2022 National Teaching Institute Research Abstracts

Jennifer Hayakawa, Melanie Go, Julia Meeves; Children’s Health of Orange County Hospital, Orange, CA

To examine the correlation between automated pupillary measurements and intracranial pressure (ICP) in pediatric critical care patients requiring ICP monitoring.

Pupillary assessment is a fundamental component of neurologic examination. In 2011, Chen et al reported an inverse relationship between objective pupillary measurements and ICP in adult patients. Subsequent studies have expanded on this work, proving that early detection of subtle changes using pupillometers may improve clinical outcomes. Despite the widespread use of automated pupillometry across diverse patient populations, few studies have addressed its use in pediatrics.

This study was a retrospective review of patients admitted for ICP monitoring at a freestanding children’s hospital and assessed per the unit’s standard of care using an automated, handheld NeurOptics NPi-200 pupillometer device. A linear mixed-effect model with subject-level random effect was used to analyze the association between pupillary and ICP measurements documented within 30 minutes of each other. Patients’ demographic and clinical characteristics were included as covariates in the model. After log transformation of ICP, a generalized estimating equation model was run with a compound symmetry covariance matrix for repeated measures.

More than 2600 ICP measurements of 15 patients (mean [SD] age, 8.7 [4] years; range, 3-16 years) were obtained. The Neurologic Pupil Index (NPi), an algorithmic score that combines pupillary reactivity measures, was negatively associated with the log of the ICP. The estimate of NPi was –0.05, meaning that a 1-unit increase in NPi was associated with a 0.05-unit decrease in the log of the ICP (P = .01).

Results are consistent with the adult data that indicate automated assessments of pupillary reactivity correlate inversely with ICP. This work contributes to the limited body of research on the use of automated pupillometry in pediatric critical care patients. Larger prospective studies are needed to validate these findings and explore if changes in pupillary reactivity precede increases in ICP.

Lauren Magee, Hilary Kremke; Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL

As first responders, nurses must have the confidence and skill set to quickly identify emergency situations and deliver the care necessary for patient survival. The purpose of this study was to evaluate the effects of high-fidelity, in situ mock code events at night in a pediatric intensive care unit (PICU) on nurses’ self-efficacy and performance of cardiac arrest skills. The outcomes of interest were change in self-efficacy, as measured by level of confidence and skill acquisition in relation to the onset of cardiac arrest.

According to previous research, time of admission and experience of staff may be associated with variations in patient outcomes. One published review reported a 28% higher mortality rate when pediatric patients were admitted during evening hours. Other researchers showed that a less-experienced primary nurse can increase the odds of unsuccessful resuscitation. Therefore, it is important to provide resuscitation training at night, when staffing with newly hired nurses is most prevalent.

A convenience sample of 43 PICU nurses voluntarily participated in this year-long, prospective pretest/posttest study conducted at night in a single tertiary-care academic pediatric medical center. The Mock Code Self-Efficacy Scale (MCSES) was used to determine nurses’ confidence before and after the intervention. Time to initiation of cardiopulmonary resuscitation (CPR), time to first epinephrine administration, and time to first defibrillation were measured using a stopwatch. Descriptive statistics were reported in frequencies and percentages for categorical data and means and SDs for continuous data. Simple bivariate statistics were performed to find associations between the primary outcome and timing of mock codes.

The Wilcoxon signed rank test revealed a statistically significant increase in confidence (n = 41; z = 5.27; P < .001) with a large effect size (r = 0.82). The median score on the MCSES increased from before (91) to after (108) the intervention. The relationship between date of simulation and time to CPR, time to epinephrine administration, and time to defibrillation was investigated with the Pearson product-moment correlation coefficient. Moderate negative correlations were found between date of simulation and each of these variables, with decreases in time to CPR (n = 44; r = –0.32; P = .03), time to epinephrine administration (n = 23; r = –0.30; P < .001); and time to defibrillation (n = 44; r = –0.68; P = .03).

