Dissertations / Theses on the topic 'Ultrasonography and Intensive Care Unit'

INTRODUÇÂO: A sepse representa aproximadamente 25% dos pacientes internados em Unidades de Terapia Intensiva (UTI) e com taxas de mortalidade de 20 a 40%. Além disso, os pacientes sépticos podem apresentar aguda e tardiamente disfunções de órgãos e alterações da musculatura esquelética comprometendo a recuperação na UTI e, posteriormente, a sua saúde relacionada à qualidade de vida. Atualmente, a ultrassonografia tem demonstrado ser uma ferramenta capaz de avaliar a degradação da musculatura esquelética em pacientes críticos. Em pacientes sépticos não se estudou a relação de degradação muscular com testes clínicos de força muscular e aferições bioquímicas. OBJETIVOS: Quantificar a área de secção transversa do reto femoral e a força muscular a beira leito em pacientes que desenvolveram sepse grave e choque séptico. Avaliar associação entre a área de secção transversa do reto femoral e a força muscular em pacientes sépticos. MÉTODOS: Coorte prospectiva que avaliou 37 pacientes na UTI com sepse grave ou choque séptico. A medida da área de secção transversa do reto femoral foi realizada através da ultrassonografia no dia seguinte ao início da sepse e acompanhada durante a internação. Os pacientes foram submetidos a testes clínicos de força muscular (escala do Medical Research Council e a força de preensão palmar) à medida que pudessem compreender comandos verbais. Amostras de sangue foram coletadas para análise de enzimas e hormônio após a admissão no estudo e durante a internação. RESULTADOS: Houve um declínio da área de secção transversa do reto femoral de 5,1 (4,4-5,9)cm2 no 2° dia de UTI para 4,4 (3,6-5,0)cm2 e 4,3 (3,7-5,0)cm2 na alta da UTI e na alta hospitalar, respectivamente (p<0,05). Por outro lado, os testes clínicos de força apresentaram um aumento na escala do Medical Research Council de 48,0 (36,0-56,0) pontos para 60,0 (48,0-60,0) pontos na alta da UTI, este aumento foi mantido até a alta hospitalar em 60,0 (52,0-60,0) pontos (p < 0,05). Em relação à força de preenssão palmar os pacientes apresentavam média de 42,1±21,9 % do predito no 1° dia de avaliação e este valor aumentou para 65,9±20,3 % do predito no dia da alta hospitalar (p < 0,05). Houve uma associação da área de secção transversa do reto femoral e das avaliações clínicas de força muscular durante a permanência na UTI. Aumentos no escore de lesão orgânica (SOFA) no 3° dia e ser do sexo masculino apresentaram-se como fatores independentes para a degradação muscular, assim como, o SOFA do 3° dia com a fraqueza muscular. CONCLUSÃO: O estudo demonstrou que a sepse pode levar a uma degradação muscular em apenas alguns dias de UTI, associada há uma recuperação incompleta da força muscular ao longo da internação. Além disso, testes clínicos de força muscular se associaram com a degradação muscular durante a internação hospitalar<br>INTRODUCTION: Sepsis represents 25% of patients in the intensive care unit (ICU) with mortality rate of 20 to 40%. In addition, septic patients can present early or lately organ dysfunction and skeletal muscles alterations that reduce patient recovery and compromises health-related to quality of life. Currently, ultrasound has been shown to be a tool capable of evaluating skeletal muscle degradation in critical patients. There are no studies in septic patients about the relation of muscle degradation with clinical tests and blood biochemistry analysis. OBJECTIVES: To quantify the rectus femoris cross-sectional area and muscle strength at the bedside in patients who developed severe sepsis and septic shock. To assess the association between the rectus femoris cross-sectional area and muscle strength in septic patients. METHODS: Prospective cohort who evaluated 37 patients in the intensive care unit with severe sepsis or septic shock. The measurement of rectus femoris cross-sectional area was performed by ultrasonography on the day after the onset of sepsis and followed up during hospitalization. Patients underwent clinical tests of muscle strength (Medical Research Council scale and handgrip strength) as they could understand verbal commands. Blood samples were collected for enzyme and hormone analysis after admission to the study and during hospitalization. RESULTS: There was a decline in rectus femoris cross-sectional area from 5.1 (4.4-5.9) cm2 on the 2nd day of ICU to 4.4 (3.6-5.0) cm2 and 4.3 (3.7-5.0) cm2 at ICU discharge and at hospital discharge, respectively (p < 0.05). In contrast, strength tests showed an increase in the scale of the Medical Research Council from 48.0 (36.0-56.0) to 60.0 (48.0-60.0) points in ICU discharge, this increase was maintained until hospital discharge reaching 60.0 (52.0-60.0) points (p < 0.05). In relation to the handgrip strength, patients presented a mean of 42.1 ± 21.9% of predicted on the 1st day of evaluation and this value increased to 65.9 ± 20.3% of predicted on the day of hospital discharge ( p < 0.05). There was an association between the rectus femoris cross-sectional area and clinical assessments of muscle strength during ICU stay. Increases in the organic lesion score (SOFA) on the 3rd day and being male presented as independent factors for muscle degradation, as well as the SOFA of the 3rd day with muscle weakness. CONCLUSION: The study demonstrated that sepsis can lead to muscle degradation in only a few days of ICU, associated with an incomplete recovery of muscle strength throughout hospitalization. In addition, clinical trials of muscle strength were associated with muscle degradation during hospital stay

Objetivos: Nesta tese, a influência de fatores laboratoriais, sistêmicos e renais sobre o índice de resistividade renal ao Doppler (IR renal) em pacientes críticos foi avaliada. Da mesma forma, a acurácia do IR renal na predição da ocorrência e da reversibilidade da injúria renal aguda em pacientes críticos também foi analisada. Métodos: Estudo prospectivo observacional realizado entre Novembro de 2013 e Outubro de 2014, numa unidade de terapia intensiva (UTI) de 14 leitos. Dados clínicos, IR renal, exames laboratoriais de sangue e de urina foram coletados. Injúria renal aguda foi avaliada quanto a sua reversibilidade, e categorizada em transitória (normalização da função renal em 3 dias) e persistente (ausência de normalização da função renal em 3 dias ou necessidade de terapia de substituição renal). Um modelo linear misto foi realizado para avaliar a influência das variáveis de interesse no IR renal, a saber: presença de sepse, Simplified Acute Physiology Score 3 (SAPS 3), idade, cloreto sérico, uso de drogas vasoativas, pressão de pulso, frequência cardíaca, lactato, presença de injúria renal aguda de acordo com sua reversibilidade (transitória ou persistente). Resultados: 83 pacientes foram incluídos. 65% eram do sexo masculino e 51% apresentavam diagnósticos clínicos como causa de internação hospitalar. SAPS 3 foi de 47 ± 16. Não foram observadas diferenças significantes em relação a idade, gênero, necessidade de vasopressor e de ventilação mecânica entre as diferentes categorias de IRA à admissão na UTI. 53 pacientes já apresentavam critérios de IRA na admissão na UTI. A presença de choque circulatório foi o fator de risco para desenvolvimento de IRA mais prevalente (41%). Os valores de pressão de pulso, lactato e cloreto séricos não foram diferentes entre as categorias de IRA durante o período de observação. Os valores de IR renal foram estatisticamente superiores nos pacientes com IRA persistente (0,70 ± 0,08), quando comparados aos pacientes com IRA transitória (0,64 ± 0,07) ou sem IRA (0,64 ± 0,06; p < 0,01). O IR renal também revelou uma boa acurácia em predizer IRA persistente nos pacientes com diagnóstico de IRA na admissão na UTI (AUC= 0,78; IC 95% 0,65-0,91). As variáveis identificadas no modelo linear misto associadas a variações de IR renal foram idade, pressão de pulso, lactato sérico e categoria de IRA (IRA persistente) (p < 0,05). Conclusão: O IR renal apresentou uma boa acurácia em predizer a reversibilidade da IRA em pacientes críticos. Contudo, uma série de fatores sistêmicos e renais (idade, pressão de pulso, lactato sérico e a categoria da IRA) podem influenciar seus resultados<br>Introduction: In the present thesis, the influence of systemic, biochemical and renal factors on renal Doppler resistive index (RI) was evaluated. The accuracy of RI to predict acute kidney injury (AKI) and its reversibility was also appraised. Methods: Prospective observational study performed at medical-surgical ICU from November 2013 to October 2014. Information regarding clinical data, doppler RI, blood and urinary laboratory data was obtained during the observation period. AKI\'s reversibility was categorized into transient (normalization of renal function within 3 days of AKI onset) and persistent (nonresolution of AKI within 3 days of onset or need for renal replacement therapy). Linear mixed model was performed to evaluate the factors that could influence RI analysis. The variables evaluated on model were presence of sepsis, Simplified Acute Physiology Score 3 (SAPS 3), age, serum chloride, vasoactive drugs requirement, pulse pressure, heart rate, serum lactate and AKI categories (transient or persistent). Results: Eighty-three consecutive patients were included. 65% were male and 51% were admitted due to medical reasons. SAPS 3 were 47 ± 16. No differences were observed in age, gender, mechanical ventilation requirement and vasopressor therapy requirement between AKI groups at ICU admission. 53 patients had already AKI at ICU admission. Circulatory shock was the most common factor associated with AKI (41%). Serum lactate, pulse pressure and serum chloride was not different between groups during observation period. Doppler RI was statistically different between no-AKI (0.64 ± 0.06), transient AKI (0.64 ± 0.07) and persistent AKI patients (0.70 ± 0.08, p < 0.01). RI also showed a good accuracy to predict persistent AKI on patients with AKI at ICU admission (AUC= 0.78, 95% CI 0.65- 0.91). Variables associated with RI variations were pulse pressure, lactate, age, and AKI category (persistent AKI) (p < 0.05). Conclusions: Although renal resistive index had showed good accuracy to predict AKI reversibility in critically ill patients, several factors (age, pulse pressure, lactate levels and AKI category) could influence its values

