTI) in the post-pandemic influenza period. METHODS: All consecutive patients who attended the emergency and outpatient departments of a private 265-bed hospital in Istanbul, Turkey with symptoms of an influenza-like illness (ILI) between January and June 2011 were included. RESULTS: Out of 1270 patients, 100 were tested for Streptococcus A infection and 16 (16%) were found to be positive; 36 patients were tested for respiratory syncytial virus and five were found to be positive. A rapid influenza test (chromatographic) was performed for 325 patients and 45% were found to be positive for influenza A or B. In total, 500 patients (40%) were prescribed antibiotics; these were fluoroquinolones (12%), macrolides (10%), amoxicillin-clavulanate (10%), cefuroxime (7%), and third-generation cephalosporins (3%). On multivariate analysis, antibiotic prescription was found to be decreased by the diagnosis of influenza, whereas antibiotic prescription increased with age >65years, C-reactive protein (CRP) >20mg/L, polymorphonuclear leukocytes >80%, the detection of rales on auscultation, the presence of cough, comorbidities, and having infiltrations on a X-ray. CONCLUSIONS: The diagnosis of influenza is important for the implementation of antimicrobial stewardship programs. Each institution should implement an algorithm for the diagnosis and management of upper respiratory tract infections. Biomarkers such as CRP and procalcitonin should be used more effectively.

Effects of nurse-led clinical pathway in coronary artery bypass graft surgery: A quasi-experimental study.

AIMS AND OBJECTIVES: To develop and evaluate the effects of a nurse-led clinical pathway for patients undergoing coronary artery bypass graft surgery. BACKGROUND: A clinical pathway is a multidisciplinary care plan, based on evidence and guidelines to provide consistent, quality care to patients and improve outcomes. DESIGN: Prospective, quasi-experimental design. METHODS: Patients hospitalised for coronary artery bypass graft between April 2014-November 2015 in a hospital in Turkey were studied. First 42 usual care patients were enrolled to determine outcomes and plan for the development of the clinical pathway followed by 40 patients in the newly developed clinical pathway. The primary outcome was length of stay and secondary outcomes related to recovery from surgery (e.g., time to extubation, first feeding). RESULTS: The mean age for the clinical pathway group was 60 and for usual care was 63 years. Most were male (CP = 78%, UC = 69%). There were significant differences between groups for the primary outcome. Length of stay in the intensive care unit was 38.9 hr for CP and 50.7 hr for usual care patients p < .01. Total hospital time was 144.4 hr for clinical pathway and 162.2 hr for usual care, p < .05. For secondary measures, the following times were less for the clinical pathway group than for the usual care: time to extubation and nasogastric tube removal (5.7 vs. 8.6 hr, p < .01), first oral feeding (4.7 vs. 10.9 hr, p < .001), first mobilisation (8.4 vs. 22.9 hr, p < .001) and first bowel movement (69.8 vs. 85.9 hr, p < .01). There were no statistically significant differences in the 3-month readmission rates and complication rates between the groups, except the renal complication rates were higher in the usual care (n = 16, 38%) than in the clinical pathway (n = 7, 17.5%) (p < .05). CONCLUSION: The nurse-led clinical pathway was effective in improving length of stay in both the ICU and hospital as well as the secondary outcomes. RELEVANCE TO CLINICAL PRACTICE: This study contributes to previous studies supporting clinical pathway use can improve the length of stay and quality of care in patients undergoing coronary artery bypass graft surgery.

Using high-fidelity simulation as a learning strategy in an undergraduate intensive care course.

Using high-fidelity simulations to facilitate student learning is an uncommon practice in Turkish nursing programs. The aim of the present study was to understand students' perceptions of the use of simulation in nursing courses. Subjects included 36 senior nursing students taking an intensive care course. This study revealed that high-fidelity simulation is an ideal method of promoting learning by helping students transfer theory into practice, build confidence and teamwork, and raise professional awareness.