This study demonstrates the positive impact of repeated in situ mock codes on nurses’ self-efficacy and cardiac arrest skills that are key for patient survival. Simulation training is a feasible education strategy, and a formalized program should be developed at night, when nurses with less experience often staff. A future study should assess the effectiveness of this training in a larger sample at various times of day and the translation of such training to skills used during actual emergencies.

Alexandria Reppi, Heather McGrane-Minton, Tara Sacco; Rochester General Hospital, Rochester, NY

To explore differences in critical care nurses’ perceptions of their work environment, compassion satisfaction, and compassion fatigue on the basis of unit and organizational accreditation status. A secondary aim was to determine if an interaction effect existed between accreditation status and work environment for compassion satisfaction and compassion fatigue.

Perceptions about one’s work environment are substantially better among people who work for accredited organizations than among people working for organizations that are not accredited. The nursing work environment is also related to professional quality of life (ProQOL). It is unknown how accreditation status affects the work environment and ProQOL of critical care nurses.

A secondary analysis of data collected using a demographic survey, the American Association of Critical-Care Nurses (AACN) Healthy Work Environment Assessment Tool (HWE), and the ProQOL Scale, version 5, was conducted. Critical care nurses (N = 177) who provided direct patient care at least 50% of the time and accessed the researcher’s social media pages or the AACN website were eligible to participate. After the normality and equal variance assumptions were assessed, multivariate analyses were conducted to reveal differences in HWE and ProQOL scores by accreditation status (Magnet or Beacon). An interaction effect between accreditation status and work environment perceptions on Pro-QOL scores also was assessed.

Participants in this study reported good work environments and average levels of ProQOL (ie, compassion satisfaction and compassion fatigue [secondary traumatic stress and burnout]). Important differences in the work environment, skilled communication, true collaboration, effective decision-making, meaningful recognition, and authentic leadership scores based on accreditation status were found. No differences were noted in compassion satisfaction or compassion fatigue scores by accreditation status. An interaction effect between accreditation status and the work environment, with notable differences in compassion satisfaction and secondary traumatic stress scores, was found.

Although data were collected in 2018, findings indicate that critical care nurses’ perceptions of their work environment differ according to accreditation status. There may be a mediating effect of the work environment when the effects of accreditation on ProQOL are considered. Additional exploratory research is necessary to fully understand the relationships among these variables. Furthermore, the influence of the COVID-19 pandemic on work environments and ProQOL needs to be investigated.

Elizabeth Talbott; University of Tennessee Medical Center, Knoxville, TN

To investigate the accuracy of temporal artery thermometers (TATs) versus core temperature–sensing rectal or bladder monitors in hemodynamically unstable (mean arterial pressure < 60 mm Hg) patients in the intensive care unit (ICU) who required vasoactive medication. Currently, the TAT is used to measure body temperature as the standard of care for all ICU patients at this hospital. If the 2 methods differ significantly, the standard of care should be changed.

The accuracy of the TAT came into question when nurses expressed concern that its objective data did not match their subjective assessment of the patient. The ability to recognize temperature changes in a critically ill patient allows the clinician to intervene quickly and prevent clinical decline. This project builds on a systematic review that showed the TAT is not analogous to core temperature thermometry, by looking specifically at a hemodynamically unstable population.

The study used an observational, comparative research design. Using TAT and continuous rectal (n = 9) or bladder (n = 19) thermometry, 174 paired temperature measurements were collected from a convenience sample of 23 patients admitted to the adult medical ICU who required vasoactive medication. The rate of vasoactive medications infusing at the time the temperatures were recorded was also documented. Data were recorded in the electronic medical record by the primary nurse and collected by the principal investigator. A paired-samples t test was used to compare the difference between the TAT and a core temperature collected simultaneously. The rate of vasoactive medication infusing was used to further classify temperature data.

