Intensive care nurses' perceptions of brain death

Research during the last 2 decades has revealed significant confusion or lack of acceptance and inconsistent application of the brain death concept within the medical and nursing professions. The aim of this naturalistic and descriptive study was to investigate the extent to which a sample of 40 Australian intensive care nurses regarded brain death as a meaningful conception of death. In contrast with the majority of the literature pertaining to health care professionals' perceptions of brain death which has focused upon clinical knowledge, the study elicited the expression of personal beliefs. The study utilised a structured interview method with nurses from seven metropolitan intensive care units (ICUs). Transcript analysis revealed five categories of perception constituting a spectrum ranging from complete acceptance to complete rejection, with almost half (48%, n=19) the sample regarding the brain dead patient as less than completely meaningfully dead.

Rather than supporting the literature's suggestion that non-acceptance of the medico-legally recognised brain death notion is, necessarily, evidence of professional ignorance, the findings suggest the participants holding these perceptions were generally well-informed about brain stem function and brain death diagnosis. The study affirms the importance of supportive workplace environments which facilitate the expression of dissonant perceptions and proposes that educators and managers must acknowledge these dissonances.

Hemodynamic team decision making in the cardiac surgical intensive care context

Purpose
The purpose of this study was to explore the extent and sources of variability of critical care nurses’ hemodynamic decision making as a function of contextual factors in the immediate 2-hour period after cardiac surgery.

Methods
A qualitative exploratory design with observation and interview was used. Eight critical care nurses were observed on different occasions in clinical practice for a 2-hour period. A brief interview immediately followed each observation to clarify observation data.

Findings
Analysis of the data revealed that patient management decisions were made both by individual nurses and by a team of nurses and health professionals. Team decision making (TDM) is described in this study as integrated or non-integrated and refers to an intra-professional nursing team. During displays of integrated TDM, the primary nurse, who was assigned to care for the patient, made most hemodynamic decisions and nurses who assisted the primary nurse deferred decisions. During displays of non-integrated TDM, nurses assisting the primary nurse assumed responsibilities for most patient-related decisions. Non-integrated TDM occurred more frequently when inexperienced cardiac surgical intensive care nurses were in the role of primary nurse, whereas integrated TDM was more common among experienced cardiac surgical intensive care nurses.

Conclusions
This observed variability can occur in multiple ways and in hemodynamic decision making has implications for patient outcomes as behaviors of non-integrated TDM led to nurses sensing a loss of control of patient management.

Improving child and family outcomes following complicated births requiring admission to neonatal intensive care units

This paper reviews current research regarding the impact of birth complications, such as preterm labour, on parents and the nuclear family system. Specifically, how parents cope with the neonatal intensive care unit (NICU) experience and the associated decision-making tasks required during complicated births will be investigated. Consequences of poor adaptation to prematurity for the parent, family and infant relationships will also be discussed. The importance of informed decision-making, perceived control, self-esteem and the benefits of certain strategies, such as kangaroo care (skin-to-skin contact), in the facilitation of greater levels of attachment and improved relationships, will be highlighted. The paper concludes with suggestions for future research areas to focus on finding better ways to prepare and support parents in these situations, thus improving the quality of relationships between parents and with their child.

Will he get back to normal? survival and functional status after intensive care therapy

The study aim was to address healthcare workers’ and patients’ questions about the likely level of recovery at 6 months of patients admitted to an Australian intensive care unit (ICU). Ninety-three consecutive, eligible adults were identified and followed prospectively. Severity of illness on admission was assessed using Acute Physiological and Chronic Health Evaluation (APACHE II), while functional status at 6 months was evaluated using the Sickness Impact Profile (SIP). Cumulative mortality was 25%. Admission severity of illness was associated with survival at 6 months (P≤0.001). Fifty-one (78%) of the 70 survivors were interviewed. Admission severity of illness scores correlated with functional status at 6 months (r=0.34, P=0.01), a finding reported in only one other study. More than half of those interviewed had returned to near pre-admission functional status. Those with poor functional status included high proportions of people with chronic illness and head injury. Overall, physical recovery was more complete than psychosocial recovery. The findings provide useful information for addressing questions relating to physical and psychosocial recovery, appetite, sleep patterns and return to work post discharge.

