SCCM Resource Library-Innovations in Nursing Research

Video Transcription

Hello Critical Care Congress, my name is Jose Chavez and I am a Clinical Nurse Specialist at Cedars-Sinai Medical Center in Los Angeles, California.  I am a CNS of the Cardiac Medicine and Cardiac Surgery ICU. I am also a member at large for the Nursing Research Section of the SCCM.  I also serve on the Quality and Safety Committee and the Thrive in Patient and Family Committee. I'll be presenting the Innovations in Nursing Research for the 2021 year in review.  This Innovations in Nursing Research subcommittee consists of Christine Schwarzman, Dr. Zachary Crum, and my CNS student Lauren Urban.  Prior to choosing the article that I'll be presenting today, our Nursing Research Committee  conducted a search for articles that had nurses as first author or primary author and studies that were done in the critical care or used a critical care population and studies that  were published between 2020 to 2021. We evaluated articles that were in nursing and medical journals and we looked at different electronic databases.  We came together, included all these articles into a literature grid and evaluated different themes of our articles.  Out of the articles, we found 55, which we included into the evidence grid and divided them into themes.  We'll be presenting today, Impact of COVID-19 on Patients and Nursing, Innovations in Nursing Research, and also two articles that were published in the American Journal of Critical  Care that originated from the SCCM Nursing Section on the subject titration of IV medications.  The title of the article that we chose for Innovations in Nursing Research is The Effect  of Emergency Critical Care Nurses and Emergency Department Boarding Time on In-Hospital Mortality  in Critically Ill Patients by Jason Nesbitt et al., published in 2021 in the American Journal of Emergency Medicine.  The authors of the study hypothesized that establishing a program of specialized emergency  care nurses in the ED would improve mortality of ICU patients boarding in the ED. This was a retrospective before-after cohort study that used electronic health record data  at an academic medical center. The authors compared in-hospital mortality between the pre- and post-intervention periods  and between non-prolonged less than six hours boarding time and prolonged greater than six hours boarding time.  The authors of this study identified the primary problem of the ED not designed to provide care for ICU patients over a prolonged period of time.  They found the ICU holds were becoming more common and that patients had worse outcomes with extended ED holds, including increased ICU and hospital length of stay, increased  ventilator days, and increased mortality. A previous study that they identified demonstrated that mortality increased with boarding time greater than six hours.  The current interventions targeted improving inpatient flow and increasing ICU capacity.  This study had a pre-intervention period between October 2013 and September 2014 and the post-intervention period of October 2015 to September of 2016.  Our first question to the audience is, in this study, was the methods of this article on ED boarding time clear?  The goals of the study included comparing ICU boarding in the ED under the pre-intervention, which included a traditional model of holding ICU patients in the ED until an inpatient  ICU bed was available, compared to using a specialized ICU nurse, also known as the emergency critical care nurse, that was stationed in the ED as a resource.  That was the primary goal of the study, but they also looked at if there was a difference between a non-prolonged time of less than six hours versus a prolonged time of greater  than six hours using the same comparison of a pre-intervention using a traditional model versus the intervention using the emergency critical care nurse.  The findings of the article show that there was no statistical significant change in the prolonged greater than six hours and the non-prolonged less than six hours boarding group.  However, they did find that there was less mortality with the interventional group in the non-prolonged less than six hours boarding group.  The question to the audience is, in the prolonged group that showed lower mortality, what other factors could have influenced this result?  Also, what processes were mentioned in the discussion but not in the methods section? The article identifies that due to increased ED flow during intervention period, it is  difficult to draw a conclusion regarding the impact of the ECC nurses on in-hospital mortality. The emergency room visits increased by 14.2% from pre-to-intervention period.  Hospitalizations also increased by 7%, which were both statistically significant. The proportion of ECC patients in prolonged boarding group doubled from pre-to-intervention  period, 13.9% to 27.1%. The mean ED boarding time increased in the intervention period, although it was not statistically significant.  Three times as many patients were downgraded to lower level of care in the ED in the intervention period versus pre-intervention.  This could be due to the ECC nurse and their influence on the admission status. Recommendations of this article show that ICU in the ED holding areas have similarities  with the 24-hour hold unit, but the ICU patients can be downgraded while more sick patients  can get transferred first, therefore decreasing the number of ICU admissions and keeping ICU beds for the sickest patients.  This article shows that the ECC nurse can be beneficial for the ED by being able to downgrade ICU patients no longer need an ICU bed and can be discharged from the ED, providing  more training or resources to ED nurses in the critical care rather than just having one ECC nurse 24-7, and continue to address other reasons that contribute to worsened  outcomes for ICU patients being held in the ED. Limitations of this study included identifying if the intervention period, or referred to  as the post-intervention period, included the year in between the ICU nurse in the ED for around 3 days a week versus the intervention of the ICU nurse being in the ED 24-7.  Other limitations included the higher number of patients that were admitted in the ED,  number of hospital and ICU admissions, and longer ED boarding times during the post-intervention  period that made it difficult to determine the true impact of the ECC nurse on the in-hospital mortality.  The last questions to the audience are, what were some strengths and weaknesses from this study that you recognized?  And how has your organization adapted to the high volume of patients during the pandemic? And even as we see cases on the decline, we still see the high volume of patients coming  into the hospital setting. Thank you for listening to the presentation, and here is the reference to the article.