Introdução: A maioria dos fetos com lesão pulmonar congênita (LPC) são assintomáticos e apresentam baixa morbidade ao nascimento. No entanto, alguns neonatos apresentam desconforto respiratório e necessitam receber de cuidados especiais neste período. Decidir quais casos com LPC precisam nascer em um centro de referência é um desafio. Objetivo: O objetivo deste estudo foi predizer a morbidade neonatal em fetos com LCP sem hidropisia avaliados pela ultrassonografia tridimensional (US3D). Método: Estudo observacional, entre janeiro de 2005 e janeiro de 2016, com fetos com LPC e sem hidropisia. Os volumes pulmonares foram mensurados pela US3D, técnica VOCAL, em dois períodos: entre 20 e 28 semanas (1o momento) e entre 29 e 34 semanas (2o momento). A variação intra e inter-operador foi analisada para os volumes pulmonares. As relações volumétricas testadas foram: volume pulmonar observado / esperado (VPTo/e); volume da lesão pulmonar / circunferência cefálica (LVR) e volume da lesão / volume pulmonar observado (VL/VPTo). As relações volumétricas foram usadas na predição da morbidade neonatal (admissão em unidade de terapia intensiva neonatal (UTI), necessidade de intubação (IOT); necessidade de cirurgia no período neonatal por sintomatologia respiratória). Regressão logística múltipla e curva ROC foram aplicadas para determinar a acurácia na predição dos resultados. Resultados: Dos 45 fetos não hidrópicos com LPC incluídos no estudo, 18 (40%) foram admitidos na UTI, 14 (31,1%) necessitaram de IOT, e sete (15,6%) cirurgia neonatal. A variação intra e inter-operador para os volumes pulmonares apresentou boa reprodutibilidade e não houve diferença estatística (p > 0,05). No 1o momento (IG: 20 - 28 semanas) observou-se que todas as relações volumétricas (1oVPTo/e, 1oLVR e 1oVL/VPTo) foram preditoras para admissão na UTI e necessidade de IOT. No 2o momento (IG: 29 - 34 semanas), apenas o 2oVPTo/e, e, 2oVL/VPTo foram preditores para IOT. Nenhuma das razões volumétricas (VPTo/e, LVR e VL/VPTo) foram preditoras para a cirurgia neonatal. No 1º momento, o melhor preditor para UTI foi 1º VPTo/e (ASC 0,86; p < 0,001) e para IOT foi 1º VL/VPTo (ASC 0,94; p < 0,001). Os cut-off escolhidos para a admissão na UTI foi 1º VPTo/e<0,53 (s:91,7%; e:70,8%; a:77,8%); e para IOT foi 1º VL/VPTo > 1,18 (s:91,7%; e:62,5%, a:72%). Para o 2o momento, a melhor relação volumétrica preditora para admissão na UTI foi 2º VL/VPTo (ASC 0,92; p < 0,001) e para necessidade de IOT foi 2º VPTo/e (ASC 0,87; p < 0,001). O cutoff escolhido foi 2ºVL/VPTo > 0,42 para a admissão na UTI (s:94,1%; e:82,3%; a:88%); e 2ºVPTo/e < 0,50 para IOT (s:92,9%; e:75%; a:82,3%). Conclusão: As relações volumétricas pulmonares mensuradas pela US3D podem predizer as morbidades neonatais em fetos não hidrópicos com LPC. O VPTo/e e VL/VPTo foram os melhores preditores da morbidade neonatal. Esses dados podem auxiliar no aconselhamento aos pais e na escolha do local mais adequado para o parto<br>Introduction: Most fetuses with congenital lung malformation (CLM) are asymptomatic and have low morbidity. However, some newborns present respiratory discomfort and need special care. Therefore, decide which cases need to be delivered in a referring center is challenging. Objectives: The purpose of this study was to predict neonatal morbidity in non-hydropic fetuses with CLM assessed by threedimensional ultrasonography (3DUS). Method: Observational study, between January 2005 and January 2016, involving non-hydropic fetuses with CLM. The fetal lung volumes were assessed by 3DUS, by VOCAL technique, in two moments: between 20 and 28 weeks (1st moment) and between 29 and 34 weeks (2nd moment). Intra- and inter-operator variabilities were also evaluated in estimating fetal lung volumes by 3DUS. The following volumetric ratios were assessed: observed / expected normal fetal lung volume (oeTLV), fetal lung lesion volume ratio (LVR), and lesion-to-lung volume ratio (LLV). The lung volumetric ratios were used for the prediction of neonatal morbidity (admission to NICU, need of orotracheal intubation (OTI), or need for lung surgery in neonatal period due to respiratory symptoms). Multivariate regression analyses and receiver operator characteristic curve (ROC) were applied to determine the best volumetric ratio to predict the neonatal morbidity. Results: Forty-five non-hydropic fetuses with CLM were selected for the study. Eighteen (40%) were admitted to the NICU, 14 (31.1%) needed intubation and seven (15.6%) needed neonatal surgery. The variation intra and inter-operator for lung volumes showed good reproducibility and no statistical difference (p>0.05). In the 1st moment (GA: 20 - 28 weeks), all 3DUS ratios (1st oeTLV, 1st LVR, and 1st LLV) demonstrated strong prediction for NICU admission and need of intubation. In the 2nd moment (GA: 29 - 34 weeks), only 2nd oeTLV and 2nd LLV correlated with need of intubation. None of the volumetric ratios (oeTLV, LVR and LLV) were predictive of neonatal surgery. In the 1st moment the best volume ratio for the prediction of NICU admission was 1st oeTLV (AUC 0.86, p < 0.001) and for the need of intubation was 1st LLV (AUC 0.94, p < 0.001). The cut-off chosen for NICU admission was 1st oeTLV < 0.53 (sensitivity 91.7%, specificity 70.8%, accuracy 77.8%); and for the prediction of the need of intubation was 1st LLV > 1.18 (sensitivity 91.7%, specificity 62.5%, accuracy 72%). In the 2nd moment, the best volume ratio for the prediction of NICU admission was 2nd LLV (AUC 0.92, p < 0.001) and the prediction of the need of intubation was 2nd oeTLV (AUC 0.87, p < 0.001). The cut-off chosen for the prediction of NICU admission was 2ndLLV > 0.42 (sensitivity 94.1%, specificity 82.3%, accuracy 88%); and for the prediction of the need of intubation was 2nd oeTLV < 0.50 (sensitivity 92.9%, specificity 75%, accuracy 82.3%). Conclusion: Lung volume ratio measured by 3DUS can predict neonatal morbidity in nonhydropic fetuses with CLM. The oeTLV and LLV were the best predictors of neonatal morbidity. These findings can be useful in counseling parents and in choosing the most appropriate place for delivery

Palliative health care is offered to any patient experiencing a life limiting or life changing illness. The palliative approach includes goals of care, expert symptom management, and advance care planning in order to reduce patient suffering. Complex care can be provided by palliative care specialists while primary palliative care can be given by educated staff nurses. However, according to the literature, intensive care unit (ICU) nurses have demonstrated a lack of knowledge in the provision of primary care as well as experiencing moral distress from that lack of knowledge. In this doctor of nursing practice staff education project, the problem of ICU nurses' lack of knowledge was addressed. Framed within Rosswurm and Larrabee's model for evidence-based practice, the purpose of this project was to develop an evidence-based staff education plan. The outcomes included a literature review matrix, an educational curriculum plan, and a pretest and posttest of questions based on the evidence in the curriculum plan. A physician and a master's prepared social worker, both certified in palliative care, and a hospital nurse educator served as content experts. They evaluated the curriculum plan using a dichotomous 6-item format and concluded that the items met the intent of the objectives. They also conducted content validation on each of the pretest/posttest items using a Likert-type scale ranging from 1 (not relevant) to 4 (very relevant). The content validation index was 0.82 indicating that test items were relevant to the educational curriculum objectives. Primary palliative care by educated ICU nurses can result in positive social change by facilitating empowerment of patients and their families in personal goal-directed care and reduction of suffering.

Kangaroo care (KC) is a cost-efficient method to increase infant-parent bonding and neonatal health outcomes worldwide. Despite evidence supporting KC in critically ill infants, nursing perceptions regarding patient safety and interrupted work flow continued to impede practice in the local high-tech neonatal intensive care unit (NICU). Their current policy failed to address the 2-person transfer method recommended for safe practice. In addition, both staff and parents lacked training and education regarding the benefits and feasibility of KC. This doctoral project aimed to decrease practice barriers and promote earlier and more frequent KC by developing and integrating an evidence-based clinical pathway within a multifaceted champion-based simulated educational training program for NICU staff and parents. Published outcomes and generated organizational data for program synthesis connected the gap in practice. Kolcaba's comfort theory served as the guiding framework to ensure a partnership in care. This quasi-experimental quantitative study used the generalized liner model for data analysis. Study findings indicated that KC occurred 2.4 more times after the intervention compared to before (p = 0.001). Descriptive data revealed that KC episodes for intubated patients nearly doubled after implementation (11.1% from 6.2%). Post-survey scores for nursing knowledge and comfort level also improved after the intervention. Although earlier KC practice was non-conclusive (p = 0.082), future trials should control groups for day of life since admission. Disseminating the KC pathway can have a positive social change on family-centered care by increasing NICU nurses' knowledge, comfort, and adoption of this evidence-based practice as an expected routine standard of care.

The rapid growth of medical sciences and technologies created the need to manage data generated by sophisticated medical equipment (e.g. lab results, vital signs, etc.). This class of equipment, especially in the modern Intensive Care Unit (ICU), emits large quantities of latient data which medical staff usually records on log sheets.<br>This thesis presents a database design that allows abstract definition of data types, and offers a unified view of data during the development phase, distinct levels of data management and a higher degree of system flexibility. This database model is an implementation of a database for a Patient Data Management System (PDMS) developed for use in the ICU of the Montreal Children's Hospital. The PDMS has a variety of application modules that handle and process various types of data according to functionality requirements.

The rapid digitalization of the healthcare domain in recent years highlighted the need for advanced predictive methods particularly based upon deep learning methods. Deep learning methods which are capable of dealing with time- series data have recently emerged in various fields such as natural language processing, machine translation, and the Intensive Care Unit (ICU). The recent applications of deep learning in ICU have increasingly received attention, and it has shown promising results for different clinical tasks; however, there is still a need for the benchmark models as far as a handful of public datasets are available in ICU. In this thesis, a novel benchmark model of four clinical tasks on a multi-center publicly available dataset is presented; we employed deep learning models to predict clinical studies. We believe this benchmark model can facilitate and accelerate the research in ICU by allowing other researchers to build on top of it. Moreover, we investigated the effectiveness of the proposed method to predict the risk of delirium in the varying observation and prediction windows, the variable ranking is provided to ease the implementation of a screening tool for helping caregivers at the bedside. Ultimately, an attention-based interpretable neural network is proposed to predict the outcome and rank the most influential variables in the model predictions’ outcome. Our experimental findings show the effectiveness of the proposed approaches in improving the application of deep learning models in daily ICU practice.

