SCCM Resource Library-Year in Review: Nursing

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 housewell 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 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 has 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 worsening  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.  Another limitation including 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.  This is Julie Graham, and I'm going to be reviewing an article that pertains to the impact of COVID-19 in patients in nursing, specifically as it relates to acute kidney  injury in patients hospitalized with COVID-19. This is from an in-press article that is available online prior to publication through PubMed for free.  Hello, I'm Julie Graham, and I'm going to be presenting a systematic review and metal analysis conducted by a nurse-led team, Passone et al., which is available for free on PubMed  prior to publication. It's currently in press, according to at least the time of this recording.  This meta-analysis is, in English, translated to occurrence of acute kidney injury in adult patients hospitalized with COVID-19, a systematic review and meta-analysis.  All right, a little background here. Many of you who are clinically active may have noticed a relationship between kidney  injury, acute kidney injury observed in patients hospitalized with COVID-19-related respiratory failure, and an associated increased risk of mortality.  The relationship between acute kidney injury and respiratory failure in COVID-19-positive patients is yet to be fully understood.  There are certain observations that we know and can infer, but really the full scope remains unknown at this point.  And the impact to nursing is significant, as the National Institute of Health recommends that continuous renal replacement therapy, or CRRT, over intermittent hemodialysis in  patients with AKI who are COVID-19-positive. And that is for the purpose of reducing exposure and frequency for nursing at the bedside.  So you can see here on the right the author's flow map of their process for retrieval of articles following the PRISMA guidelines.  That's the preferred reporting items for systematic reviews and meta-analyses, which is a best  practice guideline for a selection of literature for systematic review and meta-analysis. Studies that were included were studies published up to June 2020.  So early studies from five databases in English, Portuguese, and Spanish. Again, this was a RN-led team.  Acute kidney injury was identified using the Kidney Disease Improving Global Outcomes, the KDIGO best practice scoring criteria. And this was hospitalized patients with COVID-19.  The primary outcomes included incidence, secondary outcome was mortality, and this also included an estimation of renal replacement therapy risk.  Thirty studies included in review following our mentioned guidelines, of which 28 were then included in the meta-analysis.  Okay, looking at some of our findings, data were assessed for a total of 18,043 cases.  The acute kidney injury estimate incidence overall and in the ICU was 9.2 and 32.6, respectively.  AKI estimate incidence in the elderly patients with acute respiratory distress syndrome was significantly higher at 22.9%.  Patients with secondary infection, AKI estimates increased to 31.6%. The estimate incidence of patients that required renal replacement therapy was 3.2%, and estimate  AKI mortality was 50.4%, respectively. Now you can see, looking at the ranges, there's quite a lot of variability in terms of these rates.  So understandably, there was a considerable amount of limitations to this review. These were all very early studies.  There was a high degree of heterogeneity amongst the studies, and also a high degree of variability in outcomes.  The independent bias analysis was done by two authors using validated instruments. Risk of bias as AKI and AKI risk was not part of the initial study's design.  There's a risk of publication bias. A lot of those early studies included case reviews and observational studies among the earliest publications.  Rigor of analysis is demonstrated in the PRISMA flow diagram, and studies did not address identification of mitigation of some of these confounding factors.  So discussion of findings. Cytokine storm comes up as a theme with consequent endothelial damage, mitochondrial dysfunction, oxidative stress, hypovolemia, and hypercoagulability.  So we can infer the risk of organ damage in the context of cytokine storm. There's also direct viral damage to the ACE2 receptors, as this is the receptor by which  the coronavirus attaches itself. So disrupting the ACE2 receptor prevents our body's own restorative systems in terms of healing damaged cells and infected cells.  Proteinuria and hematuria were often the initial presenting signs in acute kidney injury and  in older age and in secondary infection, as we had seen was associated with a considerable increased risk of AKI.  Acute myocardial injury is evidenced by elevated serum troponin demonstrated in association with worse outcomes, including AKI and ARDS. And among ICU admissions, 26.7 needed CRRT.  Mortality for patients with CRRT in the context of having a COVID positive diagnosis has been reported at 100%. So a couple of questions.  Given what we gleaned from the findings in the discussion, how can these findings be applied in the clinical setting?  And in particular, in terms of decision making, when we see the risk of mortality associated  with patients requiring CRRT in the context of having also a COVID positive presentation?  And then how could further research make these findings more meaningful, perhaps with consideration to some of the limitations of the study?  So implications specifically for nursing, extracorporeal therapies are recommended for cytokine removal and organ support.  However, these therapies are resource intensive in terms of equipment, in terms of skilled staff to manage the equipment and monitor and support patients.  