Effectiveness of supporting intensive care units on implementing the guideline ‘End-of-life care in the intensive care unit, nursing care’: a cluster randomized controlled trial

This article was published in the Journal of Advanced Nursing June 2017 volume 73 number 6 by Noome et al.

Aim:  To examine the effectiveness of supporting intensive care units on implementing the guidelines.

Background:  Quality of care can be achieved through evidence-based practice. Guidelines can facilitate evidence-based practice, such as the guidelines ‘End-of-life care in the intensive care unit, nursing care’. Before intensive care nurses are able to use these guidelines, they needs to be implemented in clinical practice. Implementation is a complex process and may need support.

Methods:  Intensive care nurses of eight intensive care units in the intervention group followed a supportive programme that educated them on implementation, strategies, goals, project management and leadership. The intervention group focused on a stepwise approach to implement the guidelines. The control group (n = 5) implemented the guidelines independently or used the standard implementation plan supplementary to the guideline. The effectiveness of the programme was measured using questionnaires for nurses, interviews with nurses and a questionnaire for family of deceased patients, in the period from December 2014-December 2015.

Results:  Overall, an increase in adherence to the guidelines was found in both groups. Overall, use of the guidelines in the intervention group was higher, but on some aspects the control group showed a higher score. Care for the patient and the overall nursing care scored significantly higher according to family in the intervention group.

Conclusion:  The increase in adherence to the guidelines and the significantly higher satisfaction of family in the intervention group indicate that the supportive programme had a more positive effect.

The physical copy of available Journal of Advanced Nursing is available in the Healthcare Library on Level D of Rotherham Hospital.

Using Qualitative Research to Inform Development of Professional Guidelines

The aim of this study was to explore the importance, challenges, and opportunities using qualitative research to enhance development of clinical practice guidelines, using recent guidelines for family-centered care in the ICU as an example | Critical Care Medicine

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Methods: In developing the Society of Critical Care Medicine guidelines for family-centered care in the neonatal ICU, PICU, and adult ICU, we developed an innovative adaptation of the Grading of Recommendations, Assessments, Development and Evaluations approach to explicitly incorporate qualitative research. Using Grading of Recommendations, Assessments, Development and Evaluations and the Council of Medical Specialty Societies principles, we conducted a systematic review of qualitative research to establish family-centered domains and outcomes. Thematic analyses were undertaken on study findings and used to support Population, Intervention, Comparison, Outcome question development.

Results: We identified and employed three approaches using qualitative research in these guidelines. First, previously published qualitative research was used to identify important domains for the Population, Intervention, Comparison, Outcome questions. Second, this qualitative research was used to identify and prioritize key outcomes to be evaluated. Finally, we used qualitative methods, member checking with patients and families, to validate the process and outcome of the guideline development.

Conclusions: In this, a novel report, we provide direction for standardizing the use of qualitative evidence in future guidelines. Recommendations are made to incorporate qualitative literature review and appraisal, include qualitative methodologists in guideline taskforce teams, and develop training for evaluation of qualitative research into guideline development procedures. Effective methods of involving patients and families as members of guideline development represent opportunities for future work.

Full reference: Coombs, M.A. et al. (2017) Using Qualitative Research to Inform Development of Professional Guidelines: A Case Study of the Society of Critical Care Medicine Family-Centered Care Guidelines. Critical Care Medicine. Vol. 45 (no. 8) pp. 1352–1358

Early Antibiotics & Fluids Key in Sepsis Management

Sepsis and septic shock are medical emergencies that require immediate action | Anesthesiology News

Early resuscitation should begin with early antibiotics and fluids, as well as the identification of the source of infection, according to new guidelines that were released at the Society of Critical Care Medicine’s (SCCM) 2017 Critical Care Congress.

In addition, the new guidelines say a health care provider who is trained and skilled in the management of sepsis should reassess the patient frequently at the bedside. “It is not the initial assessment, but the frequent reassessment that will make a difference,” said Andrew Rhodes, MD, FRCP, FRCA, FFICM, the co-chair of the guidelines committee.

Read the full news story here

Quality of clinical practice guidelines in delirium

Bush, S.H. et al. (2017) BMJ Open. 7:e013809

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Objective: To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality.

Conclusions: Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice.

Read the full review here

A Users Guide to the 2016 Surviving Sepsis Guidelines

Dellinger, R.P. (2017) Critical Care Medicine. 45(3) pp. 381–385

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The 2016 Surviving Sepsis Guidelines have arrived, a remarkable document, all 67 pages with 655 references. We congratulate the lead authors and contributing committee members. With each iteration, the guidelines grow more complex and perhaps more challenging to utilize. We offer guidance toward effective application in clinical practice.

Read the full article here

Read the full guidelines here

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