Critically ill patients admitted to the intensive care unit (ICU) commonly develop severe muscle wasting and weakness and consequently impaired muscle function. This not only delays respirator weaning and ICU discharge, but has deleterious effects on morbidity, mortality, financial costs, and quality of life of survivors. Acute Quadriplegic Myopathy (AQM) is one of the most common neuromuscular disorders underlying ICU muscle wasting and paralysis, and is a consequence of modern intensive care interventions, although the exact causes remain unclear. Muscle gene/protein expression, intracellular signalling, post-translational modifications, muscle membrane excitability, and contractile properties at the single muscle fibre level were explored in order to unravel the mechanisms underlying the muscle wasting and weakness associated with AQM and how this can be counteracted by specific intervention strategies. A unique experimental rat ICU model was used to address the mechanistic and therapeutic aspects of this condition, allowing time-resolved studies for a period of two weeks. Subsequently, the findings obtained from this model were translated into a clinical study. The obtained results showed that the mechanical silencing of skeletal muscle, i.e., absence of external strain (weight bearing) and internal strain (myosin-actin activation) due to the pharmacological paralysis or sedation associated with the ICU intervention, is likely to be the primary mechanism triggering the preferential myosin loss and muscle wasting, features specifically characteristic of AQM. Moreover, mechanical silencing induces a specific gene expression pattern as well as post-translational modifications in the motor domain of myosin that may be critical for both function and for triggering proteolysis. The higher nNOS expression found in the ICU patients and its cytoplasmic dislocation are indicated as a probable mechanism underlying these highly specific modifications. This work also demonstrated that passive mechanical loading is able to attenuate the oxidative stress associated with the mechanical silencing and induces positive effects on muscle function, i.e., alleviates the loss of force-generating capacity that underlie the ICU intervention, supporting the importance of early physical therapy in immobilized, sedated, and mechanically ventilated ICU patients.

Thesis (M.S.N.)--University of North Carolina at Greensboro, 2007.<br>Title from PDF t.p. (viewed Mar. 3, 2008). Directed by Susan Letvak; submitted to the School of Nursing. Includes bibliographical references (p. 53-58).

The literature review highlighted the continuing problem of hospital acquired infection. This study examined this problem in depth, in a high-risk area, the Neonatal Intensive Care Unit. A multi-centre study was conducted using multi-methods in order to capture data regarding nurses' infection control practices in neonatal units. Ninety nurses/ nursery nurses from six neonatal units were included in the study. Non-participant observation was used to investigate nurses' existing infection control practices, interviews were used to explore nurses' opinions of infection control, questionnaires were used to collect demographic data about the sample and assess nurses' knowledge of infection control issues and a Likert-type scale was developed to investigate the unit atmosphere/environment. Microbiological laboratory work was undertaken to compare the efficacies of three products (soap, alcohol hand rub and chlorhexidine) at removing/reducing the numbers of bacteria found on the hands. The effectiveness of gloves at preventing contamination of the hands was also assessed. Finally, the numbers of bacteria recovered from the hands of university administrative staff and nurses were compared to determine whether or not nurses had higher numbers of bacteria on their hands due to the number of organisms they are exposed to and their increased frequency of hand hygiene. Overall, nurses' hand hygiene practices were found to be relatively poor. However, there was some evidence that length of shift, as a proxy indicator of fatigue, and unit atmosphere/environment may influence nurses' infection control practices. Opinions and knowledge were not associated with observed practice. Nursery nurses had lower hand hygiene scores and knowledge scores than nurses and increased experience in the neonatal unit was associated with increased infection control knowledge. The number of bacteria recovered from the hands of nurses was significantly higher than the numbers of bacteria recovered from the hands of administrative staff. In the clinical setting, chlorhexidine was found to be the only product that consistently removed significant numbers of bacteria from the hands. Indeed, the alcohol hand rub was found to increase the numbers of bacteria on the hands. The number of bacteria recovered from the hands did not differ when gloves were worn. This suggests the inside of gloves may be providing a medium for the multiplication of bacteria. However, the number of bacteria recovered from the surface of used gloves was significantly lower than the numbers of bacteria recovered from nurses' hands after nursing activities. The use of gloves for all procedures on the neonatal unit may be advantageous.

Patients admitted to the Intensive Care Unit (ICU) are critically ill and often at extremely high risk of death. These patients receive aggressive interventions to prolong their lives. Despite these measures, many patients still succumb to their illness. Although ICU physicians are good at predicting which patients have a high risk of mortality, they are still offering interventions that do not prolong life, but potentially cause more suffering at the end of life. This is because there is a lack of high quality and early communication to discuss prognosis and establish patients' goals of care. This gap in communication is even more profound when patients are transferring from rural hospitals to busy tertiary care centers. This dissertation discusses the utilization of tele-video conferencing to enhance early communication with family members/loved ones of critically ill patients prior to their transfer from a rural hospital to a tertiary care center. It begins with a description of telemedicine and its uses in the ICU to date. Chapter 2 discusses the poor prognoses of patients receiving high intensity interventions such as cardiopulmonary resuscitation (CPR). The extremely dismal outcomes underscore the importance of early, thorough discussions regarding prognosis and goals of care in these patients. The next chapter describes a pilot study utilizing telemedicine to conduct formal unstructured telemedicine conferences with family members prior to transfer. This study demonstrated that palliative care consultations can be provided via telemedicine for critically ill patients and that adequate preparation and technical expertise are essential. Although this study is limited by the nature of the retrospective review, it is evident that more research is needed to further assess its applicability, utility and acceptability. Chapter 4 describes an investigation into the barriers and facilitators of conducting conferences via telemedicine and the perceptions of clinicians regarding the use of telemedicine for this purpose. This chapter identified unique barriers and facilitators to the use of telemedicine that will need to be addressed when designing a telemedicine intervention for conducting family conferences. This thesis describes the importance and process of implementation of telemedicine for the novel purpose of enhancing early communication among physicians and family members of critically ill loved ones. Further studies are needed to refine and investigate patient and family centered clinical outcomes utilizing this intervention.

The purpose of this study was to describe the phenomenon of maternal attachment as it specifically relates to moderate premature delivery. The study investigated the impact of educational, counseling and therapeutic interventions on mothers who delivered premature infants. Research hypotheses were that mothers who participated in the treatment group would demonstrate significant increases in the independent variables of self esteem, social networking and family function strategies. This study also hypothesized that there would be a significant positive relationship between treatment and the dependent variable of maternal attachment. The sample consisted of 30 mother-infant dyads between the ages of 15 and 38 years of age. Infants' gestational age ranged from 32 to 36 weeks. Data were gathered using three measures: (1) a demographic profile of the subjects; (2) a questionnaire including the Tennessee Self Concept Scale, Sarason's Life Event Survey, Norbeck's Social Support Questionnaire, Feetham's Family Function Index; and (3) Barnard's Nursing Child Assessment Feeding Scale (NCAFS). The research study consisted of a field experiment. Fifteen subjects were assigned to the experimental and control group via a modified randomized block procedure. A questionnaire was issued during infant's hospitalization and at 4 months post infant discharge from the hospital to measure the independent variable. The dependent variable was measured at 1 month, 2-1/2 months and 4 months using the NCAFS. Treatment consisted of a minimum of seven sessions during the infant's hospitalization and discharge to home. Statistical analyses were conducted in the form of frequency distributions, means, standard deviations, t-tests and correlation scores. Stepwise multiple regression techniques were used for predictor variables. Results indicated that mothers who participated in the treatment group demonstrated significantly improved maternal attachment processes than those mothers who did not receive intervention. The results did not indicate that there was a significant difference between the two groups on self esteem, social support, life events or family function. Implications for the study were noted. Recommendations for medical and mental health practitioners and future areas of research were discussed.

Health-care-associated infections (HCAIs) affect hundreds of millions of people worldwide, causing morbidity and mortality among hospitalized patients. About 2 million patients suffer from HCAIs in the United States, and it is estimated that 99,000 of them die each year. Studies have indicated that transmission of health-care-associated microorganisms occurs through contaminated hands of health care workers. Hand hygiene (HH) is the single most effective way to prevent health-care-associated infections, yet health care workers' hand hygiene compliance remains low. One factor responsible for poor compliance with hand hygiene guide-lines are lack of knowledge of good hand hygiene and lack of hand hygiene techniques. This project evaluated the effect of educational program on hand hygiene for intensive care unit (ICU) healthcare workers. The Health Belief Model was applied as the framework in this project. Key components of the model are perceived susceptibility, perceived severity, perceived benefit, and perceived barriers. A convenience sample of 25 ICU healthcare workers participated in the educational program. Pre- and post- education surveys and tests were assessed using descriptive statistics. Results were consistent with existing findings indicating that education is needed to improve HH compliance and that effective HH reduces infections. The findings from this project may contribute to positive social change by promoting increased HH knowledge and infection prevention while decreasing complications of treatments, costs, morbidity, and mortality, thereby promoting a healthy and safe community.

Objective: The Patient Self-Determination Act of 1990 (PSDA) protects a patient’s right to predetermine the level of life-supporting care they are willing to receive (U.S. Department of Health and Human Services, 1993). In Arizona, the advance directive (AD) complies with the PSDA and is used to guide care in the event of cardiopulmonary failure. The AD may indicate “do not resuscitate” (DNR), which prohibits cardiopulmonary resuscitation in the event of cardiac arrest. In the institution used for this project, a palliative care team assists with identifying goals of care and helps guide interventions consistent with the AD. The purpose of this Doctor of Nursing Practice (DNP) project was to complete a retrospective chart review and identify patients admitted to the medical intensive care unit (ICU) with a DNR as indicated by a copy of the AD in the electronic health record (EHR) and determine if they received a palliative care consultation. This information could support a quality improvement project led by the DNP-prepared AGACNP focused on ensuring a palliative care consultation within 48 hours of admission for patients admitted to the ICU with a DNR. Methods: A search of the EHR identified patients admitted to the medical ICU over a 12-month period. The EHR of patients admitted with a DNR were reviewed to determine if they received a palliative care consultation during the ICU stay and the patient’s final disposition. Findings: A total of 38 patients had an AD indicating DNR status on admission to the medical ICU. Of those patients, 26 (68.4%) received a palliative care consultation. Twelve patients (31.6%) with a DNR status on admission did not receive a palliative care consultation. Additionally, five patients with a DNR (13.16%) died in the ICU without receiving a palliative care consultation. Conclusion: Twelve patients with an AD indicating a DNR did not receive a palliative care consultation, and five of those patients died in the ICU. The findings from this project support a quality improvement project to implement palliative care consults to review goals of care for patients with a pre-existing AD indicating a DNR code status.