Per the National Institutes of Health COVID treatment guidelines, CRRT is recommended as we discussed over HD to prevent exposure to dialysis teams.  And more robust research studies are needed to further understand this phenomenon and signs of early identification to prevent that deterioration. Okay, so one last question.  Care during the pandemic has predominantly been deferred to nursing care, while other caregivers can often remain outside of the negative pressure rooms to prevent exposure.  So this presents somewhat of a moral dilemma. Does it add, and I've framed the question this way, does it add insult to injury that  nurses on top of overwhelming surges that have led to PTSD have become metaphorically lambs to the slaughter?  So in closing, I wanted to share with you some anecdotes from my personal experience at our hospital in Southern California.  We're a border facility and that led to us being very significantly impacted by COVID-19. We lost many patients, we learned many lessons.  These pictures are from a year ago at the one year anniversary of the virus. And at that time, we came together to mourn the loss of almost 400 patients at that time,  including three of our own staff members. And I can say after being secluded for a year and seeing so much loss, I really was able  to understand how healing it is to come together and grieve the loss of these individuals. And references are listed here.  And to wrap up, thank you so much for allowing me to share this story and be part of the Society of Clinical Care Medicine Nursing Year in Review. Thank you very much.  Hello, my name is Teresa Renkon. And as part of this year's Nursing Year in Review, I'm going to talk about several studies  related to titratable medications and the Joint Commission standards. The two studies we'll focus on are Survey of Nurses' Experiences Applying the Joint  Commission Medication Management Titration Standards and Thematic Analysis of Nurses' Experiences with the Joint Commission's Medication Management Titration Standards.  Both of these manuscripts were published in September of 2021. These two manuscripts published on September 1st, 2021 in the American Journal of Critical  Care were actually born out of grassroots efforts. In fact, a post that was published in March of 2019 on SCCM's Nursing Section Connect  led to multiple posts and dialogue about how difficult it was to try to develop and adhere to orders and guidelines that met the Joint Commission titratable medication standards.  By April of 2019, Dr. Judy Davidson and I began writing a strategic proposal to submit to the Society.  A 35-member strong titratable medication task force was composed of volunteers from around the country who were experts in their fields.  They worked in academic and community-based health systems and even teaching institutes. The titratable medication task force consisted of staff nurses, advanced practice nurses,  nurse managers and directors, pharmacists, professors, researchers, and anesthesiologists. This table found in one of the manuscripts we're talking about today shows that before  2017, the Joint Commission had very little required order elements that were related to titration-specific standards.  We can see after January of 2017 how many additional elements were added, and we do know that in 2021, there were some changes that we'll talk about later in this presentation  that provided some relief. For our quantitative study design, we used a predictive cross-sectional design which  replicated a similar process used by the Institute of Safe Medication Practices that informed changes to the CMS 30-minute rule.  Some of you might recall that rule and how difficult it was to operationalize and comply with it.  We designed and validated the medication titration survey instrument, and we used a passive recruitment method by sending out a link to the survey.  The survey was available to respondents between January and September of 2020. So the changes in 2021 by the Joint Commission are not reflected in the results of these studies.  Comments were collected as part of the survey. These are the research questions that we sought to answer as part of this research.  What are the current practices of critical care nurses when titrating infusions? What is clinical judgment that cannot be provided in a predetermined order set necessary in  order to meet a patient's needs? What are critical care nurses' values and preferences regarding the boundaries of the nursing scope of practice in relation to infusion titration?  Which variables are predictors of nurses' perceptions of preferred boundaries to scope of practice related to titration of infusions?  Which variables are predictors of the intensity of moral distress among nurses when practicing according to the new titration standards?  Analysis of data included descriptive statistics to analyze demographic variables, standard ordinary least squares regression models to answer research questions.  We excluded respondents with missing data for any predictor or outcome variable. Nurses were asked to choose from any of seven possible activities associated with titrating  medications. Scoring was assigned at zero, none of these, to seven, all of these. And we fit two primary regression models.  We used an inductive thematic analysis process for analyzing the comments. We had 159 comments. As you can see on the right in the yellow box, our methods are outlined in detail for  you to review. Hopefully, you've had a chance to review the manuscript and we can take questions related to this later in the presentation.  Now to the results, 781 of 941 participant responses were included in our studies.  Approximately 80% of respondents perceived that titration standards contributed to delays in care. 93% experienced moral distress resulting from adherence to the standards.  