ACCCN national nursing workforce survey of intensive care units

A descriptive study was designed and implemented by the Australian College of Critical Care Nurses (ACCCN) Workforce Planning Advisory Committee to capture data pertaining to workforce issues of intensive care nurses. All intensive care units (ICUs) within Australia were mailed a self reporting survey. Despite a low response rate (52 per cent) and difficulty reported by respondents in gaining the appropriate data requested, the results revealed an interesting snapshot of the intensive care nursing workforce.
Types of services offered by units varied considerably; paid overtime hours were low (<2 per cent of total hours worked) and use of both part-time and agency staff was also low (10 per cent of total hours worked). Private hospitals utilised a greater proportion of part-time and agency nursing staff than public hospitals (20:10 per cent). The turnover rate for registered nursing staff was estimated at 18 per cent, with education, skill acquisition and improved communication reported as the major incentives used by managers to attract and retain staff. This study demonstrated that valuable data are currently uncaptured and recommends a more refined process of a national database to record and manage this important information for future workforce planning.

Staff perceptions on the use of a sedation protocol in the intensive care setting

Sedation protocols are increasingly being investigated as a method of achieving improved patient outcomes whilst guiding the decision making of both nursing and medical practitioners. However, only a limited number of studies have investigated the perceptions of staff towards a sedation protocol during its implementation. This study was designed to survey the perceptions of staff regarding the implementation of a sedation protocol in an Australian intensive care unit (ICU). Questionnaires were distributed to all multidisciplinary team members who had used the sedation protocol. The response rate was 50% (n=70). The questionnaire combined the use of visual analogue scales plus a comments section to obtain qualitative data.

The results revealed that staff perceived sedation management to be enhanced with the use of a protocol and therefore should be incorporated into routine clinical practice. Staff perceived that providing clear guidelines that facilitated decision making and assisted beginner practitioners enhanced sedation management. In addition, there was a perceived improvement in the patient outcomes, including a decrease in the frequency of over-sedation resulting in a reduced ICU stay.

Positive perceptions may assist in the introduction of other interventional protocols. Other protocols may target areas where variability in clinical decision making exists, despite research evidence that supports specific therapeutic interventions. Further studies addressing protocol implementation for clinical interventions are warranted in other ICU settings.

Readmission to intensive care : a review of the literature

Acutely ill patients are commonly found on general hospital wards; some of these are patients who have been recently discharged from an intensive care unit (ICU). These patients may require a higher level of care than other ward patients and, due to the acuity of their illness, are at risk of readmission to ICU. Research has indicated that patients readmitted to ICU have mortality rates up to six times higher than those not readmitted and are eleven times more likely to die in hospital. Numerous studies have retrospectively examined these readmissions but, despite this, there is still no clear indication of why ICU readmissions occur or what the common characteristics of readmitted patients are. This literature review examines the published studies on patients who have been readmitted to ICU. Further research is needed to explore why readmissions to ICU occur and the type of patient who is at greatest risk for readmission.

A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit

Objective: To compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients. Design: Randomized, controlled trial. Setting: General intensive care unit (24 beds) in an Australian metropolitan teaching hospital. Patients: Adult, mechanically ventilated patients (n = 312). Interventions: Patients were randomly assigned to receive sedation directed by formal guidelines (protocol group, n = 153) or usual local clinical practice (control, n = 159). Measurements and Main Results: The median (95% confidence interval) duration of ventilation was 79 hrs (56-93 hrs) for patients in the protocol group compared with 58 hrs (44-78 hrs) for patients who received control care (p = .20). Lengths of stay (median [range]) in the intensive care unit (94 [2-1106] hrs vs. 88 (14-962) hrs, p = .58) and hospital (13 [1-113] days vs. 13 (1-365) days, p = .97) were similar, as were the proportions of subjects receiving a tracheostomy (17% vs. 15%, p = .64) or undergoing unplanned self-extubation (1.3% vs. 0.6%, p = .61). Death in the intensive care unit occurred in 32 (21%) patients in the protocol group and 32 (20%) control subjects (p = .89), with a similar overall proportion of deaths in hospital (25% vs. 22%, p = .51). A Cox proportional hazards model, after adjustment for age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic category, and doses of commonly used drugs, estimated that protocol sedation management was associated with a 22% decrease (95% confidence interval 40% decrease to 2% increase, p = .07) in the occurrence of successful weaning from mechanical ventilation. Conclusions: This randomized trial provided no evidence of a substantial reduction in the duration of mechanical ventilation or length of stay, in either the intensive care unit or the hospital, with the use of protocol-directed sedation compared with usual local management. Qualified high-intensity nurse staffing and routine Australian intensive care unit nursing responsibility for many aspects of ventilatory practice may explain the contrast between these findings and some recent North American studies. (C) 2008 Lippincott Williams & Wilkins, Inc.