CoordenaÃÃo de AperfeÃoamento de Pessoal de NÃvel Superior<br>Hospitalization of the newborn is necessary when health conditions require immediate assistance for their recovery. Humanized actions in the neonatal unit have been developed in order to make it less painful separation parent-child when it needs technological support and team of trained professionals. It was aimed to analyze the perception and knowledge of the nursing team on the promotion of humanized care for newborn in a Neonatal Intensive Care Unit . It is a qualitative study conducted in a public hospital, large, tertiary level, in Fortaleza, Brazil, in the months October and November 2015, after approval by the Research Ethics Committee, under Protocol N. 1,191,339. The subjects were 14 nurses and 20 nursing technicians working in neonatal care. The data collected through semi-structured interviews consist identification data and five guiding issues that permeate the knowledge of the nursing team about the care and promotion of humanized care in the UTIN. In addition, we used no-participant observation and field diary. For analysis, we sought to Bardin technique that extracted the three categories lines: âTaking care of the human personâ, ânursing contributions to the humane careâ and âFactors that affect the quality of humanized care.â The results showed that the nursing team understands humanization as an indispensable element for the comprehensive care to the baby and family, which was observed from the speeches of welcome, restoring health and disease of the newborn process. The professionals had knowledge of the humanized care, played their actions conscious, oriented and appreciative way about the quality of neonatal care and parents who face the challenges inherent in the admission process. We conclude that the performance of these professionals permeates compliance with the regulations of the National Humanization Policy regarding humanized care to the newborn, family and neonatal ambience. It is believed that such actions minimize the impact caused by the characteristics of the disease treatment as well as stressors.<br>A hospitalizaÃÃo do recÃm-nascido faz-se necessÃria, quando as condiÃÃes de saÃde requerem assistÃncia imediata para o seu restabelecimento. As aÃÃes humanizadas na unidade neonatal tÃm sido desenvolvidas, a fim de tornar menos dolorosa à separaÃÃo pais-filho, quando este necessita de suporte tecnolÃgico e equipe de profissionais capacitados. Objetivou-se analisar a percepÃÃo e conhecimentos da equipe de enfermagem sobre a promoÃÃo do cuidado humanizado ao recÃm-nascido internado na Unidade de Terapia Intensiva Neonatal (UTIN). Trata-se de estudo qualitativo, realizado em hospital pÃblico, de grande porte, nÃvel terciÃrio, em Fortaleza-CE-Brasil, nos meses outubro e novembro de 2015, apÃs aprovaÃÃo pelo Comità de Ãtica em Pesquisa, sob Protocolo n 1.191.339. Os sujeitos foram 14 enfermeiros e 20 tÃcnicos de enfermagem atuantes na assistÃncia ao neonato. Os dados coletados, por meio de entrevista semiestruturada, consistem dados de identificaÃÃo e cinco questÃes norteadoras, que permeiam o conhecimento da equipe de enfermagem acerca do cuidado e a promoÃÃo da assistÃncia humanizada na UTIN. Ademais, utilizou-se observaÃÃo nÃo participante e diÃrio de campo. Para anÃlise, sÃntese e descriÃÃo, buscou-se a tÃcnica de Bardin, que se extraÃram das falas trÃs categorias: âCuidar do ser humanoâ, âContribuiÃÃes de enfermagem para o cuidado humanizadoâ e âFatores que interferem na qualidade do cuidado humanizadoâ. Os resultados revelaram que a equipe de enfermagem compreende a humanizaÃÃo como elemento indispensÃvel para o cuidado integral ao bebà e famÃlia, o que se observou desde as intervenÃÃes de acolhimento, ao restabelecimento do processo saÃde-doenÃa do neonato. Os profissionais apresentaram conhecimentos acerca do cuidado humanizado, desempenharam suas aÃÃes de forma consciente, orientada e sensibilizada, quanto à qualidade da assistÃncia ao neonato e aos pais que enfrentam os desafios inerentes ao processo de internaÃÃo. Percebe-se, portanto, que a atuaÃÃo desses profissionais permeia o cumprimento aos regulamentos da PolÃtica Nacional de HumanizaÃÃo. Conclui-se que o cuidado humanizado aplicado nessa ambiÃncia à essencial ao recÃm-nascido e famÃlia, uma vez que minimiza o impacto causado pelas caracterÃsticas da doenÃa, tratamento, bem como os fatores estressantes da UTIN.

Ventilator-associated pneumonia (VAP), catheter-related blood stream infection (CRBSI) and pressure ulcers (PU) are well recognized complications in intensive care units (ICUs). Many of these are preventable but can also complicate patient recovery, prolong length of stay, increase costs, morbidity and mortality. In Malaysia, the majority of studies investigating VAP and CRBSI in Malaysia have focussed on identifying risk factors, diagnostic criteria and treatment of ICU-related complications. Further, in spite of the burden of PU there are limited studies undertaken in Malaysia and few of these have been nurse-led. Importantly, to date there has been limited investigation of the efficacy and effectiveness of quality improvement initiatives and the contextual issues impacting on clinical practice improvement in Malaysia.In spite of the increasing emphasis on quality assurance in Malaysian ICUs there has been a limited focus on nurse-specific interventions and the majority of projects have been initiated by physicians. This study has evaluated the utility of a nurse-led action research project to drive clinical practice improvement in the ICU and is significant in demonstrating the capacity of nurses to critique and control their practice. The project conducted for this thesis was called the Improving health outcomes by preveNting intensiVe care related infEction in Malaysia intenSive care uniT - INVEST study. The INVEST Study as reported in this thesis has been undertaken using an action research approach to improve the uptake of evidence-based strategies to prevent infection in the ICU in the Malaysian cultural context.The aims of this thesis were to identify best practices, evaluate the current nursing practice in prevention of VAP, CRBSI and PU in ICU patients in a single Malaysian ICU, and evaluate the impact of the evidence-based interventions to improve patient outcomes. The specific and research objectives of this study were to:1. Identify best practice interventions for preventing VAP, CRBSI and PU in the ICU. 2. Document the current rates of VAP, CRBSI and PU in an ICU in Malaysia. 3. Implement an action research intervention to collaboratively develop and implement strategies for improvement 4. Assess the impact of the intervention on clinical outcomes, staff dynamics, work place culture and sustainability of practice change An action research approach was used in this study to involve and empower nurses and drive practice change. A literature review identified that many action research studies conducted in the ICU were mainly most focused on process measures and not outcomes. In this study the data were collected in three phases following the action research cycles which comprised of a period of planning, acting, observation, reflecting and re-planningIn Phase I of the thesis current best practice interventions for the prevention of VAP, CRBSI and PU in ICU are described. A literature search was conducted to identify evidence-based practices (EBP) that were recommended by bodies to improve the prevention of VAP, CRBSI and PU. A core set of nursing activities was identified in preventing the complications of VAP, CRBSI and PU. These were hand washing, hygiene care, positioning of patient, elevation of the head of bed and providing adequate nutrition.Pre- intervention data collection consisted of an environmental scan, including interview with the key stakeholders, patient profiling and a nurse survey. Twenty-one cases of ICU complications were identified in 18 of the 91 patients (19.8%) admitted in December 2009. Of the patients, three developed two complications - PU and VAP (two patients) or CRBSI (one patient). The findings indicated that this ICU had a high case load due to the high ICU bed demand. Patients needing ICU care were being nursed in general wards due to the unavailability of ICU beds.Nurses reported a good knowledge of prevention strategies with a mean score of 124.84 ±SD14.66 and reported a high level of positive regard for their professional practice environment based on the results of Revised Professional Practice Environment (RPPE). Three components had mean scores of ≥3 and five <3 within the eight components. Three components of RPPE subscales with highest mean scores were Internal Work Motivation (M 3.24; SD 0.3), Relationship With Physician (M 3.22; SD 0.53) and Cultural Sensitivity (M 3.04; SD 0.24). The two lowest mean scores were for Handling Disagreement and Teamwork with 2.77 (SD 0.16) and 2.45 (SD 0.47), respectively. Nurses also showed positive attitudes toward the sustainability of the change process. The Sustainability Indices ranged from 13.4 to 100 with a mean of 75.21 (SD 21.71).In Phase 2 the intervention was conducted over six months from February to July 2010. The Center of Disease Control and Prevention (CDC) criteria for diagnosis of VAP and CRBSI, and the Waterlow Pressure Ulcer Risk Assessment Scale were promoted in the unit. Nurses were exposed and encouraged to implement evidence-based nursing interventions as identified in care criteria. All nurses were invited to the unit nursing education to increase their knowledge and awareness about evidence-based practice in prevention of the ICU complications. Nurses were encouraged to gain control of their practice. Evidence-based practice articles were also provided to increase their knowledge level and posters were distributed and placed in the unit to increase nurses awareness of the quality improvement initiativesFocus group discussions were conducted in Phase 2 and found that nurses in the unit were unaware of the importance of standardized assessment in their daily practice. They had a lack of understanding regarding the importance of standardised risk assessments. Despite the reluctance of many nurses to embrace the EBP, due to a perception of their workload, the focus groups also revealed nurses were optimistic that change will get easier and could be eventually achieved. Participants were positive about the change that could take place in the future. The hierarchical relationships with medical doctors were also identified as a factor limiting nurses from adopting the guidelines.Phase 3 of the project, the post-intervention phase was conducted from March to May 2011. The data collection process was repeated as Phase 1 and Phase 2. There were 11 cases of ICU complications identified during the post-intervention phase in 10 (8.7%) of the 115 patients admitted during March 2011. One patient developed both VAP and PU, while four developed VAP and another five PU. In the post-intervention group, no cases of CRBSI were detected. The total mean score of nurses’ knowledge was 121.45±SD16.85. An independent-samples t-test was conducted to compare nurses’ knowledge pre and post intervention, and found no significant differences, t (150) =1.32, P 0.189. The Sustainability Indices ranged from 41.3 to 100 percent with a mean of 76.81±SD21.45.Approximately 84% of the nurses in pre-intervention and 70% in post-intervention scored >55%. The nurses reported a positive regard for their practice environment in the pre- and post-intervention groups. The mean scores for each component were comparable for both the pre- and post-intervention groups except for Internal Work Motivation, Control Over Practice and Staff Relationship With Physician. The highest mean scores within the eight components for the post-intervention group were for Internal Work Motivation (M 3.13; SD 0.27), Relationship With Physician (M 3.04; SD 0.33) and Cultural Sensitivity (M 3.01; SD 0.23). The three lowest were for Handling Disagreement and Conflict (2.80; SD 0.20), Control Over Practice (2.71; SD 0.34) and Teamwork (2.48; SD 0.31).There was a reduction in overall complications from 19.8% to 8.7%. Few nurses in the focus group were optimistic that at least some changes had taken place, and positively improving their knowledge on assessment of patients and some of their common practices in the ICU. The challenge, which they were presently facing was the implementation of hospital information system because most of them were not knowledgeable in information technology.The main outcome of this study was that there was a reduction in number of patients with PU from 16 to 6 in pre and post intervention groups. This reduction of PU was statistically significant (χ[superscript]2=8.14, df=1, p=0.04).In conclusion whether there was a real improvement in patient care provided due to the interventions given was not able to be determined due to methodological considerations and inability to control for confounders. These data underscore the importance of considering cultural factors, both organisational and societal in quality improvement initiatives and empowering nurses for practice change. A risk management system which acknowledges competing demands in dynamic, real world environments is important to consider in future quality improvement studies. The series of studies presented in this thesis have contributed to understanding of factors influencing implementation and sustainability of quality improvement initiatives in a Malaysia ICU. Information acquired from the thesis will be useful information for further improvement targeting education, services, research, policy and future quality improvement project plans in Malaysia.