Video Summary

In this video, Jose Chavez, a Clinical Nurse Specialist, presents on the Innovations in Nursing Research for 2021. The article chosen for presentation is about the impact of emergency critical care nurses on in-hospital mortality in critically ill patients who are boarding in the Emergency Department (ED). The study found that establishing a program of specialized emergency care nurses in the ED could improve mortality rates in ICU patients. However, there was no significant change in mortality in patients with prolonged boarding times. The study suggests that a dedicated ICU nurse in the ED can help downgrade patients who no longer require an ICU bed, thus freeing up resources for the sickest patients.

Asset Subtitle

Administration, Professional Development and Education, Research, 2022

Asset Caption

This session will highlight the latest research, lessons learned, and changes taking place in critical care nursing practice, research, and/or education during the past year. Below are links to articles and additional information that will be discussed in Year in Review: Nursing. Innovations in Nursing Research Nesbitt J, Mitarai T, Chan GK, et al. Effect of emergency critical care nurses and emergency department boarding tome on in-hospital mortality in critically ill patients. Am J Emerg Med 2021;41:120-124. Doi:10.1016/j.ajem.2020.12.067. Effect of emergency critical care nurses and emergency department boarding time on in-hospital mortality in critically ill patients - ScienceDirect or via Pub Med Impact of COVID-19 on Patients and Nursing Passoni R, Lordani TVA, Peres LAB, Carvalho ARDS. Ocurrencia de lesión renal aguda en pacientes adultos hospitalizados con COVID-19: revisión sistemática y metanálisis [Occurrence of acute kidney injury in adult patients hospitalized with COVID-19: A systematic review and meta-analysis]. Nefrologia (Engl Ed). 2021 Sep 20. doi: 10.1016/j.nefro.2021.09.002. Epub ahead of print. PMID: 34566228; PMCID: PMC8450067. Occurrence of acute kidney injury in adult patients hospitalized with COVID-19: A systematic review and meta-analysis - ScienceDirect The National Institutes of Health (NIH) COVID-19 treatment guidelines: https://www.covid19treatmentguidelines.nih.gov/critical-care/acute-kidney-injury/ Titratable Medications and The Joint Commission (TJC) Update Davidson JE, Doran N, Petty, A, et al. Survey of nurses' experiences applying The Joint Commission's medication management titration standards. Am J Crit Care 2021;30(5):365-374. https://doi.org/10.4037/ajcc2021716 https://aacnjournals.org/ajcconline/article/30/5/365/31549/Survey-of-Nurses-Experiences-Applying-The-Joint Davidson J, Chechel L, Chavez J, et al. Thematic analysis of nurses' experiences with The Joint Commission's medication management titration standards. Am J Crit Care 2021;30(5):375-384. https://doi.org/10.4037/ajcc2021280 https://aacnjournals.org/ajcconline/article/30/5/375/31550/Thematic-Analysis-of-Nurses-Experiences-With-The Firth S 'Forced to Lie': Med titration standards put critical care nurses on shaky ground. MedPage Today September 2, 2021https://www.medpagetoday.com/washington-watch/washington-watch/94342 McLean B, Chechel L. Nurses need to take the lead on medication titration. Am Nurse September 8, 2021https://www.myamericannurse.com/nurses-need-to-take-the-lead-on-medication-titration/ Rincon T. Where's the evidence guiding updated titration standards? MedPage Today September 27, 2021 Where's the Evidence Guiding Updated Titration Standards? | MedPage Today

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Professional Development and Education

Knowledge Area Research

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Nursing

Tag Innovation

Tag Outcomes Research

Year 2022

Keywords

emergency critical care nurses

mortality rates in ICU patients

prolonged boarding times

dedicated ICU nurse

freeing up resources

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