A critical review of daily sedation interruption in the intensive care unit

Background. Daily sedation interruption (DSI) has been proposed as a method of improving sedation management of critically ill patients by reducing the adverse effects of continuous sedation infusions.

Aim. To critique the research regarding daily sedation interruption, to inform education, research and practice in this area of intensive care practice.

Design. Literature review.

Method. Medline, CINAHL and Web of Science were searched for relevant key terms. Eight research-based studies, published in the English language between 1995–December 2006 and three conference abstracts were retrieved.

Results. Of the eight articles and three conference abstracts reviewed, five originated from one intensive care unit (ICU) in the USA. The research indicates that DSI reduces ventilation time, length of stay in ICU, complications of critical illness, incidence of post-traumatic stress disorder and is reportedly used by 15–62% of ICU clinicians in Australia, Europe, USA and Canada.

Conclusions. DSI improves patients' physiological and psychological outcomes when compared with routine sedation management. However, research relating to these findings has methodological limitations, such as the use of homogenous samples, single-centre trials and retrospective design, thus limiting their generalisability.

Relevance to clinical practice. DSI may provide clinicians with a simple, cost-effective method of reducing some adverse effects of sedation on ICU patients. However, the evidence supporting DSI is limited and cannot be generalised to heterogeneous ICU populations internationally. More robust research is required to assess the potential impact of DSI on the physical and mental health of ICU survivors.

The influence of medical enduring power of attorney and advance directives on decision making by Australian intensive care doctors

OBJECTIVE: Despite government encouragement for patients to make advance plans for medical treatment, and the increasing numbers of patients who have done this, there is little research that examines how doctors regard these plans.
DESIGN: We surveyed Australian intensive care doctors, using a hypothetical clinical scenario, to evaluate how potential end-of-life treatment decisions might be influenced by advance planning - the appointment of a medical enduring power of attorney (MEPA) or an advance care plan (ACP). Using open-ended questions we sought to explore the reasoning behind the doctors' decisions.
RESULTS: 275 surveys were returned (18.3% response rate). We found that opinions expressed by an MEPA and ACP have some influence on treatment decisions, but that intensive care doctors had major reservations. Most did not follow the request for palliation made by the MEPA in the hypothetical scenario.
CONCLUSIONS: Many intensive care doctors believe end-of-life decisions remain medical decisions, and MEPAs and ACPs need only be respected when they accord with the doctor's treatment decision. This study suggests a need for further education of doctors, particularly those working in intensive care, who are responsible for initiating and maintaining life support treatment.

Predicting future intensive care demand in Australia

BACKGROUND: Predicting future demand for intensive care is vital to planning the allocation of resources.

METHOD: Mathematical modelling using the autoregressive integrated moving average (ARIMA) was applied to intensive care data from the Australian and New Zealand Intensive Care Society (ANZICS) Core Database and population projections from the Australian Bureau of Statistics to forecast future demand in Australian intensive care.

RESULTS: The model forecasts an increase in ICU demand of over 50% by 2020, with current total ICU bed-days (in 2007) of 471 358, predicted to increase to 643 160 by 2020. An increased rate of ICU use by patients older than 80 years was also noted, with the average bed-days per 10 000 population for this group increasing from 396 in 2006 to 741 in 2007.

CONCLUSION: An increase in demand of the forecast magnitude could not be accommodated within current ICU capacity. Significant action will be required.

Critical ethnographic study of an intensive care unit in Hong Kong

This critical ethnographic study was initiated to explore the ways in which the concepts of caring and caring practices were constructed by nurses working in an intensive care unit in a Hong Kong hospital using a broadly Habermasian critical framework. A reform of the health care system has disturbed both the nurses and the structure of nursing.