An analysis of 10 years of health data showed that risk factors for needing mechanical ventilation changed for patients with newly diagnosed sepsis as more time passed after onset.
In the study, 13.5% of patients with a new diagnosis of sepsis required initiation of mechanical ventilation. Over half of these patients required mechanical ventilation within the first 24 hours after sepsis onset, while initiation occurred after 24 hours in 47.4% of patients.
Robert Freundlich, MD, MS, MSCI, associate professor, department of anesthesiology, and chief of the anesthesiology informatics research division at Vanderbilt University Medical Center, Nashville, Tennessee
“Requiring mechanical ventilation is often a pivotal point for patients with sepsis, and their risk of respiratory failure may vary with time,” says co-author Robert Freundlich, MD, MS, MSCI, associate professor, department of anesthesiology, and chief of the anesthesiology informatics research division at Vanderbilt University Medical Center, Nashville, Tennessee. “Identifying patients at high risk and implementing targeted interventions in a timely manner has the potential to significantly improve outcomes.”
A total of 35,020 patients met sepsis criteria, and 28,747 patients were eligible for inclusion after exclusion criteria were applied. The dataset spanned July 10, 2009, to Sept. 7, 2019.
Of all eligible patients, 3,891 (13.5%) required mechanical ventilation within 30 days after sepsis onset. Of these, 2,046 (52.6%) required mechanical ventilation within 24 hours of diagnosis. Mechanical ventilation was subsequently initiated for 441 (11.3%) patients from one to two days after sepsis onset and 312 (8.0%) patients from two to three days after diagnosis. The remaining 1,092 (28.1%) experienced late respiratory failure or required mechanical ventilation three to 30 days after diagnosis.
Patients requiring mechanical ventilation had higher baseline illness severity and a higher prevalence of 27 of the 35 comorbidities on the Elixhauser Comorbidity Index, which measures the overall severity of comorbidities.
They also had a higher in-hospital mortality rate (21%) than patients who did not require mechanical ventilation (7%). Further analysis revealed that of the patients who received mechanical ventilation before but not after sepsis onset, only 35 (4% of 822) died before hospital discharge.
Factors independently associated with an increased likelihood that mechanical ventilation would be needed included race, systemic inflammatory response syndrome (SIRS) score, Sequential Organ Failure Assessment (SOFA) score, and congestive heart failure. Risks decreased with time for the SOFA score and congestive heart failure and varied for four comorbidities and three culture results.
The researchers recommend future proactive studies focusing on the effects of fluid resuscitation and other care processes on the need for mechanical ventilation in this patient population. Noninvasive ventilation and high-flow nasal cannula may also impact the need for intubation and mechanical ventilation and should be evaluated.
Improved organ donation practices and greater program visibility led to a sustained increase in referrals, donors, and transplanted organs at a Georgia hospital, thanks to a focus on enhanced staff education and family communication.
Co-author Jesse Gibson, MBA, BSN, RN, TCRN, is the trauma program director and chair of the Donation Advisory Committee at the trauma center, serving 18 counties in a predominantly rural area. Part of a five-hospital health system, the medical center serves more than 2,600 trauma patients annually, with 95% having blunt trauma. Since the initiative was conducted, the hospital has been nationally verified as a Level I trauma center by the American College of Surgeons Committee on Trauma.
“By investing in staff members and partnering with bedside providers, our facility improved the organ donation experience for nurses, physicians, donors, and families,” Gibson says. “The outcome of that investment has been a hospital culture that values and celebrates organ donation as a standard of care for patients and families and an important part of honoring end-of-life wishes.”
The performance improvement initiative began at the end of 2017 to address concerns about lower-than-expected metrics related to the medical center’s organ donation process. Initial reviews of patient care revealed deviations from best practice, including missed referrals, care team members initiating discussions about donation with families, and misconceptions about the donation process.