The intensive care unit (ICU) is one of the most complicated areas' of a hospital, with multidisciplinary teams providing life-saving care to critically ill patients. Root-cause analyses of medical errors in the rcu have indicated that poor teamwork and a lack of shared understanding between team members for aspects of patient care are important causal factors in medical errors. This thesis investigated teamwork and team cognition in the intensive care unit. Study 1 found teamwork to be important for sa'ty in the ICU. An analysis of critical incident studies showed that approximately 43% of the contributory factors underlying critical incidents in the ICU were related to 'non-technical skills'. Of those, 16% were associated with teamwork. Studies 2 investigated the influence of team structures upon the perceptions of ICU team members in the UK. The survey showed ICU staff at four ICUs to have positive perceptions of communication and leadership in the rcu. However, team member roles were found to influence perceptions, with nurses and junior doctors having less positive perceptions (compared to senior doctors) of communication and leadership in the rcu. Study 3 investigated a facet of team cognition known as team situation awareness (team SA). Regression analysis found minimal support for the hypothesis that the involvement and contributions of team members during patient reviews would predict the degree to which team members formed similar anticipations of future patient conditions (i.e. team SA). However, the involvement of trainee doctors in the patient decision-making process was found to predict the degree to which they formed similar anticipations with the senior doctor on two measures of situation awareness. The data presented in this thesis indicates the importance of teamwork for safety in the ICU, and identifies the factors (e.g. team hierarchies) that influence team process and team performance. Keywords: ICU, patient safety, medical error, teamwork, team cognition, team situation awareness.

This thesis presents the design and implementation of an automated task scheduler developed for the Patient Data Management System (PDMS) of the Pediatric Intensive Care Unit of the Montreal Children's Hospital. The principal objective of the Nursing Workload Scheduler (NWS) is to automatically generate schedules for the condition of multiple patients and multiple nurses.<br>This thesis begins with a literature review of computerized medical information systems. It follows with a description of the design and the implementation of the NWS. Evaluation and performance results are then presented and discussed. An outline of future extensions for the system are discussed before the conclusion.

Ongoing evaluation of current practice and incorporation of evidence based research into guidelines and protocols is a requirement for the provision of high quality, cost efficient care. Despite some literature describing observational data, midline catheters (MCs) are not an appropriate vascular access device for Newborn Intensive Care Unit (NICU) patients due to insufficient high level evidence demonstrating safety and efficacy. In addition, national guidelines for MC use in neonatal and infant patients lacks sufficient information for safe and effective use of MCs. The results of this small, online survey indicate that while some neonatal nurses and Nurse Practitioners report the use of MC use in the NICU, there is a wide range of practice pertaining to MC unit-specific protocols, competencies, success with placement, and clinician agreement of appropriate use for this vascular access device (VAD). Multicenter, randomized control trials are needed to evaluate current MC practice in the NICU, and institutions must incorporates current, evidence based practice into policies, procedures, and guidelines.

The aim of this thesis is to explore nurses’ understanding of technology in the intensive care unit. The study brings together empirical data gathered from nurses’ practice in the ICU environment, along with theoretical insights from science and technology studies, to illuminate how nurses’ understanding informs their use of technology in their care activities. The empirical data was gathered through intensive fieldwork over a period of 5 months in an ICU department within a large teaching hospital. In addition, recorded in-depth interviews were carried out with ICU nursing staff. The interviews uncover themes such as nurses’ practice with technology; nurses’ ambivalence around the use of technology in relation to patient care; and nursing identity and professional status. Current theories of technological determinism, social essentialism and technology-in-practice within science and technology studies are examined for their usefulness in illuminating the world of ICU nursing research. In particular, Actor-Network Theory, as an example of technology-in-practice, is utilised as a theoretical lens to explore the contingent nature of social and technological relations on the ICU, where nurses’ understanding of technology emerges as an effect of multiple associations between human and non-human actors. The thesis informs existing research by offering further empirical insight into the ICU world through in depth analysis of the semiological and material qualities of technology in the ICU, and develops a number of conceptual themes such as ‘balancing patients,’ ‘chasing numbers’ and the ‘technology vigil’ to frame nurses’ understanding of technology. The study also adds insight into the construction of nursing identity, suggesting it is an emergent property of nurses’ interactions with technology. The thesis concludes by indicating that knowledge of how nurses understand, use and frame their identity in relation to technology can inform current research into technology adoption and diffusion in healthcare environments.

Exposure to noise in hospital intensive care units (ICUs) can disrupt patients’ sleep and delay their recovery. In this intervention study, noise levels were measured in eight patient rooms of a medical ICU (MICU) every minute with sound level meters for eight weeks before and after an intervention. Implemented over six weeks, the intervention was designed to educate nurses and other staff members to reduce noise levels through behavior modification, including instituting a “quiet time” in the afternoons, encouraging patients to keep televisions off or at lower volumes, and speaking more quietly during conversations. Sound equivalent levels (Leq) were calculated from one-minute measurements for each hour in each room. These hourly Leq (Leq-H) values were compared by pod (group of rooms within the MICU), room position (in proximity to a central nurses’ station), occupancy status, and time of day. Days with more than ten hours of one-minute noise levels above 60 dBA were flagged as the loudest time periods and compared to MICU activity logs. The intervention was ineffective with Leq-H values always above World Health Organization guidelines for ICUs (35 dBA in day; 30 dBA at night) before and after the intervention. Leq-H values frequently exceeded more modest project goals during the day regardless of the intervention (50% of Leq-H > 55 dBA both pre- and post-intervention) and at night (68% and 62% of Leq-H > 50 dBA pre- and post-intervention). Statistical analysis of the Leq-H suggests a general source is contributing to the high baseline noise in the MICU, most likely the heating, ventilation, and air-conditioning (HVAC) system. Our analysis of one-minute data indicated that high noise was often associated with high-volume respiratory-support devices. We concluded that our intervention focusing on administrative controls (e.g., education and training) was not enough to reduce noise in the MICU but that an intervention designed with engineering controls (e.g., shielding, substitution) would be more effective.

Alarm fatigue is a practice problem that applies to hospitalized patients and the nurses who care for them. Addressing alarm fatigue is important to promote alarm safety and to decrease the risk of patient harm or death. The purpose of this study was to decrease alarm fatigue and improve alarm safety in a regional neonatal intensive care unit (RNICU). Guided by the conceptual model for alarm fatigue and alarm safety, this study addressed whether or not alarm management protocols designed to decrease false and nuisance alarms in the physiological monitoring of neonates improve alarm safety via decreased alarm burden and alarm fatigue as evidenced by statistically significant reductions in false and nuisance alarms. A quantitative, time series quasi-experimental design was used with 4 waves of data collection. One wave was baseline data collected preintervention, and 3 waves of data were postprotocol implementation to obtain an initial indication of sustainability. Alarm observation data collection sheets were developed and used to track numbers and types of alarms pre- and post-protocol implementation. The data analysis showed statistically significant decreases in both false alarms and nuisance alarms related to the physiological monitoring protocol and lead changing protocol. Overall, high protocol adherence was noted, and the total number of alarms per hour per bed was reduced by 42% (p < .001), 46% (p < .001), and 50% (p < .001) from baseline at Weeks 2, 4, and 6, respectively. Implications from this study include impact on practice and policy, direction for future study, and a call for social change to promote alarm safety in the care of neonates.

This electronic version was submitted by the student author. The certified thesis is available in the Institute Archives and Special Collections.<br>Thesis: M. Eng. in Computer Science and Molecular Biology, Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science, 2019<br>Cataloged from student-submitted PDF version of thesis.<br>Includes bibliographical references (pages 85-86).<br>An ICU stay involves invasive treatments, and frequently, the decision to continue therapy is made with limited information based on the physician's personal experience. This thesis proposal describes a tool to assist this decision by identifying similar patients and using their outcomes for prediction. We used the eICU Collaborative Research Database (eICU-CRD) v2.0 for the project. Different time varying and time constant features about the patient's demographics and clinical trajectory was used as input data, such as patient age and longitudinal blood pressure measurement. Using this information, a Cox Proportional Hazards model was built to map the multivariate time series of input data to a univariate time series, which was used to match the patient to a cohort of similar patients. Based on the cohort, this model predicted the probability of a healthy discharge by using the aggregate outcome of the cohort for prediction.<br>by Joseph Seung Young Park<br>M. Eng. in Computer Science and Molecular Biology<br>M.Eng.inComputerScienceandMolecularBiology Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science

