Basic competence in intensive and critical care nursing: development and psychometric testing of a competence scale.

AIMS AND OBJECTIVES: To develop a scale to assess basic competence in intensive and critical care nursing. In this study, basic competence denotes preliminary competence to practice in an intensive care unit. BACKGROUND: There is a need for competence assessment scales in intensive care nursing practice and education. The nursing care performed in the intensive care unit is special by its nature and needs to be assessed as such. At this moment, however, there is no tested, reliable and valid scale in this field. DESIGN: A multi-phase, multi-method development and psychometric testing of the scale was conducted. METHODS: The scale was developed in three phases. First, following a literature review and Delphi study, the items were created. Second, the scale was pilot tested twice by nursing students (n1 = 18, n2 = 56) and intensive care nurses (n1 = 12, n2 = 54), and revisions were made. Third, reliability and construct validity were tested by graduating nursing students (n = 139) and intensive care nurses (n = 431). RESULTS: The Intensive and Critical Care Nursing Competence Scale (ICCN-CS-1) is a self-assessment test consisting of 144 items. Basic competence is divided into patient-related clinical competence and general professional competence. In addition, basic competence is comprised of knowledge base, skill base, attitude and value base and experience base. ICCN-CS-1 is a reliable and tolerably valid scale. CONCLUSIONS: The ICCN-CS-1 is a promising scale for use among nursing students and nurses. Future research is needed to evaluate its construct validity further and to assess its suitability for completion during intensive care unit's orientation programmes and nursing students' clinical practice in an intensive care unit. RELEVANCE TO CLINICAL PRACTICE: The ICCN-CS-1 can be used for basic competence assessment in professional development discussions in intensive care units, in mentor evaluation situations during nursing students' clinical practice and in intensive care nursing education.

Graduating nursing students' basic competence in intensive and critical care nursing.

AIMS AND OBJECTIVES: To describe and evaluate the basic competence of graduating nursing students in intensive and critical care nursing. BACKGROUND: Intensive and critical care nursing is focused on severely ill patients who benefit from the attention of skilled personnel. More intensive and critical care nurses are needed in Europe. Critical care nursing education is generally postqualification education that builds upon initial generalist nursing education. However, in Europe, new graduates practise in intensive care units. Empirical research on nursing students' competence in intensive and critical care nursing is scarce. DESIGN: A cross-sectional survey design. METHODS: A basic competence scale (Intensive and Critical Care Nursing Competence Scale, version 1) and a knowledge test (Basic Knowledge Assessment Tool, version 7) were employed among graduating nursing students (n = 139). RESULTS: Sixty-nine per cent of the students self-rated their basic competence as good. No association between self-assessed Intensive and Critical Care Nursing-1 and the results of the Basic Knowledge Assessment Tool-7 was found. The strongest factor explaining the students' conception of their competence was their experience of autonomy in nursing after graduation. CONCLUSION: The students seem to trust their basic competence as they approach graduation. However, a knowledge test or other objective method of evaluation should be used together with a competence scale based on self-evaluation. RELEVANCE TO CLINICAL PRACTICE: In nursing education and in clinical practice, for example, during orientation programmes, it is important not only to teach broad basic skills and knowledge of intensive and critical care nursing, but also to develop self-evaluation skills through the use of special instruments constructed for this purpose.

Feasibility and cardiac safety of inhaled xenon in combination with therapeutic hypothermia following out-of-hospital cardiac arrest.