The Donation Advisory Committee helped clarify language and revise policies related to end-of-life care, partnering with the hospital liaison at its organ procurement organization to increase physician and staff education and provide visibility for the process. Beyond engaging staff to reinforce the expected practice, a transitional language guide was provided to physicians and advanced providers to assist them in any initial discussions that may arise with families. A series of organ donation presentations in 2018 and 2019 provided staff education. They encouraged a dialogue about the process and review of the most recent organ and tissue data, metrics, and expectations.
To improve the program’s visibility, the project team arranged for a “Donate Life” flag to be raised on the main campus each time a family authorized organ donation. The team also implemented an “honor walk” to recognize the donor and family as donors are transported from the inpatient area to the operating room for organ procurement, with staff members lining the hallway to show respect and support. In 2019, the hospital held its first donation remembrance celebration, attended by families of organ donors and the clinical staff members who cared for them.
Since the project began, the number of organ referrals, donors, and transplanted organs has increased yearly, except for a slight dip in 2020 during the early COVID-19 pandemic. The number of organ referrals doubled, from 169 in 2015 to 320 in 2021. The number of organ donors in 2021 was 31, with more than 22 donors in 2015, 2016, and 2017. Similarly, the total number of organs donated in 2021 was 102, up from 16 in 2015. The rate at which an appropriate requestor initiated the conversation about organ donation with the family increased from 52% in 2015 to 90% in 2021.
Patients with alterations in level of consciousness are among the most difficult to assess and may have subtle neurological changes that can occur suddenly and become life-threatening if they go unnoticed.
Nurses who care for these patients must have the knowledge, skill, and time to confidently perform comprehensive neurological assessments to identify changes that require quick diagnosis and intervention by the multidisciplinary team, according to a new article in Critical Care Nurse.
Co-author Melissa Moreda, MSN, APRN, ACCNS-AG, CDCES, CNRN, SCRN, is an inpatient diabetes clinical nurse specialist at Duke Raleigh Hospital in North Carolina.
“Neurologically impaired patients are among the most vulnerable, often unable to communicate, advocate for, or defend themselves,” she says. “Direct care nurses are at the forefront of care, and it’s imperative to understand key components of an assessment and be able to evaluate trends rather than isolated events.”
The article provides guidance for conducting a thorough neurological assessment, including:
General behavior and body position
Vital signs
Level of consciousness
Mental status
Motor control and sensory function
Cranial nerve function
Pupillary response
Language and speech
Reflexes
Cerebellar function
Many of the components of a neurological assessment are subjective, and changes in status may be subtle, requiring ongoing and astute monitoring. When minute changes are identified quickly, interventions critical for brain preservation can be implemented rapidly to prevent long-term complications and provide quality care for patients with altered levels of consciousness.
Older patients with Alzheimer’s disease and related dementia (ADRD) have almost twice the risk of dying soon after they are discharged from an intensive care unit (ICU) and within the 12 months afterward, according to research published in the American Journal of Critical Care (AJCC).
The study found that older adults with ADRD who were admitted to an ICU were much less likely to be discharged home and faced almost twice the risk of death in the same calendar month as discharge and the 12 months after discharge when compared with patients who did not have an ADRD diagnosis.
“Patients with ADRD often have a limited life expectancy, which can be further shortened after an ICU admission or other acute event,” she says. “Our findings raise questions about proactive strategies to diminish the likelihood of an ICU admission or early discussions with families and caregivers about palliative care.”
Deaths in the ADRD cohort were almost twice as common within the same calendar month after discharge and within the following 12-month period, compared with deaths in the non-ADRD cohort.
In addition to short-term and long-term mortality, the analysis revealed that more than one-third (37.6%) of patients with ADRD went home after hospital discharge, compared with more than two-thirds (68.6%) of non-ADRD patients.
Being dual-eligible for Medicare and Medicaid further raised patients’ risk of not being discharged home from the ICU and dying within the same calendar month after discharge and within 12 months following their discharge.
The observational study used Optum’s de-identified Clinformatics Data Mart Database version 8.1, which covers the period from 2016 to 2019. The analysis included adults age 67 or older with continuous MA coverage who were first admitted to an ICU in 2018. ADRD and comorbid conditions were identified from claims.
