Background Restraining therapies (physical or pharmacological) are used to promote the safety of both patients and health care workers. Some guidelines recommend nonpharmacological or pharmacological interventions be used before physical restraints in critically ill patients. Objectives To characterize psychotropic drug interventions before and after use of physical restraints in critically ill adults receiving mechanical ventilation. Methods A single-center, prospective, observational study documenting psychotropic drug use and Sedation-Agitation Scale (SAS) scores in the 2 hours before and the 6 hours after application of physical restraints. Results Ninety-three patients were restrained for a median of 21 hours (interquartile range, 9-70 hours). Thirty percent of patients did not receive a psychotropic drug or had a drug stopped or decreased before physical restraints were applied. More patients received a psychotropic drug intervention after use of physical restraints than before (86% vs 56%, P = .001). Administration of opioids was more common after the use of physical restraints (54% vs 20% of patients, P = .001) and accounted for more drug interventions (45% vs 29%, P = .001). Fifty patients had SAS scores from both time periods; 16% remained oversedated, 24% were appropriately sedated, and 16% remained agitated in both time periods. Patients became oversedated (20%), more agitated (10%), less agitated (8%), and less sedated (6%) after restraint use. Conclusions Psychotropic drug interventions (mostly using opioids) were more common after use of physical restraints. Some patients may be physically restrained for anticipated treatment interference without consideration of pharmacological options and without documented agitation.

Background Oral care plays a clear and important role in the prevention of ventilator-associated pneumonia. However, few studies have explored the actual work of oral care by nurses in the intensive care unit. Objective To explore intensive care nurses’ knowledge of and experiences with the delivery of oral care to reveal less visible aspects of this work. Methods In an institutional ethnography, go-along and semistructured interview methods were used to explore the oral care practices and perspectives of 12 bedside nurses and 12 interprofessional (intensivist, allied health, and management) participants in an intensive care unit at a large urban teaching hospital in Ontario, Canada. Results Nurses described how obstacles frequently inhibited the delivery of oral care. Technical barriers included oral crowding with tubes and aversive responses by patients, such as biting. Contextual impediments to oral care included time constraints, lack of training, and limited opportunities for interprofessional collaboration. A key discovery was the presence of an informal unit-based nursing curriculum, whereby nurses acquired strategies to overcome barriers to oral care. Although the nurses did extensive problem solving in providing oral care, the interprofessional participants had limited knowledge of how oral care was accomplished. Conclusion These data suggest the complexity of performing oral care in intensive care is underestimated and perhaps undervalued. Future research is needed to address technical and contextual barriers to optimize current guideline expectations for the provision of regular and effective oral care.

Background Weaning from mechanical ventilation is influenced by patient, clinician, and organizational factors. Objective To identify factors that may influence weaning and adoption of weaning strategies and tools, clinicians’ perceptions of weaning strategies, and weaning experiences of patients and patients’ families. Method A scoping review of indexed and nonindexed publications (1990–2012) was done. Qualitative studies of health care providers, patients, and patients’ families involved in weaning were included. Two investigators independently screened 8350 publications and extracted data from 43 studies. Study themes were content analyzed to identify common categories and themes within the categories. Results The study sample consisted of nurses in 15 studies, nurses and patients in 1 study, various health care providers in 11, patients in 10, and physicians in 4. Categories identified were as follows: for nurses, role or scope of practice, informing decision making, and influence on weaning outcome; for health care providers, factors influencing weaning decisions or use of protocols, role or scope of practice related to weaning, and organizational structure or practice environment; for patients, experience of mechanical ventilation and weaning, experience of the intensive care environment, psychological phenomena, and enabling success in weaning; and for physicians, tools or factors to facilitate weaning decisions and perceptions of nurses’ role and scope of practice. Conclusions Important issues identified were perceived importance of interprofessional collaboration and communication, need to combine subjective knowledge of the patient with objective clinical data, balancing of weaning systematization with individual needs, and appreciation of the physical and psychological work of weaning.

Background Critically ill adults often cannot self-report pain. Objective To determine the effect of the Critical-Care Pain Observation Tool on frequency of documentation of pain assessment and administration of analgesics and sedatives in critically ill patients unable to self-report pain. Methods Data on patients in 2 intensive care units of a university-affiliated hospital were collected before and after implementation of the tool. Patients were prospectively screened for eligibility; data were extracted retrospectively. Results Data were recorded for a maximum of 72 hours before and after implementation of the tool in the cardiovascular intensive care unit (130 patients before and 132 after) and in the medical/surgical/trauma unit (59 patients before and 52 after). Proportion of pain assessment intervals with pain assessment documented increased from 15% to 64% ( P < .001) in the cardiovascular unit and from 22% to 80% ( P < .001) in the other unit. Median total dose of opioid analgesics decreased from 5 mg to 4 mg in the cardiovascular unit ( P = .02) and increased from 27 mg to 75 mg ( P = .002) in the other unit. Median total dose of benzodiazepines decreased from 12 mg to 2 mg ( P < .001) in the cardiovascular unit and remained unchanged in the other unit. Increased documentation of pain assessment was associated with increased age in the cardiovascular unit and with decreased maximum scores on the Sequential Organ Failure Assessment in the other unit. Conclusion Implementation of the tool increased frequency of pain assessment and appeared to influence administration of analgesics in both units.