OBJECTIVES: Preclinical studies reveal the neuroprotective properties of xenon, especially when combined with hypothermia. The purpose of this study was to investigate the feasibility and cardiac safety of inhaled xenon treatment combined with therapeutic hypothermia in out-of-hospital cardiac arrest patients. DESIGN: An open controlled and randomized single-centre clinical drug trial (clinicaltrials.gov NCT00879892). SETTING: A multipurpose ICU in university hospital. PATIENTS: Thirty-six adult out-of-hospital cardiac arrest patients (18-80 years old) with ventricular fibrillation or pulseless ventricular tachycardia as initial cardiac rhythm. INTERVENTIONS: Patients were randomly assigned to receive either mild therapeutic hypothermia treatment with target temperature of 33°C (mild therapeutic hypothermia group, n=18) alone or in combination with xenon by inhalation, to achieve a target concentration of at least 40% (Xenon+mild therapeutic hypothermia group, n=18) for 24 hours. Thirty-three patients were evaluable (mild therapeutic hypothermia group, n=17; Xenon+mild therapeutic hypothermia group, n=16). MEASUREMENTS AND MAIN RESULTS: Patients were treated and monitored according to the Utstein protocol. The release of troponin-T was determined at arrival to hospital and at 24, 48, and 72 hours after out-of-hospital cardiac arrest. The median end-tidal xenon concentration was 47% and duration of the xenon inhalation was 25.5 hours. The frequency of serious adverse events, including inhospital mortality, status epilepticus, and acute kidney injury, was similar in both groups and there were no unexpected serious adverse reactions to xenon during hospital stay. In addition, xenon did not induce significant conduction, repolarization, or rhythm abnormalities. Median dose of norepinephrine during hypothermia was lower in xenon-treated patients (mild therapeutic hypothermia group=5.30 mg vs Xenon+mild therapeutic hypothermia group=2.95 mg, p=0.06). Heart rate was significantly lower in Xenon+mild therapeutic hypothermia patients during hypothermia (p=0.04). Postarrival incremental change in troponin-T at 72 hours was significantly less in the Xenon+mild therapeutic hypothermia group (p=0.04). CONCLUSIONS: Xenon treatment in combination with hypothermia is feasible and has favorable cardiac features in survivors of out-of-hospital cardiac arrest.

[Group A streptococcal pneumonia]. / A-ryhmän streptokokin aiheuttama vaikea keuhkokuume.

Group A betahemolytic streptococcus may cause a severe pneumonia that is accompanied by septic shock and multiorgan failure. The disease is rare and may develop slowly and thus the diagnosis and the most efficient treatment may be delayed. We describe two children and two adults with pneumonia and toxic shock syndrome caused by group A streptococci. All patients needed ventilator treatment. In addition to other antibiotics clindamycin, that restrains toxin production by group A streptococci, was administered to three of the patients. All patients had a full recovery, but one patient developed optic neuropathy and lost his vision.

Competence requirements in intensive and critical care nursing--still in need of definition? A Delphi study.

BACKGROUND: Empirical studies in competence are lacking in the field of intensive and critical care nursing. OBJECTIVE: To identify competence requirements, by soliciting the views of intensive care unit nurses and physicians. METHODS: Two rounds of the Delphi method were used in 2006 in Finland. Data were analysed by content analysis and with descriptive statistics. RESULTS: Competence requirements in intensive and critical care nursing can be divided into five main domains: knowledge base, skill base, attitude and value base, nursing experience base and personal base of the nurse. Four of these domains can be found in the existing requirements and one new domain - personal base of the nurse - was identified. CONCLUSIONS: Competence requirements are multidimensional. Earlier descriptions of competence are not sufficient; more comprehensive and cohesive descriptions are needed. The personal base of a nurse should also be included in the competence requirements in intensive and critical care nursing.

Managing daily intensive care activities: an observational study concerning ad hoc decision making of charge nurses and intensivists.