After applying exclusion criteria, the final study population included 145,342 patients with a first-time admission to the ICU in 2018 and who were discharged from the ICU. Among this group, 10.5% (15,289) were diagnosed with ADRD.
The analysis did not examine reasons for the initial ICU admission and causes of death or differentiate between types of ADRD or between mild and severe dementia and other elements that might influence outcomes.
It is well known that many U.S. healthcare organizations face a significant nurse staffing challenge, and as leaders and administrators seek solutions, we must emphasize an essential element of nurse recruitment and retention — establishing and sustaining healthy work environments (HWEs).
The most recent “National Nurse Work Environments” study, conducted in 2021 by the American Association of Critical-Care Nurses (AACN), shows that the health of nurse work environments across the country has declined dramatically. In that study, 67% of nurses reported plans to leave their current positions due to high levels of job dissatisfaction, moral distress, and inappropriate staffing. For this reason alone, it is well past time for organizations to address this HWE challenge.
Report improved staffing with an appropriate skill mix
Report higher quality of patient care
Score higher on every HWE standard
Why Is an HWE So Important?
In addition to AACN’s 2021 study findings, a significant body of research underlines the importance of healthy nurse work environments. A meta-analysis byLake, et al and a systematic review completed byWei and colleagues are just two examples of research that supports the correlation between HWEs and positive patient, nurse, and hospital outcomes. From the mounting research that now spans nearly two decades, we know the following:
Without immediate and bold action, work environments may worsen, which will further imperil our national healthcare system. Responses from the more than 9,000 nurses who answered AACN’s 2021 survey indicated significant declines in the health of the work environment compared with AACN’s previous 2018 survey:
Nurse Well-being Declined
Nearly 40% of RNs rate their emotional health poorly.
52.8% of RNs report that their organization does NOT value their health and safety.
48% of RNs report feeling moral distress either “frequently” or “very frequently.”
The number of RNs experiencing moral distress “very frequently” doubled from 11% in 2018 to 22% in 2021.
72% of RNs report having experienced at least one form of abuse (verbal, physical, discrimination, or sexual harassment).
Quality of Care Decreased
The perception of “good” or “excellent” quality of care has fallen 13 percentage points since 2018.
53% of RNs report that the overall quality of care has declined.
The number of RNs who report the quality of care has become “somewhat worse” or “much worse” grew by 16 percentage points.
Staffing is a Problem
Only 46% of RNs report their unit ensures an effective match between patient needs and nurse competencies.
Just 25% of RNs report being appropriately staffed on a regular basis.
Ratings on the Appropriate Staffing standard fell 15 percentage points since 2018.
Job Satisfaction Fell
Job satisfaction decreased by 18 percentage points since 2018.
Satisfaction with the nursing profession fell for the first time (only 76% of RNs reporting satisfaction with being an RN compared with 92% in 2018).
67% of RNs plan to leave their current positions in the next three years, compared with 54% in 2018.
Of those RNs planning to leave, 82% report adequate staffing would make them reconsider.
Take the First Step
The first step to remedy these issues is to assess the work environment using the AACN Healthy Work Environment Assessment Tool (HWEAT). Recently updated to provide a more informative analysis, the new assessment tool highlights unit and organizational influences on the work environment and dives deeply into each of the six standards. The free assessment features 24 web-based questions, takes less than 15 minutes, and comes with a department report with national benchmarking data and a comprehensive toolkit to guide the next steps. Gathering assessment baseline information in this way helps identify department strengths and opportunities while enabling the team to track progress over time.
Review the report as a team, and develop an implementation plan to ensure everyone’s voice is heard. This procedure is key to engaging team members and driving meaningful change.
A Call to Action
Establishing HWEs is everyone’s responsibility. The work is not easy, but the benefits of doing so are increasingly clear, as are the consequences of inaction. When nurses work in unhealthy environments, patient and family outcomes, nurse well-being, and staff retention decline. With a national nursing shortage projected to be from 200,000 to 450,000 nurses by 2025, the viability of our healthcare system is at stake. It’s time for everyone to begin this important work.