On the moral distress scale that ranges from zero to 10, there was a mean score of 4.97 and a standard deviation of 2.67.  All details and information are located in the quantitative manuscript for your review. From the thematic analysis of nurse experiences, we were able to identify two major themes,  harm and professionalism. Within those themes, we identified categories, erosion of workplace wellness, moral dilemma, patient safety, autonomy, and nurse proficiency.  Within each of those categories, we also identified specific codes. We hope you've had a chance to review this information prior to this presentation and  we hope that we'll have some good dialogue about it in the open question and answer. In conclusion, what we found were that critical care nurses perceive the joint commission  medication titration standards to adversely impact patient care and contribute to moral distress.  Although we've seen updates from 2021, we're concerned that those updates to the standards may not address the delays in care and the inability to comply with orders that we found  in these two manuscripts and studies. The standards from the joint commission imposed harm by eroding workplace wellness and introducing moral dilemmas and patient safety concerns.  Professionalism is threatened through limits on scope of autonomy and we need to talk about that and address it.  Further advocacy is necessary in order to resolve unanticipated consequences related to these titration standards.  In addition, we believe that there are some key take home messages. First of all, we have not been able to find any evidence to support the shift from what  was previously nurse managed practice patterns, nurses using clinical judgment to titrate therapeutic interventions, to a new practice pattern requiring nurses to follow detailed  orders. We believe that nurses are equipped with the situational awareness and pattern recognition  to evaluate, analyze, and interpret patients' individual adaptive responses to targeted therapeutic interventions and that those interventions are happening on a moment by  moment basis. This form of nurse knowing is hidden. It has not been clearly articulated or studied.  It is something that is passed down from generation to generation and even shift to shift and it is part of the cognitive stacking of the expert nurse.  The January 1, 2021 Joint Commission changes brought some relief. They allowed for block charting.  They permitted nurses to select which medication to start first and provided some clarification regarding range orders. Implications and impact of these studies.  First of all, the comments from the nurses provided additional context around the results of the quantitative study.  It helped us understand the why and the rationale behind the nurses' choices on the survey instrument.  Nurses expressed a lack of autonomy, limits on nurses' scope of practice, and issues of harm including workplace wellness, moral dilemmas, and even patient safety concerns.  As nurse leaders, we need to advocate for further changes in accreditation standards related to titration of continuous medication infusions. We don't believe we're done yet.  Future research is needed to test strategies to optimize nurse autonomy while maintaining patient safety.  Three opinion pieces came out after the publication of the manuscripts we've discussed today. They are listed here on this slide and the blue font that is underlined are hyperlinks  to the actual opinion pieces if you would like to review those further. Some of what is spoken about in those opinion pieces are about what we can do. What can hospitals do better?  Well, they could allow use of range orders if they're not doing it already. They could create a culture of nurse involvement, use a collaborative root cause analysis process  to find and fix system issues, and they can speak up and stand up to regulatory agencies when standards just don't make sense.  What can regulatory and accreditation agencies do better? Well, they could start by collaborating with professional nursing organizations before making changes to the standards.  We appreciate that the Joint Commission has spent time collaborating now with the American Association of Critical Care Nurses, but it would help if they would do that prior  to making these changes. They can make standards that are clear and simple to understand.  They could pilot test them before implementation, and we ask that they don't make changes without evidence and a clear understanding of the unique contributions of each role.  As nurses, there are things that we could do better. We could manage our own knowledge, our nursing knowledge.  We could find better ways to support novice and proficient nurses' decision-making and conduct more research around these things.  We can use case studies to illustrate the problems and challenges with implementing  guidelines or orders specifically around Joint Commission standards, but also around other things.  We can work within health systems and units, professional organizations, unions, and shared  governance groups to address issues, participate in polls, letter writing, and research regarding  this topic, submit a patient safety concern to the Joint Commission on their website. We've listed some questions for the audience that we hope we can go back to during the  open Q&A period. These questions are around knowledge about block charting, around the fact that nurses  can select which medication to start first, and that the Joint Commission permits range orders. We want to hear from you. Have you implemented these in your institutions?  And if so, how have they worked? Do you believe that these changes by the Joint Commission are meaningful? Why or why not?  And let's always remember, nurses must act now to protect nursing scope of practice and our patient safety.  Thank you for your time, and we look forward to having dialogue with you about the content of our nursing year in review.