INTRODUCTION: Management of daily activities in ICUs is challenging. ICU shift leaders, charge nurses and intensivists have to make several immediate ad hoc decisions to enable the fluent flow of ICU activities. Even though the management of ICU activities is quite well delineated by international consensus guidelines, we know only a little about the content of the real clinical decision making of ICU shift leaders. METHODS: We conducted an observational study with the think-aloud technique to describe the ad hoc decision making of ICU shift leaders. The study was performed in two university-affiliated hospital ICUs. Twelve charge nurses and eight intensivists were recruited. Observations were recorded and transcribed for qualitative content analysis using the protocol analysis method. The software program NVivo 7 was used to manage the data. The interrater agreement was assessed with percentages and by Cohen's κ. RESULTS: We identified 463 ad hoc decisions made by the charge nurses and 444 made by the intensivists. During our data collection time, this breaks down to over 230 immediately made decisions per day (24 hours). We divided the ad hoc decision making of ICU shift leaders into two types: process-focused and situation-focused. Process-focused decision making included more permanent information, such as human resources, know-how and material resources, whereas situation-focused decision making included decisions about single events, such as patient admission. We named eight different categories for ICU ad hoc decision making: (1) adverse events, (2) diagnostics, (3) human resources and know-how, (4) material resources, (5) patient admission, (6) patient discharge, (7) patient information and vital signs and (8) special treatments. CONCLUSIONS: ICU shift leaders make a great number of complex ad hoc decisions throughout the day. Often this decision making involves both intensivists and charge nurses. It forms a bundle that requires versatile, immediate information for a successful outcome. In the future, we need to investigate which information is crucial for ad hoc decision making. These challenges should also be emphasised when information technology programs for ICU care management are developed.

Studies on the effects of heparin products on pregnancy-associated plasma protein A.

BACKGROUND: Intravenous low molecular weight (LMWH) and unfractionated heparin (UFH) increase the circulating concentrations of pregnancy-associated plasma protein A (PAPP-A), a novel cardiac risk marker, in haemodialysis and coronary angiography patients. METHODS: To further investigate the mechanisms of heparin effects, free PAPP-A was analysed in serial serum samples collected during haemodialysis (intravenous LMWH), carotid endarterectomy or abdominal aortic aneurysm surgery (intravenous UFH), treatment at intensive care unit (subcutaneous LMWH), and coronary angiography (intravenous bivalirudin). PAPP-A was extracted from plaque tissue samples of endarterectomy and aneurysm patients. The interaction between heparin products and free PAPP-A was studied with gel filtration. RESULTS: After intravenous UFH and LMWH free PAPP-A increased significantly but bivalirudin had no effect. After LMWH bolus in haemodialysis patients 85% of free PAPP-A was cleared with a half-life of 13.1 min and the rest with a half-life of 96.6 min. Subcutaneous LMWH led to lower and slower free PAPP-A elevation. PAPP-A extracted from plaque tissues was in free form and extraction was strongly enhanced by LMWH. Heparin products increased the molecular size of free PAPP-A. CONCLUSIONS: The heparin-induced PAPP-A elevation is seen in various patients and should be taken into account when PAPP-A is studied as a biomarker.

[Update on current care guidelines. Treatment of severe sepsis in adults]. / Aikuisten vaikean sepsiksen hoito.

According to the Finnsepsis Study, the incidence in Finland of severe sepsis requiring intensive care was 0.38/1,000 inhabitants/year. ICU and hospital mortality was 15.5% and 28.3%, respectively. The Finnsepsis Study showed that compliance with protocols was rather poor and antimicrobial treatment was often delayed. These guidelines emphasize the importance of prompt antibiotic and fluid therapy. In shock, norepinephrine is the first line vasopressor. Low-dose hydrocortisone may be used to shorten the need for vasopressors. Activated protein C should be considered in selected patients. The blood glucose target recommendation is between 5 and 8 mmol/l.

Incidence of iatrogenic dyscarbia during mild therapeutic hypothermia after successful resuscitation from out-of-hospital cardiac arrest.