This project was statistically powered with 174 paired temperature readings. A standard deviation greater than ±0.5, reported with a 95% CI, was considered statistically significant. Rectal temperatures ranged from 34.8 °C (94.5 °F) to 39.1 °C (102.4 °F); bladder temperatures ranged from 34.2 °C (93.6 °F) to 40.3 °C (104.4 °F); and TATs ranged from 30.0 °C (86.0 °F) to 38.5 °C (101.2 °F). The mean difference between TAT data and bladder data ranged from 0.86 °C (1.54 °F; SD, 0.86 °C [1.55 °F]; 95% CI, 0.71 °C [1.28 °F] to 1.0 °C [1.80 °F]). The mean difference for TAT data compared with rectal data ranged from 1.1 °C (2.06 °F; SD, 0.85 °C [1.52 °F]; 95% CI, 0.86 °C [1.55 °F] to 1.43 °C [2.58 °F]). Medication infusion rates did not predictably affect the mean temperature difference between thermometry types.

These results show that a TAT is not as accurate as core temperature thermometry and supports staff concerns. The standard of care for monitoring body temperature of patients requiring vasoactive medication at this hospital needs to be reevaluated. Invasive temperature monitoring is not ideal, so there is an opportunity to try other non-invasive temperature monitoring devices to fit this patient population.

Nicole Reagan, Kaitlin Jones, Kaylee Keith, Michael Luna, Bethany Lussier, Debby Miller, Rachel Rudberg, Samuel White; Parkland Health and Hospital, Dallas, TX

To identify the benefit of a structured training program for extracorporeal membrane oxygenation (ECMO) for both novice and experienced nurses with various intensive care unit (ICU) backgrounds. Identifying a framework of replicable, evidence-driven educational methods that both improve staff confidence and competence in providing ECMO therapy would be invaluable to providing improved outcomes for patients receiving ECMO therapy.

Few studies have shown efficacy of a standardized ECMO education program. The need for training novice or experienced ECMO nurses was identified in a published, replicable education guideline.

The study’s design consisted of a 15-question survey distributed before and after training and completed by bedside ECMO nurses and ECMO specialists with areas of experience from multiple ICU backgrounds. Data were collected via SurveyMonkey (Momentive) and organized in Microsoft Excel. Differences in proportions were initially analyzed using 2-proportion z test and subsequently divided into additional groups of specialist confidence to be analyzed using Χ² or Fisher exact tests. Scores from before and after the training were evaluated using a paired t test. All statistical analyses were performed using Stata, version 12.0 (StataCorp). Results were considered significant when P was .05 or less.

Compared with pre-training survey results, there was a statistically significant increase in the confidence of specialists providing care to patients receiving ECMO therapy (21.6% vs 60.0%; P = .001), ability to respond to clinical changes (24.3% vs 56.6%; P < .01), participate in multidisciplinary discussion (21.6% vs 56.6%; P < .01), and assess changes in the condition of the patient receiving ECMO therapy (27.0% vs 66.6%; P = .001). No statistically significant increase was found in respondents’ confidence in their ability to respond to a code involving a patient receiving ECMO therapy (27.0% vs 40.0%; P = .26), showing room for improvement. There was a statistically significant increase in examination scores after training (correct answers: 65.8% vs 94.7%; P < .001).

The data indicate that a structured training program for nurses with various ICU backgrounds, integrated into specialized patient care as the ECMO bedside nurse and ECMO specialist, improves confidence in caring for patients receiving ECMO therapy. Scores after the training indicate improved understanding of therapy among the ECMO bedside nurse group.

Karen Robinson, Samantha Bartelt, Michelle Gierach, Gwenneth Jensen, Coreen McClellan, Brenda Wolles; Sanford Medical Center Fargo, Fargo, ND

This multisite study was conducted to describe the lived experience of registered nurses (RNs) caring for patients with COVID-19 during the COVID-19 pandemic in rural regional hospital intensive care and COVID-19–designated medical units, with specific emphasis on bedside caring, work environment, and balancing work and home life experiences. It was anticipated that the findings of the study would help prepare the nursing discipline as well as nurse managers and educators for future pandemics or similar situations.

The focus of this study was the pandemic’s impact on hospital frontline nurses. The context surrounding nurses’ experiences in rural states is essential background. Published studies have been focused on providers’ mental health outcomes and emotional responses. This left a gap about the lived experience in rural areas.

