Clinicians need to have a better understanding of the potential impact of patients’ anxiety sensitivity, or “fear of fear,” according to an article published in American Journal of Critical Care (AJCC).
When a patient has anxiety sensitivity, they misinterpret nonthreatening symptoms as threatening, assessing the potential meaning across physical, social or cognitive domains. These “what if” thoughts may trigger a spiral effect, stimulating the nervous system and resulting in stronger sensations and further catastrophic misinterpretations.
It may lead to a patient avoiding activities they associate with anxiety-related sensations, such as physical activities or social situations. While in the hospital, they may resist interventions, such as repositioning or being weaned from sedatives. They may avoid physical or occupational therapy or struggle with efforts to help their recovery.
“Patients with anxiety sensitivity may falsely believe that their symptoms are the early signs of something bad, such as a heart attack, cognitive decline or social isolation,” she said. “It’s important for clinicians to be able to identify the difference between anxiety sensitivity and other medical conditions,” says Leanne Boehm, PhD, RN, ACNS-BC, FAAN, assistant professor at Vanderbilt University School of Nursing, Nashville, Tennessee, and investigator at the Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center at Vanderbilt University Medical Center.
For example, patients who have difficulty weaning from mechanical ventilation should first undergo a detailed workup to search for any underlying medical causes before anxiety sensitivity is considered as a primary cause.
ICU clinicians should be aware of patients’ possible anxiety sensitivity so they can use clear communication and implement pain management or relaxation techniques to mitigate distress and improve patient outcomes.
The Anxiety Sensitivity Index (ASI-3) is one tool clinicians can use to measure the extent of a patient’s physical, cognitive and social concerns about their anxiety. Providing basic psychoeducation to ICU patients on common symptoms may temper anxiety sensitivity, reassuring them their feelings are not unusual and putting their symptoms into context.
After discharge from the hospital, patients may continue to experience anxiety sensitivity and need increased assessment time, detailed explanations and extra demonstrations before participating in physical therapy or other activities.
Research specific to anxiety sensitivity in the critical care setting is limited, and future studies should incorporate assessment and management techniques across the critical care recovery continuum.
The American Association of Critical-Care Nurses (AACN) is bringing the lessons learned from its proven nurse leadership and innovation program and its Healthy Work Environment (HWE) initiative to help nurses at hospitals around the country improve the health of their workplaces.
AACN Clinical Scene Investigator (CSI) Academy is a unit-based program using implementation science to leverage direct care nurses’ expertise and build additional skills, preparing and supporting them as clinician leaders who effect positive changes that improve patient, nurse, and hospital outcomes.
Building on CSI Academy’s successful 11-year history and the documented benefits of sustaining an HWE, AACN has established a special version of its 12-month, team-oriented CSI program that will focus on the implementation of “AACN Standards for Establishing and Sustaining Healthy Work Environments” (HWE standards).
The initial cohort is underway in Los Angeles, with nurses from Los Angeles General Medical Center and Cedars-Sinai Medical Center. Nurses from Ohio, Oregon, Delaware, Texas, and Washington hospitals will participate in other regional cohorts launching through spring 2024. The program will eventually encompass 80 teams with three to four nurses each.
The HWE standards are the cornerstone of AACN’s comprehensive HWE initiative, a long-term commitment to creating environments where nurses can provide the highest standards of safe, compassionate patient care while being fulfilled at work.
Findings from AACN’s most recent National Nurse Work Environments study indicate healthcare teams who have implemented the HWE standards or are in the process of doing so report better results than those who have not. Teams implementing HWE standards reported higher nurse well-being scores, improved staffing with an appropriate skill mix, and higher quality of patient care, among other outcomes.
“A healthy work environment is an essential element to nurse recruitment, satisfaction and retention, while also improving patient, nurse and hospital outcomes,” said AACN Chief Clinical Officer Vicki Good, DNP, RN, CENP, CPPS. “While the positive impact of HWEs has been demonstrated through decades of research, the nursing community still struggles to translate evidence into practice and gain sustained support for HWE implementation. We aim to change that.”
A grant from the AACN Innovation Fund is underwriting the program, with participating hospitals paying a fee of up to $1,500 per unit and providing paid time away from patient care for nurses to participate in the program and attend CSI Academy workshops and sessions.
