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This issue of Nursing in Critical Care focuses broadly around improving safety and quality in intensive care. Efforts to improve quality and safety in critical care units have featured heavily in the last two decades.1 A key report from the King's Fund (2017) argues that with the National Health Service (NHS) under significant pressure to maintain care standards, leaders must focus on improving the quality and safety of care.2 This is even more of a priority in the ongoing COVID-19 era. However, many quality improvement (QI) initiatives are let down by a less than robust methodology, a poor description of the intervention, and inadequate measurement of outcomes.3, 4 Our guest editorial for this issue is from Nicky Credland and Karin Gerber, respectively, the Chair and the Conference Director of the British Association of Critical Care Nurses (BACCN). They discuss the issue of humanizing critical care5 and claim that this is an instrumental role that the critical care nurse plays, in addition to all the technical aspects of the role. They argue that this is what truly defines the intensive care unit (ICU) nurse. The first paper is a BACCN produced consensus-based position paper describing best practice in oral care in critically ill adults.6 Utilizing a nominal group technique, an expert nurse panel met and reviewed the evidence around this topic. They examined five practices around oral care and graded the evidence using GRADE system.7 This important and useful paper presents the recommendations made and discusses the rationale for each of these. Providing effective oral care is essential in reducing morbidity and improving quality, and as such this paper is highly recommended reading for every clinical adult ICU nurse. The first step in improving quality involves defining and agreeing on quality indicators and standards. The next paper in this issue has attempted to do this within a Cypriot adult ICU health context.8 Evangelou and colleagues aimed to develop a set of potential quality indicators to quantify nursing care provided to adult critically ill patients and did this via a three-phase (survey followed by two focus groups with voting) consensus study involving two distinct expert panels. The first phase involved experts from 13 European countries, but the second part was focused on Cypriot experts only. At the end, 15 potential QI indicators were identified. These, as they claim, now need to be prospectively studied to determine the extent to which they can accurately measure ICU nursing care quality. The next paper in this issue examines the quality and safety of intrahospital transport of critically ill patients.9 Sharafi et al, in a cross-sectional survey of 160 nurses, studied the incidence of adverse events during intrahospital transport of critically ill adults in Iran and sought suggestions to improve the safety of transport. They used a 53-item, previously validated questionnaire to assess nurses' experience of adverse events during the three phases of intrahospital transport related to equipment, patient physiology, monitoring, medications, and fluid management. They found that oxygen desaturation, haemodynamic instability, and agitation were the most frequent adverse events in all transport phases. Nurses' suggestions for improving the safety of the transport were related to paying attention to the patient's clinical condition and checking connections before, during, and after the transfer. Most of these issues can be addressed by good education and training and the use of checklists, which are important for them to consider in their context as they are well used internationally. Nevertheless, they have begun the safety and QI journey by taking the initial steps to examine in detail these adverse events and take steps to address them. Continuing with the theme of QI, the next paper examines the factors influencing the use of alternatives to physical restraints in ICUs through a survey of critical care nurses in three hospitals in Turkey.10 This survey was undertaken to examine the reasons for the comparatively high incidence of restraint use in Turkey11 and to inform the development of guidelines to support a reduction in use. The study used a previously validated survey tool and had a high response rate of 80%. The authors identified insufficient knowledge and the use of alternatives to physical restraints in their sample. They also identified several factors that influenced the use of alternatives to physical restraint, including delirium, nursing workload, and lack of training. The authors conclude that training and clear guidelines are required to support a reduction in the use of physical restraints in Turkish ICUs. The next paper in this issue presents a systematic review of case reports and case series of the uncommon but potentially fatal misplacement of central venous catheters in paraspinal veins.12 The aim of this review was to describe the clinical characteristics of this complication. This knowledge is essential for nurses caring for patients who have central venous catheters placed in lower extremities, especially in paediatrics where this occurs most commonly. The review included 30 articles reporting cases in 36 patients, 28 of whom were infants. These case studies describing the presentation of this complication are used to illustrate the warning signs, which may indicate paraspinal vein misplacement. The authors conclude that nurses should be vigilant for this complication in patients with lower limb central venous catheters. They also suggest using lateral abdominal X-rays to confirm the placement of the catheter tip. In the following paper in this issue, the authors report the results of a survey to examine the occurrence of sharp injuries in two hospitals in Egypt, and the impact of this on stress among nursing staff working in acute care settings.13 Data were collected using two validated tools for assessing the impact of an event and associated post-traumatic stress disorder (PTSD). The survey identified 13.3% of surveyed nurses as having experienced a sharps injury in the previous 12 months. Varying degrees of stress were identified in those who had experienced a sharps injury, when compared with nurses who had not. The authors conclude that in order to reduce the incidence in Egypt, further research is required into the factors that contribute to sharps injuries. However, of course, many other potential confounding factors can affect these measures of stress and PTSD in ICU nurses, and it is difficult to conclude that this is down to sharps injuries alone. The authors also advocate for dedicated support for