Video Summary

In this presentation for the Critical Care Congress, Jose Chavez, a Clinical Nurse Specialist at Cedars-Sinai Medical Center, presented the Innovations in Nursing Research for the year 2021. The Nursing Research Committee searched for articles published between 2020 and 2021 that had nurses as first or primary authors and focused on critical care. They reviewed 55 articles related to the impact of COVID-19 on patients and nursing, innovations in nursing research, and the titration of IV medications.<br /><br />One article they focused on was titled "The Effect of Emergency Critical Care Nurses and Emergency Department (ED) Boarding Time on In-Hospital Mortality in Critically Ill Patients." The authors of the study hypothesized that having specialized emergency care nurses in the ED would improve the mortality of ICU patients. The study found that while there was no significant change in mortality for prolonged boarding time, there was less mortality in the non-prolonged boarding group with the intervention of an emergency critical care nurse.<br /><br />Another article discussed the occurrence of acute kidney injury in adult patients hospitalized with COVID-19. A systematic review and meta-analysis were conducted to analyze the incidence and mortality rates associated with acute kidney injury in these patients. The study found that the incidence of acute kidney injury was 9.2% overall and 32.6% in the ICU. The mortality rate for patients with acute kidney injury was 50.4%.<br /><br />The presentation also discussed the Joint Commission's medication management titration standards and two studies conducted on nurses' experiences with these standards. The studies found that nurses perceived the standards to adversely impact patient care and contribute to moral distress. The studies called for further changes in accreditation standards related to titration of continuous medication infusions and advocated for strategies to optimize nurse autonomy while maintaining patient safety.<br /><br />Overall, the presentation highlighted the importance of nursing research and its impact on patient outcomes and nursing practice.

Asset Subtitle

Professional Development and Education, Administration, Quality and Patient Safety, 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.

Learning Objectives:
-Critique and synthesize information from selected evidence on critical care nursing practice
-Identify relevant topics in critical care nursing from the past year
-Cite evidence learned during the session applicable to nursing practice, research, and/or education

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Area Administration

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Professional Development

Tag Nursing

Tag Evidence Based Medicine

Year 2022

Keywords

Critical Care Congress

Nursing Research

COVID-19 impact

Emergency critical care nurses

In-hospital mortality

Acute kidney injury

Medication management

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