CSI Academy encourages participating teams of nurses to immediately apply what they learn in a capstone project that improves outcomes in their units. Over the past 11 years, participants have reported achieving significant results, including:
Reduced length of stay, ventilator days, infection rates, delirium, pressure injuries and falls
An average median return on investment of 605% per team
Nationwide, more than 512 nurses at 105 hospitals in 15 states have completed the CSI Academy program since its launch in 2012. The program has touched over 1.2 million patients and over 7,200 nurses, with an estimated positive fiscal impact on hospitals of $111 million.
AACN offers access to its online collection of CSI Academy innovation projects― including project plans, clinical interventions, data collection tools, outcomes, and references ― as part of the program’s goal to inspire and empower as many progressive and critical care nurses as possible. With over 115,000 unique downloads of project materials, the CSI innovation project library has become a resource for hospitals, healthcare administrators, and clinical leaders seeking solutions that improve outcomes and reduce costs.
To learn more about bringing CSI Academy to your hospital or health system, visit the CSI Academy FAQ page.
Recent advances in ultrasonography technology have led to increased usage at the point-of-care, with handheld devices offering diagnostic and therapeutic applications.
Point-of-care ultrasonography (POCUS) has proven to be an effective tool for various medical and surgical conditions, including those experienced by patients who are critically ill. Its numerous benefits are that it can be performed quickly and cost-effectively without transporting the patient, uses no radiation, and is easily reproducible and noninvasive. POCUS can be performed at the patient’s bedside as clinical questions arise and rapidly repeated as a clinical situation mandates.
“Point-of-Care Ultrasonography in the Critical Care Setting: Abdominal POCUS,” published in AACN Advanced Critical Care, describes several applications for POCUS in abdominal imaging, including the biliary tract, liver, kidneys, bladder, and appendix, as well as intra-abdominal free fluid. For each one, the article covers indications, relevant anatomy and physiology, clinical pitfalls, scanning techniques, and documentation of findings.
The authors are Bryan Boling, DNP, AGACNP-BC, and Abbye Solis, DNP, ACNP-BC. Boling is a nurse practitioner in the anesthesiology department, division of Critical Care Medicine at the University of Kentucky, Lexington. Solis is a nurse practitioner in the Weinberg Surgical ICU at Johns Hopkins Hospital, Baltimore. They are both adjunct faculty in the adult-gerontology acute care nurse practitioner program at Georgetown University, Washington, D.C.
“The most-known application of abdominal POCUS is to quickly assess the trauma patient for occult intra-abdominal injury, but it can also help clinicians evaluate the function of several abdominal organs that may fail during critical illness and contribute to morbidity and mortality,” Boling says. “POCUS is redefining how illness and injuries are diagnosed and treated, and its growth and expansion will only continue.”
The American Association of Critical-Care Nurses (AACN) named Vicki Good, DNP, RN, CENP, CPPS, CPHQ, as its chief clinical officer (CCO).
“As a member of our executive team, the CCO provides leadership of AACN’s initiatives to drive the transformation of acute and critical care work environments to align with AACN’s Standards for Establishing and Sustaining Healthy Work Environments,” says Dana Woods, AACN CEO. “Our CCO collaborates widely within the AACN community and beyond to identify, translate, and facilitate opportunities and integrated action to address current and emerging practice needs and advocacy priorities on issues that matter most to nurses and their patients.”
Nationally known for her patient safety expertise, Good succeeds Connie Barden, MSN, RN, CCRN-E, CCNS, who retires after serving as AACN’s inaugural CCO since 2014.
“Nursing is at a pivotal point. The pandemic illuminated several key areas that have long impacted nursing, and AACN is positioned to be at the forefront to help the profession move forward in areas such as establishing and sustaining healthy work environments, supporting nurses transitioning to critical care, and staffing,” says Good.
After beginning her critical care nursing career at Parkland Memorial Hospital in Dallas, Good served in executive positions for Mercy Health System in Springfield, Missouri, since 2018, including systemwide responsibility for nursing professional development and quality. During the COVID-19 pandemic, she took on an additional role in emergency care for the health system. She has held leadership and clinical roles with CoxHealth, Baylor Health Care System, and Harborview Medical Center.
As AACN president from 2013-2014, a one-year term, Good advocated for nurses to lead the redefinition of safe patient care and optimal outcomes. She recently served on the National Nurse Staffing Think Tank and Task Force, co-led by AACN, to develop recommendations for long-term solutions to the current staffing crisis and the systemic issues exacerbated by the COVID-19 pandemic. As CCO, Good is a member of the AACN Staffing Advisory Group, which is charged with defining the scope and standards of safe staffing for critical care patients.
