Hand Hygiene in Intensive Care Units: A Matter of Time?

Stahmeyer, J.T. The Journal of Hospital Infection. Published online: January 28, 2017

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Background: Healthcare-associated infections are a frequent threat to patient safety and cause significant disease burden. The most important single preventive measure is hand hygiene (HH). Barriers to adherence with HH recommendations include structural aspects, knowledge gaps, and organizational issues, especially a lack of time in daily routine.

Conclusion: Complying with guidelines is time consuming. Sufficient time for HH should be considered in staff planning.

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Immunotherapy improves the prognosis of lung cancer: do we have to change intensive care unit admission and triage guidelines?

Guillon, A. et al. Critical Care. Published online: 27 January 2017

Bald heads may soon not be a sign that identifies a cancer patient receiving treatment. Indeed, therapies for cancer patients are improving dramatically leading to increased survival rates, and most are associated with a different toxicity profile. Recently, antibody-based therapy has transformed the therapeutic landscape and biology of non-small cell lung cancer (NSCLC) and other solid tumors. This may also reshuffle the playing cards for an intensive care unit (ICU) admission policy due to improved outcomes.

In November 2016, the results of the KEYNOTE-024 trial showed for the first time the superiority of immunotherapy over chemotherapy as first-line treatment for NSCLC [1]. In this phase 3 trial, a humanized monoclonal antibody (mAb) against programmed death 1 (PD-1) was tested in patients who had previously untreated advanced NSCLC. The clinical trial was stopped by the safety monitoring committee on the basis of substantial clinical benefit of immunotherapy, and patients remaining in the chemotherapy group were switched to receive immunotherapy.

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Nurses’ prioritization of enteral nutrition in intensive care units

Bloomer, M. J et al. Nursing in Critical Care. Published online: 30 January 2017

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Background: Enteral nutrition is important in critically ill patients to improve patient outcomes, with nurses playing a pivotal role in the delivery and ongoing care of enteral nutrition. A significant deficit in nurses’ knowledge and education relating to enteral nutrition has been identified, leading to iatrogenic malnutrition and potentially compromising patient care. Enteral nutrition appears to be prioritized lower than many other aspects of care. However, there is scant research to show how nurses prioritize enteral nutrition.

Conclusion:Respondents relied on their clinical judgement to inform decisions in relation to enteral nutrition in critically ill patients. Most respondents agreed that enteral nutrition was an important aspect of patient care, but acknowledged that other aspects of care were prioritized more highly. Despite this, some delays to enteral nutrition were perceived to be avoidable, and nurses recognized a need to advocate on the patient’s behalf to increase the visibility of enteral nutrition.

Relevance to clinical practice: The findings of this study demonstrate that enteral nutrition is often prioritized lower than other competing care needs in the critically ill patient. Given the importance of enteral nutrition to patient recovery, changes to clinical practice to improve enteral nutrition management are necessary.

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Guideline: Management of Sepsis and Septic Shock

Howell, M.D, & Davis, A.M. JAMA. Published online: 19 January 2017

Managing infection:

  • Antibiotics: Administer broad-spectrum intravenous antimicrobials for all likely pathogens within 1 hour after sepsis recognition (strong recommendation; moderate quality of evidence [QOE]).

  • Source control: Obtain anatomic source control as rapidly as is practical (best practice statement [BPS]).

  • Antibiotic stewardship: Assess patients daily for deescalation of antimicrobials; narrow therapy based on cultures and/or clinical improvement (BPS).

Managing resuscitation:

  • Fluids: For patients with sepsis-induced hypoperfusion, provide 30 mL/kg of intravenous crystalloid within 3 hours (strong recommendation; low QOE) with additional fluid based on frequent reassessment (BPS), preferentially using dynamic variables to assess fluid responsiveness (weak recommendation; low QOE).

  • Resuscitation targets: For patients with septic shock requiring vasopressors, target a mean arterial pressure (MAP) of 65 mm Hg (strong recommendation; moderate QOE).

  • Vasopressors: Use norepinephrine as a first-choice vasopressor (strong recommendation; moderate QOE).

Mechanical ventilation in patients with sepsis-related ARDS:

  • Target a tidal volume of 6 mL/kg of predicted body weight (strong recommendation; high QOE) and a plateau pressure of ≤30 cm H2O (strong recommendation; moderate QOE).

Formal improvement programs:

  • Hospitals and health systems should implement programs to improve sepsis care that include sepsis screening (BPS).

Read the full guidelines here

Nurses’ practices and knowledge about interventional patient hygiene

El-Soussi, A.H. & Asfour, H.I. Intensive and Critical Care Nursing. Published online: 25 January 2017

Background: The Nursing profession is struggling to return to basic nursing care to maintain patients’ safety. “Interventional patient hygiene” (IPH) is a measurement model for reducing the bioburden of both the patient and health care worker, and its components are hand hygiene, oral care, skin care/antisepsis, and catheter site care.

Conclusion: The mean percentage IPH knowledge score is higher than the mean percentage IPH practice score of all IPH items. Barriers for implementing IPH include workload, insufficient resources, and lack of knowledge/training.

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Patients’ experience of thirst while being conscious and mechanically ventilated

Kjeldsen, C.L. et al. Nursing in Critical Care. Published online: 25 January 2017

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Background: Because of changes in sedation strategies, more patients in the intensive care unit (ICU) are conscious. Therefore, new and challenging tasks in nursing practice have emerged, which require a focus on the problems that patients experience. Thirst is one such major problem, arising because the mechanical ventilator prevents the patients from drinking when they have the urge to do so. To gain a deeper understanding of the patients’ experiences and to contribute new knowledge in nursing care, this study focuses on the patients’ experiences of thirst during mechanical ventilation (MV) while being conscious.

Conclusion: Patients associate feelings of desperation, anxiety and powerlessness with the experience of thirst. These feelings have a negative impact on their psychological well-being. A strategy in the ICU that includes no sedation for critically ill patients in need of MV introduces new demands on the nurses who must care for patients who are struggling with thirst.

Relevance to clinical practice: This study shows that despite several practical attempts to relieve thirst, it remains a paramount problem for the patients. ICU nurses need to increase their focus on issues of thirst and dry mouth, which are two closely related issues for the patients. Communication may be a way to involve the patients, recognize and draw attention to their problem.

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Oral care in ventilated intensive care unit patients

Diaz, T.L. et al. American Journal of Infection Control. Published online: 23 January 2017

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Highlights:

  • A quality improvement project was developed to evaluate the pre/post effects of standardized placement and supply of oral care equipment in patient rooms.
  • Daily audits were performed to assess nursing behavior related to the performance of oral care on intubated patients with components from a 24 hour kit.
  • Increasing supply and creating uniform placement of oral care tools in patient rooms contributes to increased performance of oral hygiene interventions by nurses.

Read the full abstract here