A qualitative phenomenological design was used. From January to June 2021, using the purposeful sampling method, 19 frontline nurses were interviewed regarding their experience caring for patients seriously ill with COVID-19 in 3 Upper Mid-west tertiary care hospitals. Participants completed a demographic questionnaire. Three doctorally prepared nurses transcribed and analyzed verbatim interviews, with data interpreted separately and conjointly. Data were analyzed through approved qualitative methods specific to transcendental phenomenology. Group meetings with the interview team ensured that the lived experiences of study participants were properly captured.

A total of 14 women and 5 men (N = 19) were interviewed; the mean age was 28.6 years and mean of their years of nursing experience was 4.7. Four themes describing the lived experience were identified: (1) overwhelmed feeling, (2) frustration, (3) abandonment, and (4) perseverance or resilience. Frontline nurses were overwhelmed by the intense human suffering and death and by emotional and physical exhaustion. Rapid changes in the environment caused frustration and barriers to safe practice. Abandonment was perceived because of the nurses’ lack of a voice with leaders and their ostracism by families and communities. Nurses demonstrating perseverance were more likely to overcome adversity and experience personal and professional resilience.

Study nurses had experiences similar to those of nurses in high-population US and international cities where high volumes of critically ill patients were in hospitals frenzied by rapid change and uncertainty. Differences in rural nurses’ experiences included close social connection to patients, families, and communities. Future pandemic planning must involve frontline nurses. Nurses need better communication, real-time frontline education, supportive coworkers, and accessible mental health services.

Annette Bourgault, Lillian Aguirre, Ansu Sebastian, Michele Upvall; University of Central Florida, Orlando

To assess enteral feeding tube practice by critical care nurses, focusing on 2 practice gaps: (1) de-implementation of (ie, stopping) auscultation to verify feeding tube placement and (2) feeding tube stylet practice and cleansing methods. This study is aligned with the American Association of Critical-Care Nurse’s (AACN’s) research agenda to move nurses away from rituals in practice.

Feeding tube insertion is associated with harm events such as pneumothoraces and pneumonia. Previous national surveys have not captured the use of enteral access devices to assist feeding tube insertion or the use of reusable feeding tube stylets. Also, clinical practice guidelines no longer support auscultation to verify feeding tube placement in adults. Follow-up was necessary to determine if use of the auscultation method had decreased during the past 7 years.

An online survey of national feeding tube verification practices was completed at AACN’s National Teaching Institute & Critical Care Exposition conference in May 2019. A 20-item survey tool of categorical and Likert-style questions was adapted from an instrument used in a previous national survey of feeding tube practices. Descriptive statistics were used to describe demographics and practice data. Binomial regression was used to describe relative risk for the likelihood of using auscultation. This research built on a findings from a 2015 study by Bourgault et al.

Findings from 408 critical care nurses who completed the survey were included in the analysis. The auscultation method was used by most nurses (n = 311; 76%) to assess feeding tube placement, and the majority (n = 359; 88%) had observed this practice being performed by their colleagues. Variables associated with auscultation use in the multivariable model included having a bachelor’s of science in nursing level of education, working in a nonacademic facility, observing colleagues using auscultation, and lacking an institutional policy. Enteral access devices were used by 35% of survey responders to assist with the initial feeding tube insertion and verification. Cleansing methods for reusable stylets were variable; 38% of nurses did not clean the stylets.

Despite clear messages to de-implement auscultation for feeding tube verification in adults, no progress has been made during the past 7 years. Passive education does not result in change. An interdisciplinary, multifaceted program is needed to de-implement tradition-based practices like auscultation. Also, new research on enteral access systems needs to be incorporated into clinical practice guidelines along with stylet cleansing and storage practices.

Disclosures: This study received financial support from Drs Diane and Thomas Andrews Faculty Research Award. The article “National Survey of Feeding Tube Verification Practices: An Urgent Call for Auscultation Deimplementation“ was published in the November/December 2020 issue of Dimensions of Critical Care Nursing.

Tiffany Dzou, Jo-Ann Eastwood, Carol Pavlish, Huibrie Pieters; Cedars-Sinai Medical Center, Los Angeles, CA

To understand how patients’ views of their experiences with mechanical circulatory support (MCS) affect decision-making about advance care planning (ACP). This research addresses the gaps in our understanding of the perceptions of ACP among patients receiving MCS. This nurse-led study was done to evaluate the status of ACP communication over the MCS trajectory and to enhance the awareness of advanced practice nurses (APRNs) and staff nurses of how to engage patients in ongoing communication.