“Vicki’s expert personal and professional experience with the issues direct care nurses face is one of many strengths she brings,” says Woods. “As a highly engaged AACN volunteer for more than 20 years, Vicki is well versed in our strategic priorities and the care environments our community members practice.”
She served on the external advisory board of Transforming Healthcare through Innovative Nurse-Led Care Delivery Solutions, an initiative of the Institute for Healthcare Improvement and Johnson & Johnson Center for Health Worker Innovation. She is also a member of the American Organization for Nursing Leadership and the Missouri Organization of Nurse Leaders.
She is a scholar of Just Culture and a frequent author and national speaker on workforce solutions, healthy work environments, burnout, and patient safety and quality.
“Just Culture and healthy work environments are pivotal in creating inclusive environments where nurses thrive and patients receive optimal care,” says Good. “As an association, we must continue to advocate for the intersection of these critical components to support our workforce and patients.”
Good earned a Bachelor of Science in Nursing, a Doctor of Nursing Practice from Texas Christian University, and a Master of Science in Nursing from Seattle Pacific University. She completed the Parkland Memorial Hospital critical care trauma nurse internship.
She is a current adjunct faculty member at Missouri State University and active in community organizations in the Springfield, Missouri, area, including as a current board member and past president of the Springfield Child Advocacy Center.
Minutes matter when a patient may have had a stroke, but being far from a physician with advanced training in neurology no longer needs to be a barrier to rapid diagnosis and intervention thanks to telestroke programs designed to improve access to the limited number of specialists, regardless of the geographic isolation of patients who may have experienced a stroke.
Telestroke, or stroke telemedicine, is a form of telehealth in which physicians with advanced training in stroke care use technology to provide immediate consultation to a local healthcare professional to recommend diagnostic imaging and treatment for patients with stroke at an originating site. Patients who present within 4.5 hours of when they were last known to be well may be eligible for thrombolytic drug therapy or endovascular intervention, often measured as door-to-needle time.
After launching a telestroke consultation program, Essentia Health, an integrated health system serving patients in Minnesota, Wisconsin, and North Dakota, increased the percentage of patients receiving thrombolytics in less than 60 minutes and decreased the average door-to-needle time.
Essentia Health initiated the telestroke program in the fall of 2019, with coverage provided by four interventional neurologists, three of whom work in the system’s Comprehensive Stroke Center in Fargo, North Dakota. In addition to this center, telestroke services are provided to five other acute stroke-ready hospitals throughout rural areas in the upper Midwest.
Through the telestroke program, neurology consultations are available to all sites 24 hours a day, every day of the year. They can be used for inpatient and emergency department stroke activations at each facility.
The team developed a tiered stroke alert algorithm and telestroke workflow chart to help healthcare professionals at rural sites determine eligibility for telestroke consultation to decide the treatment plan.
The algorithm categorized strokes as levels I to III according to the symptoms and time when the patient was last known to be well. Telestroke consults were most often used for patients with level I stroke alerts since they were within the timeframe when they might be eligible for thrombolytic drug therapy or endovascular intervention.
Once staff members determine whether a telestroke consultation will be initiated, they refer to the step-by-step workflow chart, which specifies actions needed for each multidisciplinary team member.
“Regardless of the type of stroke, rapid diagnosis and intervention are critical for improving survival rates and reducing the long-term effects of stroke,” says Chelsey Kuznia, BSN, RN, SCRN, the stroke program manager for Essentia Health’s Comprehensive Stroke Center in Fargo, one of only two such facilities in North Dakota. “People living in rural areas not only have increased stroke risk factors, but they also face challenges to getting the advanced care they need in a timely way, which leads to higher rates of disability and death.”
In 2022, telestroke connections for 42 patients were completed, with a stroke diagnosis confirmed in 25 (61%). Fourteen patients with confirmed stroke received thrombolytic therapy. In contrast, others were not eligible, either because of patient-related contraindications or because more than 4.5 hours had elapsed since their last-known well time.
Of the 25 patients with confirmed stroke, 18 (72%) were discharged home, three were discharged to skilled nursing facilities, one to an inpatient rehabilitation unit, one to hospice, and two died.
The year before the implementation of the telestroke program, 11 of 15 eligible patients (73%) received thrombolytic therapy in less than 60 minutes, with a mean door-to-needle time of 61 minutes. During the year after implementation, the results improved: 11 of 12 eligible patients (92%) received thrombolytic therapy in less than 60 minutes, and the mean door-to-needle time decreased to 38 minutes.