Background Organizational processes affect the duration of mechanical ventilation in adult and pediatric intensive care units, but surprisingly little is known about role responsibilities for mechanical ventilation and weaning and related contextual factors that may influence timely liberation from mechanical ventilation. Objective To determine the professional group and seniority of clinicians responsible for key decisions regarding ventilation and weaning; use of ventilation protocols and automated closed loop systems; and provision of education on mechanical ventilation. Methods Mailed survey to nurse managers of pediatric intensive care units in the United Kingdom. Results Response rate was 61%. In most units, nurse managers reported that physicians and nurses usually collaborated in making decisions about initializing (63%) and adjusting (94%) ventilator settings and for determining weaning readiness (88%), weaning method (59%), extubation readiness (82%), and weaning failure (100%). Protocols for mechanical ventilation were available in 35% of units, some specific to weaning (18%) and others for noninvasive ventilation (35%). Automated closed loop systems were used in 18% of units. Competency training was required before nurses could adjust ventilator settings in 35% of responding units; in the remaining units, settings were adjusted by nurses who had no specific competency training. Conclusions Key decisions were mainly collaborative, but nurses were limited in their ability to adjust ventilator settings independently. This limitation may be due to a lack of standardized competency programs and the infrequent use of non–physician-led weaning protocols and automated systems. These findings indicate some ways of improving processes to avoid delays in ventilator weaning.

Background Regular pain assessment can lead to decreased incidence of pain and shorter durations of mechanical ventilation and stays in the intensive care unit. Objectives To document knowledge and perceptions of pain assessment and management practices among Canadian intensive care unit nurses. Methods A self-administered questionnaire was mailed to 3753 intensive care unit nurses identified through the 12 Canadian provincial/territorial nursing associations responsible for professional regulation. Results A total of 842 nurses (24%) responded, and 802 surveys could be evaluated. Nurses were significantly less likely ( P < .001) to use a pain assessment tool for patients unable to communicate (267 nurses, 33%) than for patients able to self-report (712 nurses, 89%). Significantly fewer respondents ( P < .001) rated behavioral pain assessment tools as moderately to extremely important (595 nurses, 74%) compared with self-report tools (703 nurses, 88%). Routine (>50% of the time) discussion of pain scores during nursing handover was reported by 492 nurses (61%), and targeting of analgesia to a pain score or other assessment parameters by physicians by 333 nurses (42%). Few nurses (n = 235; 29%) were aware of professional society guidelines for pain assessment and management. Routine use of a behavioral pain tool was associated with awareness of published guidelines (odds ratio, 2.5; 95% CI, 1.7–3.7) and clinical availability of the tool (odds ratio, 2.6; 95% CI, 1.6–4.3). Conclusions A substantial proportion of intensive care unit nurses did not use pain assessment tools for patients unable to communicate and were unaware of pain management guidelines published by professional societies.

Background Recently, clinical and research attention has been focused on refining weaning processes to improve outcomes for critically ill patients who require mechanical ventilation. One such process, use of a weaning protocol, has yielded conflicting results, arguably because of the influence of existing context and processes. Objective To compare international data to assess differences in context and processes in intensive care units that could influence weaning. Methods Review of existing national data on provision of care for critically ill patients, including structure, staffing, skill mix, education, roles, and responsibilities for weaning in intensive care units of selected countries. Results Australia, New Zealand, Denmark, Norway, Sweden, and the United Kingdom showed similarities in critical care provision, structure, skill mix, and staffing ratios in intensive care units. Weaning in these countries is generally a collaborative process between nurses and physicians. Notable differences in intensive care units in the United States were the frequent use of an open structure and inclusion of respiratory therapists on the intensive care unit’s health care team. Nurses may be excluded from direct management of ventilator weaning in some institutions, as this role is primarily assumed by respiratory therapists guided by medical directives. Availability of critical care beds was highest in the United States and lowest in the United Kingdom. Conclusion Context and processes of care that could influence ventilator weaning outcomes varied considerably across countries. Further quantification of these contextual influences should be considered when translating research findings into local clinical practice and when designing randomized controlled trials.