To investigate the incidence of iatrogenic dyscarbia in survivors of out-of-hospital cardiac arrest treated with induced mild hypothermia.We performed a retrospective cohort study of the ventilatory management based on blood gas analyses of patients resuscitated from prehospital cardiac arrest. In the pilot phase, we assessed the ventilatory management in the patients treated in one university hospital during a 4-year study period. Subsequently, a more recent (1-year) retrospective cohort of resuscitated patients from all five Finnish university hospitals concerning the first 48h after hospital admission was analyzed. Core temperatures and temperature corrected (or non-corrected) blood gas analysis results with focus on carbon dioxide tension were analyzed. In addition, a survey was performed to investigate the ventilatory strategies in all Finnish hospitals providing mild hypothermia for cardiac arrest victims.The pilot cohort suggested a high incidence of hypo- or hyper-carbia during hypothermia treatment. In the multicenter patient population of 122 patients contributing a total of 1627 measurements, the PaCO(2) distribution was as follows: less than 4 kPa in 148 samples out of 1627 (9%), 4-4.6 kPa in 404 (25%), 4.7-6 kPa in 887 (55%) and more than 6 kPa in 188 samples (12%). There was a significant difference in the incidence of hypercarbia between the hospitals (p<0.05).We conclude that normocarbia was achieved/maintained only in approximately 55% of the samples. The incidence of hypo- or hyper-carbia (dyscarbia) was high (45%). This may predispose for serious derangements in the cerebral perfusion of the resuscitated patient. These results call for vigilance in adjustment of the ventilatory management to meet the needs of the patients treated with mild hypothermia.

Acute respiratory failure in intensive care units. FINNALI: a prospective cohort study.

OBJECTIVE: To evaluate the incidence, treatment and mortality of acute respiratory failure (ARF) in Finnish intensive care units (ICUs). STUDY DESIGN: Prospective multicentre cohort study. METHODS: All adult patients in 25 ICUs were screened for use of invasive or non-invasive ventilatory support during an 8-week period. Patients needing ventilatory support for more than 6 h were included and defined as ARF patients. Risk factors for ARF and details of prior chronic health status were assessed. Ventilatory and concomitant treatments were evaluated and recorded daily throughout the ICU stay. ICU and 90-day mortalities were assessed. RESULTS: A total of 958 (39%) from the 2,473 admitted patients were treated with ventilatory support for more than 6 h. Incidence of ARF, acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) was 149.5, 10.6 and 5.0/100,000 per year, respectively. Ventilatory support was started with non-invasive interfaces in 183 of 958 (19%) patients. Ventilatory modes allowing triggering of spontaneous breaths were preferred (81%). Median tidal volume/predicted body weight was 8.7 (7.6-9.9) ml/kg and plateau pressure 19 (16-23) cmH2O. The 90-day mortality of ARF was 31%. CONCLUSIONS: While the incidence of ARF requiring ventilatory support is higher, the incidence of ALI and ARDS seems to be lower in Finland than previously reported in other countries. Tidal volumes are higher than recommended in the concept of lung protective strategy. However, restriction of peak airway pressure was used in the majority of ARF patients.

[Optimal blood sugar level of intensive care patient]. / Tehohoitopotilaan optimaalinen verenglukoosiarvo.

Hyperglycemia is a very common phenomenon in intensive care patients. Upon prolongation it becomes injurious and will predispose the patients to many complications. Apparently, a strict blood sugar level control by intensive insulin therapy is not as beneficial as believed. The development of hypoglycemia during the treatment is particularly dangerous. A more flexible blood sugar target may reduce this risk without sacrificing the expected benefits of the treatment. An assured and consistent glucose supply for the patient must, however, be remembered also in such situations.

Panhypopituitarism after traumatic head injury.

INTRODUCTION: We describe a case report of panhypopituitarism after traumatic head injury. A previously healthy young man suffered a closed head injury and multiple spinal fractures after a motorcycle accident. METHODS: His treatment in the intensive care unit was prolonged because of numerous problems with raised intracranial pressure, hemodynamics, and electrolyte balance. RESULTS: Eventually, hypocortisolism and other pituitary hormone deficiencies were diagnosed. Magnetic resonance images showed incoherent pituitary stalk and re-review of the first computed tomography scans of the day of the accident confirmed hemorrhage in the infundibulum. CONCLUSION: This case and review of the literature suggests that hormone deficiencies are not uncommon after head injuries.