Introduction - Maximising efficient and effective use of resources without compromising quality of care is essential in the current healthcare climate. Intensive care unit services are one of the most resource intensive and therefore expensive services within a hospital. Because intensive care unit services comprise a significant portion of hospital costs and resources, appropriate utilisation of intensive care units is imperative. The occurrence of delayed discharges and the reason for the delays is important as they impact on the efficiency and effectiveness of intensive care unit services. Patients who no longer need intensive care unit care block beds for impending admissions, unnecessarily utilise the costly and often scarce resources and by remaining in a stressful environment may experience negative psychological and social effects detrimental to their well being. Study objectives - To determine to what extent delayed discharge from the intensive care unit occurs and ascertain the reasons for these delays. Design - A prospective cross sectional design to determine the number of delayed discharges from the intensive care unit and reasons causing the delay. A discharge was considered to be delayed if the patient was not discharged from the intensive care unit within 8 hours of being deemed suitable for discharge by intensive care unit medical staff. Setting - A level III intensive care unit with 22 beds (12 general and 10 surgical beds in 2 adjacent areas) in a metropolitan tertiary teaching hospital of 955 beds located across two campuses. Sample - A prospective convenience sample of consecutive patients admitted over a 6-month period from September 2000 to March 2001. Exclusions were patients who died whilst in the intensive care unit and those patients who could be discharged prior to commencement of the study. Method. - Intensive care unit medical staff informed nursing shift coordinators when patients could be discharged. The nursing shift coordinators completed the data collection tool on all patients discharged from intensive care unit. Admission and discharge times and APACHE-11 data (a predictive scoring system for ICU patient outcome) were recorded from intensive care unit records. Results - There were 652 discharges, 468 patients were not delayed (71.8%), 176 were delayed (27.0%, 95% CI 23,9%-30.7%) and 8 (1.2%) patients had no delay information available. There were substantial delays in discharging patients from the intensive care unit; for every 5 discharges that were not delayed, 2 patients would be delayed. Unavailable ward beds (81 %) were cited as the main reason for delay in discharge. Delay time from the intensive care unit ranged from 0.2 hours (1 0 minutes) to 617.5 hours (3 weeks, 4 days, 17.5 hours). Mean delay time was 42 hours (I day, 18 hours) and median delay time 21.3 hours. There was a statistical significance difference between-non delayed and delayed patients for APACHE II score on admission (Ɩ = -3.824 {642), p <0.0001) and worst APACHE 11 score in first 24 hours e (Ɩ = -5.123 (642), p <0.0001 ). There was also a statistically significant difference between delay from the intensive care unit and non delayed discharge by admitting diagnosis (Chi sq (12) = 43.235, p < 0.0001); primary organ system failure (chi sq (6) = 14.231, p = 0.027); ward destination (chi sq (7) = -51.486, p < 0.0001 ); specialty (chi sq (23) = -43.371, p = 0.006) and day of eligible discharge (chi sq (6) = 34.008; p < 0.0001 ). Conclusion - Discharge from the intensive care unit is delayed on average by 27% in the study hospital. These delays can be related to how sick the patient was, principle admitting diagnosis, discharge destination and weekend discharge. Reducing these delays would free up beds for other admissions, may result in a cost saving for the health care facility through more efficient resource utilisation and ultimately benefit patients by better managing the discharge process.

This item is only available in print in the UCF Libraries. If this is your Honors Thesis, you can help us make it available online for use by researchers around the world by following the instructions on the distribution consent form at http://library.ucf.edu/Systems/DigitalInitiatives/DigitalCollections/InternetDistributionConsentAgreementForm.pdf You may also contact the project coordinator, Kerri Bottorff, at kerri.bottorff@ucf.edu for more information.<br>Bachelors<br>Nursing<br>Nursing

The growing concern over the nursing shortage has affected the intensive care unit (ICU) and how these units provide quality care, adhere to best practices, and maintain high satisfaction scores. Implementing telemedicine technology allows the ICU to have additional staff available, via cameras at an offsite location, to assist with patient care. The purpose of this project was to evaluate the potential benefits of telemedicine application used within an ICU on quality of care, adherence to best practices, and satisfaction, as evidenced by data from the hospital's telemedicine dashboard. The goals of this project were to reduce length of stay, increase staff satisfaction, and increase compliance with best practices. The diffusion of innovation theory was used to bring about successful change among team members in the ICU. The Focus Plan, Do, Study, Act methodology was used to determine what improvements were needed in the ICU. The evaluation of the telemedicine unit demonstrated early signs of positive progress. Actual length of stay (3.25 days) from the hospital's telemedicine dashboard was less than the predicted length of stay (3.8 days), and adherence to best practice was at or above target (95%) when compared to all telemedicine units across the nation, as provided by the telemedicine dashboard. Implementing a telemedicine unit will bring about a transparency and standardization of Intensive Care services, leading to positive social change in the organization. This social change, combined with the success of the unit, can influence other non-academic healthcare institutions to pursue telemedicine technology.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.<br>Introduction: Patients who develop delirium while hospitalized are increasingly recognized as at risk for the development of long term cognitive impairment. We became interested in the contribution of delirium to the development of post-operative cognitive dysfunction (POCD) when we found that patients at Mayo Clinic in Arizona, compared to patients at the Mayo facilities in Rochester, MN, were 17 times more likely to receive the drug physostigmine (Antilirium®) for the treatment of delirium in the Post Anesthesia Care Unit (PACU). However, before we could examine the relationship between delirium and POCD we needed to validate a tool we could use to quickly assess the presence of delirium in patients emerging from anesthesia in the PACU. Hypothesis: The Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) can be used in the PACU to identify patients with delirium. Methods: Patients 65 years of age or greater who were going to have a standardized general anesthetic for a surgical procedure were identified on the day of surgery and consent to participate in the study was obtained. The CAM-ICU was used preoperatively to determine study eligibility (patients who scored less than 7 [scale of 1-10], indicating delirium, on the test were not followed further) and postoperatively, one hour after the patient was admitted to the PACU, to assess for delirium. The CAM-ICU was administered after we asked the patient’s nurse whether or not he or she had determined that the patient was delirious. Results: 168 patients, mean age 75 ± 7 (SD) with the majority of participants having urologic or orthopedic procedures were assessed pre- and post-operatively with the CAM-ICU, and post-operatively by a nursing assessment for delirium. The CAM-ICU took little time to administer and was easy for patients to understand and use. The nurse at the bedside identified 5 of 168 patients as delirious (prevalence of 2.98%). The CAM-ICU was positive for delirium in 11 of 168 (6.55%). The CAM-ICU had a sensitivity of 60% (3/5) and a specificity of 95% (155/163). Conclusion: In this investigation, the CAM-ICU was easy to use and had a high specificity for identifying post-operative delirium.

Medical error and patient safety have become important issues. It is clear that medical error is more influenced by systemic factors rather than human characteristics. Communication patterns, in particular interruptive communication, maybe one of the systemic factors that contribute to the burden of medical error. Objective: An exploratory study to examine interruptive communication patterns of healthcare staff within an intensive care unit during ward rounds. Methods: The study was conducted in a tertiary hospital in Sydney, Australia. Nine participants were observed individually, for a total of 24 hours, using the Communication Observation Method (COM). The amount of time spent in conversation, the number of conversation initiating and number of turn-taking interruptions were recorded. Results: Participants averaged 75% [95% confidence interval 72.8-77.2] of their time in communication events during ward rounds. There were 345 conversation-initiating interruptions (C.I.I.) and 492 turn-taking interruptions (T.T.I.). C.I.I. accounted for 37% [95%CI 33.9-40.1] of total communication event time (5hr: 53min). T.T.I. accounted for 5.3% of total communication event time (56min). Conclusion: This is the first study to specifically examine turn-taking interruptions in a clinical setting. Staff in this intensive care unit spent the majority of their time in communication. Turn taking interruptions within conversations occurred at about the same frequency as conversation initiating interruptions, which have been the subject of earlier studies. These results suggest that the overall burden of interruptions in some settings may be significantly higher than previously suspected.

The psychometric properties of this Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) were assessed, before using the scale to describe stress experienced by parents in a Neonatal Intensive Care Unit (NICU). The extent to which parental stress from the parent-infant relationship in the unit was linked to parenting they received as a child, and adjustment to their couple relationship, was also examined. The sample consisted of 182 mothers and 183 fathers, who were in a cohabitating relationship, of infants from the NICU at Christchurch Women's Hospital. The self-report questionnaires included the PSS:NICU, Parental Bonding Instrument, and the Dyadic Adjustment Scale, and were administered to parents within 2-3 weeks of their infant's birth. This study extends the finding of satisfactory psychometric properties of the PSS:NICU (Franck, Cox, Allen & Winter, 2005; Miles, Funk & Carlson, 1993; Reid & Bramwell, 2003) to this New Zealand sample. Mothers experienced significantly higher stress from the unit compared to fathers (p < .01). A previous finding, for mothers, of the parent-infant relationship being the most stressful aspect of the unit (Franck et al., 2005; Reid & Bramwell, 2003; Shields-Poe & Pinelli, 1997) extends to the New Zealand sample. The most stressful aspect of the unit for fathers was sights and sounds. Lack of evidence was found for associations between parental stress from the parent-infant relationship in the unit and parenting received as a child, or adjustment to their couple relationship. A weak but significant negative correlation was, however, found between stress from the mother-infant relationship and maternal care received in childhood. It is unnecessary to provide all parents with intervention further to what is already being practiced in the unit, as overall low levels of stress were reported. Some parents, however, did find the unit more stressful, and they may benefit from increased intervention.