nurses dealing with the potential stress of experiencing a sharps injury; however, the priority should really be on preventing these injuries in the first place. Mechanical ventilation and the use of neuromuscular blocking agents are two of the main causative factors to exposure keratopathy (damage to the cornea due to failure of the eyelids to close fully) in critically ill patients.14 This can lead to serious complications; therefore, early treatment to promote healing is essential. In the next paper, Kocaçal and colleagues reported on a randomized controlled trial comparing carbomer eye drops (viscotears) alone and in combination with polyethylene covers for treating exposure to keratopathy in two intensive care units in a hospital in Turkey.15 Carbomer eye drops are commonly used to maintain corneal health, but the authors hypothesized that the addition of polyethylene covers would promote quicker healing in the presence of exposure keratopathy. This study randomized 43 patients and the primary outcome was a decrease in or absence of corneal damage, assessed by an ophthalmologist using fluorescein dye. The authors found that using a combination of carbomer eye drops and polyethylene covers was more effective at promoting corneal healing by day 2 than carbomer eye drops alone. The authors conclude that polyethylene covers may be an effective tool in promoting eye health; however, further research is warranted in a larger sample. The final paper in this issue relates to a robustly undertaken QI initiative to improve the experience of mealtimes for children and their families, in a paediatric intensive care unit (PICU) in France.16 Valla et al undertook a prospective, before-and-after intervention study as part of a wider PICU quality-of-care improvement programme over 3 years (2013–2016). Including children who were able to eat orally, they sought to improve the mealtime experience for both the child and family and for the staff. Detailed satisfaction questionnaires were competed by both parents (and children if able) and staff before and after the initiative. The QI initiative involved the staff (predominantly nurses and nurse assistants) undertaking an intensive 2-day training programme in addition to the unit purchasing new and more appropriate equipment to facilitate a better mealtime experience and involving the parents more actively in the child's mealtimes. After the intervention, there was a marked improvement in the perceived quality of meal service rating by both staff and families (P = <.01) in parental involvement, in the children's, families', and healthcare professionals satisfaction; in meal-dedicated equipment; and in the perception that oral nutrition was an important aspect of PICU care. This study shows that seemingly small QI initiatives can impact positively on the patients and staff's satisfaction with care. In the first critical commentary for this issue, Poiroux and colleagues described the impact of the COVID-19 pandemic from the perspective of French critical care nurses, and the impact this has had on the recognition of critical care nursing as a speciality.17 In response to the pandemic in France, ICU beds increased from 5000 to 10 200 between March and April 2020. Like many countries, this increase was staffed by redeploying nurses into critical care from operating theatres and wards. To ensure patient safety, trained critical care nurses, including those redeployed from paediatric ICUs, took the role of educating this redeployed nursing workforce and supervising care. Unlike other European countries, such as the United Kingdom,18 France does not recognize critical care nursing as a speciality and there is currently no recognized postgraduate training requirement for ICU nurses, despite this being recommended by the World Federation of Critical Care Nurses in 2005.19 Given the great skill and professionalism demonstrated by French critical care nurses during the pandemic, the authors have negotiated for the recognition of the specialism of critical care nursing in France, which is now accepted, and work is ongoing to develop a nationally recognized education programme to support this. The last critical commentary in this issue reports on one region of Italy's preparedness for and experience with the COVID-19 pandemic.20 The focus was on the huge increase in demand and increased workload pushed onto existing already overstretched trained critical care nurses. The authors found that the nursing workload, when measured with the Nursing Activities Score (NAS), increased by 33% for the COVID-19 adults, compared to usual adult ICU nursing workload. They argue that despite increasing evidence of improved outcomes with better registered nurse (RN) staffing, even before the COVID-19 pandemic, inadequate nurse staffing and lack of specialized education remained an unrecognized and unaddressed problem in Italy. This is likely to be the case in many countries worldwide. Only time will tell if the pandemic has highlighted the importance of this issue of ensuring adequate numbers of critical care trained RNs in critical care units, sufficiently that actions are taken, rather than simply more rhetoric. QI initiatives offer the opportunity to be involved in leading change that results in better patient care.21 This issue focussed on QI and safety highlights the important role that nurses play in improving the care of critically ill patients. The studies included in this issue used a variety of methods including expert consensus, literature review, surveys, before-and-after studies, and randomized controlled trials to advance patient care in ICU. Topics included are diverse and range from oral and eye care to recognizing the signs of uncommon complications of lower limb venous catheterization, improving safety during transfer of the critically ill patient, and improving mealtimes in paediatric ICUs. The two critical commentaries emphasize the importance of critical care nursing as a recognized speciality, requiring formal educational preparation. Furthermore, adequate RN staffing must be in place if we are to retain the skilled critical care nursing workforce internationally, provide safe quality care, and improve care for our patients.
Critical care nursing
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Pandemic
Coronavirus
2019-20 coronavirus outbreak
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Over the last several months one healthcare issue has been the focus of attention, globally, nationally, locally, and personally: COVID-19.Though it is too soon to comprehend all of the lessons lea...
2019-20 coronavirus outbreak
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