Background Positioning of patients is a modifiable risk factor for ventilator-associated pneumonia. Current guidelines for prevention of ventilator-associated pneumonia recommend semirecumbency at 30º, with 45º preferable unless contraindicated. Objective To assess the use of semirecumbency for ventilator patients in Australian and New Zealand intensive care units. Methods In a multicenter, observational study, backrest elevation, mean arterial pressure, use of inotropic agents, enteral feeding, and weaning status were recorded 3 times per day by using a predetermined randomization schedule for 7 consecutive days (maximum 21 observation episodes). Severity of illness was recorded daily by using the Sepsis-Related Organ Failure Assessment (SOFA) score. Results Measurements (n = 2112) were recorded for 371 ventilator patients in 32 intensive care units. Backrest elevation at ≥45º was noted for 112 of 2112 (5.3%; 95% confidence interval [CI], 4.3–6.3) measurements; elevation ≥30º but <45º for 472 of 2112 (22.3%; 95% CI, 20.6–24.1). Contraindications to semirecumbency were noted during 447 measurements. Increased back-rest elevation occurred during enteral feeding (2.2º, P < .001) and weaning (3.1º, P < .001). Decreased backrest elevation was associated with inotropic support (2.8º, P < .001), decreased mean arterial pressure (0.7º/10 mm Hg, P < .001), and organ failure (0.5º/1-point increment in SOFA max score, P < .001). For measurements recorded with no contraindication to semirecumbency, weaning status ( P = .003) and SOFA max score ( P = .008) remained associated with the degree of backrest elevation. Conclusions The findings of this multicenter, observational study suggest that backrest elevation was less than recommended and was influenced by clinical practices and patient condition.

Background Cuff management varies widely in Europe and North America. Little is known about current practice in Australia and New Zealand. Objective To characterize important aspects of cuff management in intensive care units in Australia and New Zealand to compare with international reports. Methods A questionnaire was sent to all nurse managers of adult intensive care units in Australia and New Zealand. Results Survey response was 53% (92/175). After intubation, most units (50/92, 54%) used both minimal occlusive volume technique and cuff pressure measurement; 5 (5.5%) used these methods along with pilot balloon palpation. Twenty units (22%) used cuff pressure measurement exclusively and 16 units (17.5%) used the minimal occlusive volume technique exclusively. Only 1 unit (1%) used the minimal leak technique after intubation. For ongoing management, cuff pressure measurement was the preferred method, used exclusively in 42 units (46%), with the minimal occlusive volume technique used in 40 units (43%; sole method in 6 units [7%]) and palpation in 4 units (4%). In most units (65/92, 71%), cuffs were monitored once per nursing shift. In units using the minimal occlusive volume technique, oropharyngeal suctioning (74%) and semirecumbent positioning (58%) were routinely incorporated; sigh breaths (6%), discontinuation of enteral feeding (10%), and nasogastric tube aspiration (26%) were uncommon. Cuff management protocols (37%) and subglottic suctioning (12%) were used infrequently. Conclusions Cuff pressure measurement was the preferred method, used exclusively or in combination with other methods. The minimal occlusive volume technique was used more often after intubation than for ongoing management.

Background Responsibilities of critical care nurses for management of mechanical ventilation may differ among countries. Organizational interventions, including weaning protocols, may have a variable impact in settings that differ in nursing autonomy and interdisciplinary collaboration. Objective To characterize the role of Australian critical care nurses in the management of mechanical ventilation. Methods A 3-month, prospective cohort study was performed. All clinical decisions related to mechanical ventilation in a 24-bed, combined medical-surgical adult intensive care unit at the Royal Melbourne Hospital, a university-affiliated teaching hospital in Melbourne, Victoria, Australia, were determined. Results Of 474 patients admitted during the 81-day study period, 319 (67%) received mechanical ventilation. Death occurred in 12.5% (40/319) of patients. Median durations of mechanical ventilation and intensive care stay were 0.9 and 1.9 days, respectively. A total of 3986 ventilation and weaning decisions (defined as any adjustment to ventilator settings, including mode change; rate or pressure support adjustment; and titration of tidal volume, positive end-expiratory pressure, or fraction of inspired oxygen) were made. Of these, 2538 decisions (64%) were made by nurses alone, 693 (17%) by medical staff, and 755 (19%) by nurses and staff in collaboration. Decisions made exclusively by nurses were less common for patients with predominantly respiratory disease or multiple organ dysfunction than for other patients. Conclusions In this unit, critical care nurses have high levels of responsibility for, and autonomy in, the management of mechanical ventilation and weaning. Revalidation of protocols for ventilation practices in other clinical contexts may be needed.