MCS is the last therapeutic resort for patients with heart failure, but living with the device also increases the likelihood of catastrophic incidents occurring, such as stroke, gastrointestinal hemorrhage, and sepsis. To address these potential complications and enhance shared decision-making, ongoing ACP is needed, yet few guidelines address personal preferences about the termination of MCS devices and possible death.

Grounded theory was used to examine patients’ experiences of living with MCS. Included were English-speaking adults aged 18 years or older who were receiving MCS. Individuals who were cognitively disabled or hospitalized were excluded. Participants (N = 24) were recruited with flyers from 2 MCS clinics. A semistructured guide was used to conduct focused interviews. Data analysis was systematic, with the first and last authors conducting 3 rounds of coding. The analytic dyad used reflexive memos and diagrams to develop categories further. Constant comparison of subsequent interviews with previous interviews was used to examine participants’ experiences and to clarify their impact on decision-making processes until data saturation was met.

The theory of pivoting uncertainties was a novel framework that elucidated processes of ACP decision-making. The core category, complexities of ACP, was organized into 3 subcategories: impediments, uncertainties, and promoters. Impediments to ACP conversations included framing MCS care positively. Uncertainties involved recognizing incongruencies between initial expectations and the reality of living with MCS over time. Narratives about events such as pump thrombosis led to uncertainties about the future and prompted pivoting from passive to active ACP communication. Last, promoters were actions taken to advocate for personal values and preferences about ACP.

This research provides critical information for APRNs and bedside nurses about how to facilitate meaningful ACP conversations. Content for discussions can focus on incongruencies between expectations and uncertainties of living with MCS. The authors recommend a shift away from conversations focused on transplant but invite questions about potential adverse events. The optimal setting for conversations is to schedule them separately from MCS clinic visits with a clear goal of discussing uncertain outcomes.

Regina Prusinski, Tamara Clark, Virginia Cox, Jennifer Gauntt, Janet Simsic; Otterbein College, Westerville, OH

To evaluate the current degree of agreement or identification reliability of bedside registered nurses regarding the identification of low cardiac output syndrome (LCOS) in a pediatric cardiothoracic intensive care unit (CTICU). A second aim was to determine if education given to professional adult learners in a virtual format would improve test scores even after some time had elapsed since the education.

LCOS is a transient constellation of signs and symptoms that indicate the heart’s inability to supply sufficient oxygen to the body and is the leading cause of morbidity and mortality in children after cardiac surgery. Nordness et al evaluated concordance among pediatric intensive care nurses. The nurses disagreed on the presence of LCOS in case studies. Virtual education is beneficial to increase access to education and flexibility, but little is known about knowledge retention after virtual education.

An anonymous REDCap survey was distributed to 69 registered nurses in the CTICU before and after a PowerPoint presentation lasting less than 30 minutes and was distributed again 6 months later. The survey described 10 randomly selected patients aged 6 months or younger who had cardiac surgery at a freestanding children’s hospital in a tertiary academic center. For each case-study patient, data were presented corresponding to 5 time points (0, 6, 12, 18, and 24 hours postoperatively). The nurse noted whether the patient had LCOS at each time point. A total of 47 of the same nurses received education and responded to the survey a second time; 39 of the same nurses took the final survey 6 months after they received the education.

Nurses were expected to have better test scores immediately after education. Whether the virtual presentation would leave a lasting impression was unknown. Nurses working in cardiac-centered care were expected to have a greater consensus in defining LCOS. One-way analysis of variance results were statistically significant at P = .02, indicating that nurses improved test scores immediately after and 6 months after the education. A violin plot shows that respondents answered more alike 6 months after the education than before or immediately after the education. Word counts from the essay question, to write the definition of low cardiac output, indicated that nurses’ responses are varied when comparing preeducation with immediately posteducation.