<p> Skin breakdown occurs when one or more layers of the skin have been disrupted (McLane et al., 2004; National Pressure Ulcer Advisory Panel, 2007). While some literature uses the terms skin breakdown and pressure ulcer interchangeably, these are actually two distinct conditions and pressure ulcers are encompassed in the definition of skin breakdown (Kuller, 2001; Lund, 1999; Suddaby et al., 2006). The consequences of skin breakdown in the pediatric population can include increased cost of treatment, infection, increased morbidity and mortality as well as psychological consequences from resulting alopecia or scarring (Schindler, 2010; Willock &amp; Maylor, 2004). Development of skin breakdown has also been associated with increased morbidity, increased length of stay, and higher costs of care (McCord et al., 2004). </p><p> Prevention of skin breakdown can be accomplished by the use of barriers and specialty surfaces. Barrier protection is achieved by the use of preparations, such as zinc oxide, petrolatum-containing compounds, and alcohol-free barrier films, and also by the application of transparent film and hydrogel dressings (Atherton, 2004; Atherton, 2005; Baharestani, 2007; Campbell et al., 2000; Lund et al., 2001). Surfaces can be useful in the prevention of skin breakdown by aiding in the distribution of pressure and decreasing moisture, and can also be used to aid in temperature control for some patients (Norton, Coutts, &amp; Sibbald, 2011). The PICO format question used to guide this project is: For patients in Pediatric Intensive Care Units, is barrier protection or use of specialty surfaces more effective at preventing skin breakdown? </p>

Part One: Literature Review - Background: People who experience an intensive care unit admission may also experience post-traumatic stress and other forms of psychological distress. Such phenomena are only partly explained by the reason for admission. This distress can impede physical recovery and full participation in everyday life. Method: Using specified criteria, several databases were systematically searched and 279 abstracts highlighted; 215 articles were subsequently screened with a total of 104 articles being retained for specified quality criteria screening and critique. Results: Following critique, a total of 19 articles were retained for their relevance to the research question. Conclusions: The literature presented sufficient information to enable the investigator to propose a model describing the mechanism for PTSD development in ICU. Despite the extensive selection and screening process, most articles contained methodological flaws, however the investigator advocates that the information provided by the literature should not be dismissed and that future research might be directed towards replication of such research to RCT standards. Part Two: Research Report - Introduction: Despite the literature indicating that PTSD and other forms of psychological distress are significant problems for intensive care unit patients, the mechanisms involved in the development of PTSD remain largely unexplained. The investigator hypothesised that PTSD may occur as a result of implicit learning/classical conditioning/pairing of auditory stimuli to emotional distress experienced in the intensive care unit. Aim: To test the hypothesis that classical conditioning (pairing) of ICU environment sounds to patient distress or anxiety in the ICU which can then be detected after discharge as an emotional conditioned response to the presentation of a range of sounds (Train/Rain and ICU) sounds whilst monitoring skin conductance. Method: Thirty-three patients were recruited into the study and twenty participants were able to provide data to permit testing relating to the main hypothesis at 4-5 weeks post-ICU discharge. Results: A non-significant trend was noted in the relationship between presentation of ICU sounds and increased skin conductance responses, but the investigator was unable to find significant evidence of any relationship between skin conductance responses to ICU sounds and measures of psychological distress. There was significant evidence to suggest that the presence of memories as measured by the ICU Memory Tool at one-to-two weeks post-discharged from ICU were related to PTSD development. Conclusion: Patients demonstrating increased memories of feelings at one-to-two weeks, should be monitored carefully for any subsequent signs of PTSD and other forms of psychological distress. Future research should perhaps attempt to replicate the ICU sounds findings in a larger sample size with comprehensive recording of ICU sedation and memory phenomena details. Any attempts to find evidence of implicit memory using prompted recall questions should plan to capture this within 24 hours of stimuli presentation. Part Three: Critical Appraisal - Reflections regarding the research process and content are discussed.

A method and prototype device to provide artificial speech for intensive care unit (ICU) patients and laryngectomees is presented. The method assists these patients to produce natural sounding speech by "mouthing the words". A review of the current communication techniques for these patients is presented. The limitations of these techniques suggests that there is a need for a device that produces natural sounding speech (pitch variation and glottal sound source that resembles the actual glottal pulse generated by the vibrating vocal folds) and a device that is user friendly. As vocal folds only vibrate during vowel production, only vowel sounds are considered. Since pitch variation plays a major role in the naturalness of a person's voice, a number of alternative (automatic) pitch control techniques were explored. A unique pitch control technique utilising the changes in jaw height when a person "mouth the words" is presented. The electroglottographic (EGG) signal is used as the glottal sound source signal for this research as the properties of the EGG signal offers a number of advantages compared with other glottal sound source measurement techniques. A new glottal source model known as the twin-bar model, based on EGG measurements from normal volunteers, is also introduced. This model changes the shape of the glottal pulse based on a single parameter: pitch. Perceptual testing of the simulated voice using the twin-bar glottal model and two other well-known models on volunteers showed that the twin-bar model produces more natural sounding voice than the other two models. A new artificial speech system combining the automatic pitch control technique (jaw height) and the glottal sound source (twin-bar model) was constructed. It also includes a number of extra functions that would further improves the speech produced with this system. Existing technology on a laptop (e.g. serial port communication, bluetooth transceivers and USB port) is utilised for the construction of the prototype, with the laptop as the signal processing unit. The prototype was tested on a normal subject.

Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 2004.<br>Includes bibliographical references (p. 36).<br>This project focuses on characterizing intravenous (IV) medication administration in an intensive care unit at a partner hospital. Information regarding IV medication dose was extracted from MIMIC II, a large database containing real patient data; this information was used to characterize the use of twelve hemodynamic drugs. Characterization was performed by extracting features such as maximum dose and overall shape from each trend plot. Additionally, because the administration of vasoactive drugs is generally accompanied by a change in blood pressure, several methods were explored of representing patient state by combining the mean blood pressure and drug dose trends to gain more information than can be obtained by each trend alone. The results of drug use characterization show that an adequate picture of drug use can be gained by examining the characteristic shape of the dose trend in addition to features such as maximum dose administered. The patterns of medication administration have been shown to be indicative of overall patient state. The development of algorithms which match drug use trends to underlying physiology may aid in the annotation of large databases such as MIMIC II, and may also prove useful in tracking the hemodynamic state of a patient during his or her stay in intensive care.<br>by Catherine A. Thorn.<br>S.M.

Thesis: M. Eng., Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science, 2017.<br>This electronic version was submitted by the student author. The certified thesis is available in the Institute Archives and Special Collections.<br>Cataloged from student-submitted PDF version of thesis.<br>Includes bibliographical references (page 83).<br>Intensive care unit (ICU) patients undergo detailed monitoring so that copious information regarding their condition is available to support clinical decision-making. Full utilization of the data depends heavily on its quantity, quality and manner of presentation to the physician at the bedside of a patient. In this thesis, we implemented a visualization system to aid ICU clinicians in collecting, processing, and displaying available ICU data. Our goals for the system are: to be able to receive large quantities of patient data from various sources, to compute complex functions over the data that are able to quantify an ICU patient's condition, to plot the data using a clean and interactive interface, and to be capable of live plot updates upon receiving new data. We made significant headway toward our goals, and we succeeded in creating a highly adaptable visualization system that future developers and users will be able to customize.<br>by Shruthi Narayanan.<br>M. Eng.