Nurses’ current degree of agreement on identifying LCOS in a pediatric CTICU was evaluated. A range of responses before education became more uniform after education. The future focus will be on providers in the Heart Center. The goal is to determine if this same degree of disagreement is present and if this type of education has the same results after an education session. How to educate professionals on a complex topic about which all have not received the same training warrants further research.

Zhan Liang; University of Miami School of Nursing, Coral Gables, FL

To evaluate effects of a self-managed, music-guided exercise intervention on muscle strength among intensive care unit (ICU) survivors.

This study was designed to address rehabilitation challenges often faced by patients after they have left the ICU. An individualized, music-guided exercise playlist was created for each patient immediately after ICU discharge to prevent additional muscle loss and to improve muscle strength.

A 2-arm randomized controlled trial design was used. After ICU discharge, eligible participants were assigned to 1 of 2 groups: music group (n = 13) or active control group (n = 13). The music group was taught to self-manage upper and lower extremity exercise movements by listening to an individualized music-guided playlist twice daily for 5 days. The active control group was provided an exercise brochure and advised to perform the same exercises at the same intervals. Dynamometers were used to measure muscle strength. The intervention effect between groups was tested by using t tests and weighted generalized estimating equation models.

A total of 26 participants were enrolled. Their mean age was 62.8 (SD, 13.8) years, 53.8% were men, 65.4% were White, and the mean Acute Physiology and Chronic Health Evaluation severity of illness score was 59 (SD, 23.4). Reasons for ICU admission were mainly cardiac and medical. The music group showed significant improvements in handgrip plantar flexion, leg extension, elbow flexion, and shoulder adduction strengths on left and right sides. In addition, leg and right leg extensor and left plantar flexor strengths differed significantly between the music group and control group after the intervention, and there were small to moderately large effect sizes between the 2 groups.

These findings suggest that a music-guided exercise intervention has the potential to improve muscle strength and prevent further post-ICU deterioration in ICU survivors. Future trials should build on these preliminary findings.

Bryce Bandfield, Jason Gable, Julie Hevezi, Ali Mendelson; University of California, San Diego, Thornton Hospital, La Jolla, CA

A new standard of practice was implemented in which patients choose a single photograph that reflects how they want to be seen by health care providers. The effects of this practice on patients’ or their surrogates’ sense of dignity was investigated, with the goal of expanding the definition of and access to dignity-conserving therapy. The effect of this new standard of practice on clinicians’ sense of meaningful work and feelings of burnout also was evaluated.

Patients with a perceived change in appearance have a heightened risk for a fractured sense of dignity, yet few data are available on tools to improve dignity. Patients, their family members, and multidisciplinary staff reported that bedside photographs encouraged a greater understanding of the patient, personalized their environment, and improved connections.

Patients admitted to 1 of 3 units at an academic medical center, or their surrogates, identified a single photograph representing how the patient would like to be seen. The photograph was hung at the head of the patient’s bed for the duration of their hospitalization. Surveys of health care providers before and after the intervention explored feelings of burnout, sense of meaningful work, and the impact of the intervention. Semistructured interviews were conducted with patients or their surrogates to explore the effect of the intervention on their perceived sense of dignity. Thematic content analysis was used to identify common themes among the responses of patients or surrogates and staff responses.

Thematic analysis of staff surveys (n = 79) yielded the following themes: humanizing the patient, stimulating conversation and/or connections, goals, joy, meaningful work, compassion, and empathy. Thematic analysis of patient or surrogate participant interviews revealed similar themes (n = 19): conveying goals, acceptance, joy, capturing spirit, humanizing the patient, faith and spirituality, sense of belonging, physical appearance, and stimulating conversation. The impact of the intervention on burnout and meaningful work was deemed unreliable because of the COVID-19 pandemic, which occurred after implementation of the intervention.

This was an expansion of a prior study investigating the use of photographs as a novel tool to improve dignity, and this new standard of practice stimulated conversations with providers and improved patients’ sense of dignity. Health care providers reacted positively to the photographs and felt that they improved interactions with patients/surrogates. It was difficult to ascertain if the intervention reduced burnout because of the impact of COVID-19.