Background: Endotracheal suction (ETS) is one of the most common airway interventions performed on children requiring invasive mechanical ventilation. It is an essential airway clearance strategy to prevent retained secretions from occluding the endotracheal tube (ETT) or causing pulmonary complications such as diffusion impairment. More than 40% of children admitted to the paediatric intensive care unit (PICU) will require ETS, which in Australia is predominantly a nursing responsibility. Despite the ubiquity of the procedure, adverse events (AEs) such as oxygen desaturation occur in approximately one quarter of all ETS events. Additionally, ETS practice is varied across clinicians, intensive care units and healthcare institutions. Complications arising from the inappropriate application or failure to apply interventions, such as normal saline instillation (NSI) or lung recruitment manoeuvres (RMs), may contribute to significant patient harm and result in a longer duration of mechanical ventilation or PICU admission. Evidence-based nursing practice is vital for the prevention of AEs associated with ETS and to improve patient outcomes. Aims and objectives: The overarching aim of this PhD research was to investigate two ETS interventions— NSI and RMs—which may optimise ETS practice and outcomes in mechanically ventilated children. Four objectives guided the three research phases: 1. Identify current ETS practice and establish a baseline of NSI and RM application.; 2. Determine risk factors associated with ETS AEs.; 3. Explore PICU nurses’ experience with NSI and RMs with ETS.; 4. Evaluate the feasibility of conducting a full-scale definitive factorial randomised controlled trial (RCT) of NSI versus no NSI, and RM versus no RM, using pre-defined feasibility criteria. Two systematic literature reviews and a critical appraisal of current ETS clinical guidelines were also undertaken to determine the current strength of evidence supporting ETS interventions and current practice recommendations. This preliminary work was necessary to identify the gap in the existing evidence base and to clearly identify the scope and aim of the PhD program of research. Design: The research was underpinned by the Medical Research Council’s framework for the evaluation of complex interventions and consisted of three phases: a prospective clinical audit of current ETS practice; a qualitative exploration of nurses’ experiences using NSI and RMs with ETS; and a pilot factorial RCT comparing NSI versus no NSI, and RM versus no RM for paediatric ETS. Phase 1 Research questions: 1. What is current practice for NSI and RM use with ETS?; 2. How frequently do AEs occur with ETS?; 3. What risk factors are associated with ETS AEs in the PICU population? Setting: PICU of a Queensland tertiary hospital. Sample: 100 children, aged less than 18 years, requiring ETS during an episode of invasive ventilation. Measurements: The main outcome was a composite measure of any ETS related AE. Data on patient and suction variables (indication for ETT suction, number of suction episodes per invasive ventilation episode, indication for NSI and NSI dose), including potential predictive variables (age, Paediatric Index of Mortality 3 severity of illness [PIM3], NSI, positive end-expiratory pressure [PEEP], hyperoxygenation), were collected. Main result: A total of 955 suction episodes were recorded in 100 children. AEs occurred in 211 (22%) ETT suctions. Suction related AEs were not associated with age, diagnostic category or index of mortality score. Desaturation was the most common AE (180 suctions; 19%), with 69% of desaturation events requiring clinician intervention. Univariate logistic regression showed the odds of desaturation decreased as the internal diameter of the ETT increased (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.37-0.95; p = 0.02). Multivariable modelling revealed NSI was significantly associated with an increased risk of desaturation (adjusted OR [aOR] 3.23; 95% CI 1.99-5.40; p<0.001) and the occurrence of an AE (aOR 2.76; 95% CI 1.74 -4.37; p<0.001). Presuction increases in the fraction of inspired oxygen (FiO2) were significantly associated with an increased risk of experiencing an AE (aOR 2.0; 95% CI 1.27 - 3.15; p = 0.003). Phase 2 Research questions: 1. What are nurses’ experiences with using NSI and RM with ETS in their practice?; 2. What are the clinical indicators that influence nurses’ use of NSI or RMs with ETS? Setting: PICU of a Queensland tertiary hospital. Sample: 12 registered nurses. Study design: A descriptive, exploratory study was conducted using semi-structured interviews. Interview data were analysed using inductive thematic analysis. Main findings: Variability in nurses’ ETS practice was evident. Thematic analysis revealed three themes: patients’ clinical presentation, clinician judgement and unit practice norms. In the absence of evidence-based clinical guidelines, nurses relied on knowledge derived from clinical experience and the local setting to guide NSI and RM intervention decisions. Participants reported uncertainty regarding ETS best practice and perceived the lack of research evidence as a barrier to making informed clinical decisions at the bedside. Phase 3 Research questions: 1) Is it feasible to conduct a factorial RCT to test the effectiveness and safety of NSI and RMs with ETS in mechanically ventilated children?; 2) In mechanically ventilated children requiring ETS, is (i) NSI superior to (ii) no NSI to prevent ventilator associated pneumonia (VAP) and improve measures of gas exchange, lung function and impedance measures?; 3) In mechanically ventilated children requiring ETS, is (i) RM superior to (ii) no RM to prevent VAP and improve measures of gas exchange, lung function and impedance measures? Setting: PICU of a Queensland tertiary hospital. Sample: 60 children who were less than 16 years of age and required ETS during an episode of invasive mechanical ventilation. Study Design: Single-centre, pilot factorial RCT. Interventions: Participants were first randomised to receive, either: - NSI 0.1 ml/kg (maximum 2 ml); or - no NSI with ETS. In a second randomisation, participants were allocated to receive either: - RM, an increase in PEEP by a factor of two, for two minutes (maximum PEEP 18 mm Hg); or - No RM following ETS. Primary and secondary outcomes: As per the trial protocol (Schults et al., 2018), the primary outcome was the feasibility of a definitive factorial RCT. Feasibility was determined through composite analysis of eligibility, recruitment, retention, protocol adherence and missing data, and sample size calculations based on effect size estimates (Lancaster, Dodd, & Williamson, 2004; Thabane et al., 2010). Secondary outcomes were ratio of oxygen saturation (SpO2) to FiO2, dynamiccompliance (Cdyn, ml/cmH2O), end-expiratory lung impedance (EELI), tidal impedance variation (VARt) and VAP (clinically suspected, not confirmed microbiologically, which was defined in accordance with best practice literature; (Centers for Disease Control and Prevention, 2004a; Foglia, Meier, & Elward, 2007). Data analysis: Comparability of groups at the baseline was assessed using clinical parameters and reported using descriptive statistics. Means and standard deviations were used to report normally distributed continuous data; medians and interquartile ranges were used for interval data that could not be approximated with a normal distribution. Feasibility was reported descriptively against predefined criteria. Incidence rates of VAP per 1000 ventilator days and 95% CIs were calculated using Poisson regression. Interaction effects between NSI and RMs were investigated in the regression models. In the absence of significant interaction, Poisson regression models were constructed with treatment as the main effect and the pre-suction measurement of the outcome included as a covariable. Secondary outcomes measured using interval data (Sp02/Fi02, Cdyn) were analysed, adjusting for baseline measurement using linear regressions in a pairwise sequential manner to compare NSI and RMs (Bland & Altman, 2011). To assess EELI and VARt, we used a mixed effects linear regression model with time and intervention (NSI or RM) included as main effects and a time by intervention interaction. Patient was included as a random effect to account for the repeated measures nature of the data. Analyses were undertaken on an intention-to-treat basis. Data were analysed using StataSE v14.1 (StataCorp Pty Ltd, College Station, Texas). The Type I error was set at 0.05. Main findings: Recruitment, retention and missing data feasibility criteria were achieved, with 90% of patients approached agreeing to enrol and no patient lost to follow up. Eligibility and protocol adherence criteria were not achieved, with 3881 screened (2521 non-ventilated), 818 (21%) patients eligible and 58 enrolled. Cardiac surgery was the primary reason for exclusion (479/818; 59%), followed by readmission (123/818; 15%). Approximately 30% of patients in the RM and no NSI groups had at least one episode of non-adherence; good protocol adherence was achieved in the NSI and no RM groups. Participants were, on average, 11 months old (interquartile range [IQR] 2–43), admitted for a respiratory diagnosis (27/58; 47%), with a median PIM3 of 1.0 (IQR 0.45–3.38). Participants in the NSI group had a reduced incidence rate (IR) (3%; IR 13 per 1,000 ventilator days, 95% CI 1.89–95.60) and were eight times less likely to acquire VAP when compared with the no saline group (14%; IR 109 per 1,000 ventilator days, 95% CI 40.88–290.23). However, this did not reach statistical significance (Incidence Rate Ratio 0.12, 95% CI 0.01–1.10; p = 0.06). When compared to no RM (IR 26 per 1,000 ventilator days, 95% CI 6.63–106.03), the application of an RM resulted in a decreased risk of developing VAP; however, this was not statistically significant (IR 84 per 1,000 ventilator days, 95% CI 27.21–261.59; incident rate ratio [IRR] 0.31, 95% CI 0.05–1.88, p = 0.20). RMs were found to result in a significantly improved SpO2/FiO2 ratio at 2 (10.11 mm Hg, 95% CI 1.02–19.37; linear regression, p = 0.02) and 10 minutes (16.62 mm Hg, 95% CI 6.94–26.24, linear regression, p = 0.01) post ETS. When compared with no NSI, NSI led to a significantly reduced SpO2/FiO2 ratio at 2 (-12.58, 95% CI - 21.83–3.45; p = <0.01) and 10 minutes (-10.63, 95% CI -20.51–0.87; linear regression, p = 0.03) post ETS. When compared to no RM, RM application increased the mean Cdyn by 0.20 ml/cmH2O/kg at 10 minutes post ETS (95% CI 0.14–0.34; linear regression, p = 0.001). RMs applied post-ETS significantly increased EELI at 2 and 5 minutes postsuction (p = <0.001). No significant difference in tidal volume impedance measures was found in either factorial group following ETS. Conclusion: This PhD research revealed a high rate of AEs associated with current ETS practices and has extended current evidence related to modifiable risk factors for suction related AEs. Evidence practice gaps were identified in suction guidelines, which were found to impact on clinician decision-making in the context of NSI and RM use in the PICU. The pilot trial confirmed it is feasible to conduct a definitive factorial RCT of NSI and RMs with protocol modifications to widen participant eligibility to include cardiac surgical patients and PICU readmissions. It also confirmed the need for further research to identify effective methods to prevent ETS AEs by definitively testing the safety and efficacy of NSI and RMs to reduce retained respiratory secretions and alveolar collapse.<br>Thesis (PhD Doctorate)<br>Doctor of Philosophy (PhD)<br>School of Nursing & Midwifery<br>Griffith Health<br>Full Text

Objective: To determine the risk factors for extubation failure in the intensive care unit. Methods: The present case-control study was conducted in an intensive care unit. Failed extubations were used as cases, while successful extubations were used as controls. Extubation failure was defined as reintubation being required within the first 48 hours of extubation. Results: Out of a total of 956 patients who were admitted to the intensive care unit, 826 were subjected to mechanical ventilation (86%). There were 30 failed extubations and 120 successful extubations. The proportion of failed extubations was 5.32%. The risk factors found for failed extubations were a prolonged length of mechanical ventilation of greater than 7 days (OR = 3.84, 95%CI = 1.01 - 14.56, p = 0.04), time in the intensive care unit (OR = 1.04, 95%CI = 1.00 - 1.09, p = 0.03) and the use of sedatives for longer than 5 days (OR = 4.81, 95%CI = 1.28 - 18.02; p = 0.02). Conclusion: Pediatric patients on mechanical ventilation were at greater risk of failed extubation if they spent more time in the intensive care unit and if they were subjected to prolonged mechanical ventilation (longer than 7 days) or greater amounts of sedative use.<br>Revisión por pares<br>Revisión por pares

A pediatric intensivist in the University of Iowa Hospitals and Clinic's (UIHC) Pediatric Intensive Care Unit (PICU) was concerned about antimicrobial use in the unit. However, no one had quantified antimicrobial use in the UIHC's PICU or described the patterns of antimicrobial use in this unit. To address the intensivist's concern, the principal investigator (PI) conducted a retrospective study to determine the percentage of patients who received antimicrobial treatments, to determine the indications for antimicrobial use, and to identify antimicrobial agents used most frequently in the unit. On basis of our data, we hypothesized that empiric antimicrobial use, particularly the duration of therapy, could be decreased. We implemented a six-month intervention during which we asked the pediatric intensivists to complete an antimicrobial assessment form (AA) to document their rationale for starting antimicrobial treatments. We postulated that this documentation process might remind physicians to review antimicrobial therapies, especially empiric therapies, when the microbiologic data became available. In addition, we utilized the AA form to identify factors pediatric intensivists considered when deciding to prescribe empiric antimicrobial treatments. Data from the AA forms suggested that pediatric intensivists in the UIHC's PICU often considered elevated C-reactive protein, elevated white blood cell counts, and elevated temperatures when deciding to start empiric antimicrobial therapy. Data from the three nested periods showed that the median duration of empiric and targeted treatments decreased during the intervention and remained stable during the post-intervention period. The PI estimated that 193 days of empiric antimicrobial therapy and 59 days of targeted antimicrobial therapy, respectively, may have been saved by the decreased durations of therapy. Time series analysis assessing the trend in use of piperacillin-tazobactam, cefepime, and ceftriaxone (measured in mg/wk) did not reveal a significant change over time. On the basis of our results, an intervention strategy using an AA form alone may not be an effective strategy for antimicrobial stewardship in PICUs. Additional measures such as automatic stop orders and computer decision support may be useful for reducing the duration of empiric therapy in PICUs.

Patients in hospital intensive care units are at increased risk to develop delirium, a condition which is characterized by a disturbance of consciousness and a change in cognition. Critical care nurses must have the knowledge to assess, recognize, and manage delirium. The purpose of this project was to develop an evidence-based policy for the assessment of delirium and a comprehensive nursing education plan which included an analysis and synthesis of the literature, a curriculum plan, and a pretest/posttest. The Johns Hopkins Evidence-Based Practice Model framed the project, which used a multidisciplinary team approach. Two nursing leaders, each with a doctor of philosophy degree, served as content experts for the educational curriculum plan and the pretest/posttest. The curriculum plan was evaluated using a dichotomous scale of 1 = not met and 2 = met. An average score of 2 was achieved showing the content met the objectives. The pretest/posttest items were validated using a Likert-type scale ranging from 1 = not relevant to 4 = very relevant. A content validation index score of 1.0 was computed, revealing that the items met the objectives and content of the curriculum. The pretest/posttest was administered before and after the educational program to determine the knowledge gained. A paired samples t test was conducted and found to have a statistically significant difference in the scores for the pretest (M = 81.25, SD = 11.29) and post-test (M = 94.06, SD = 7.12); t (31) = -5.92, p = 0.01, revealing that the critical care nurses gained significant knowledge with the delirium educational program. This project can promote positive social change because early recognition and management of the patient with delirium can facilitate positive outcomes for patients, families, and systems.