Implementing evidence-based practice in areas that consume significant resources may help control... more Implementing evidence-based practice in areas that consume significant resources may help control costs while maintaining care quality.
Background Critical care nurses titrate continuous infusions of medications to achieve clinical e... more Background Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses’ autonomous decision-making. Objectives To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions. Methods A survey of nurses’ experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses. Results The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulti...
AACN Clinical Issues: Advanced Practice in Acute and Critical Care, 2003
The use of capnography has expanded over recent years. Currently, capnography is used in a variet... more The use of capnography has expanded over recent years. Currently, capnography is used in a variety of acute care settings. This article describes what capnography is and how it is used. The normal and abnormal capnogram or waveforms are described to assist in identifying various clinical situations. The multiplicity of clinical indications include detection of pulmonary embolism as well as malpositioned endotracheal/tracheal, gastric, and small bowel tubes. Capnography also provides clinicians with information regarding expiratory breathing patterns and assists in perfusion assessments such as those for cardiopulmonary resuscitation. Finally, case studies are provided to help the reader apply the concepts of capnography to a variety of acute care settings.
Objectives: To provide a series of recommendations based on the best available evidence to guide ... more Objectives: To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis. Design: Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus. Methods: We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding. Results: Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central linerelated, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points. Conclusion: Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NH... more This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Weaning patients from mechanical ventilation by nurses and respiratory therapists using protocol guidelines or by traditional physician-directed procedure. Type of intervention Rehabilitation. Economic study type Cost-effectiveness analysis. Study population The study population was patients receiving mechanical ventilation. All patients aged over 18 years who were in the ICUs and who were receiving mechanical ventilation were eligible to be included in the study sample. The exclusion criteria were as follows: (a) head or facial burns or trauma, (b)transfer from other hospitals with prior mechanical ventilation and (c) a need for mechanical ventilation to allow organ retrieval following brain death. Setting The setting was a teaching hospital ICU. The economic study was carried out in Washington, USA.
To determine whether the use of continuous IV sedation is associated with prolongation of the dur... more To determine whether the use of continuous IV sedation is associated with prolongation of the duration of mechanical ventilation. Design: Prospective observational cohort study. Setting: The medical ICU of Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. Patients: Two hundred forty-two consecutive ICU patients requiring mechanical ventilation. Interventions: Patient surveillance and data collection. Measurements and results: The primary outcome measure was the duration of mechanical ventilation. Secondary outcome measures included ICU and hospital lengths of stay, hospital mortality, and acquired organ system derangements. A total of 93 (38.4%) mechanically ventilated patients received continuous IV sedation while 149 (61.6%) patients received either bolus administration of IV sedation (n)46؍ or no IV sedation (n)58؍ following intubation. The duration of mechanical ventilation was significantly longer for patients receiving continuous IV sedation compared with patients not receiving continuous IV sedation (185؎190 h vs 55.6؎75.6 h; p<0.001). Similarly, the lengths of intensive care (13.5؎33.7 days vs 4.8؎4.1 days; p<0.001) and hospitalization (21.0؎25.1 days vs 12.8؎14.1 days; p<0.001) were statistically longer among patients receiving continuous IV sedation. Multiple linear regression analysis, adjusting for age, gender, severity of illness, mortality, indication for mechanical ventilation, use of chemical paralysis, presence of a tracheostomy, and the number of acquired organ system derangements, found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous IV sedation compared with patients who did not receive continuous IV sedation (148 h [95% confidence interval: 121, 175 h] vs 78.7 h [95% confidence interval: 68.9, 88.6 h]; p<0.001). Conclusion: We conclude from these preliminary observational data that the use of continuous IV sedation may be associated with the prolongation of mechanical ventilation. This study suggests that strategies targeted at reducing the use of continuous IV sedation could shorten the duration of mechanical ventilation for some patients. Prospective randomized clinical trials, using well-designed sedation guidelines and protocols, are required to determine whether patientspecific outcomes (eg, duration of mechanical ventilation, patient comfort) can be improved compared with conventional sedation practices.
Critical care practices have evolved to rely more on physical assessments for monitoring cardiac ... more Critical care practices have evolved to rely more on physical assessments for monitoring cardiac output and evaluating fluid volume status because these assessments are less invasive and more convenient to use than is a pulmonary artery catheter. Despite this trend, level of consciousness, central venous pressure, urine output, heart rate, and blood pressure remain assessments that are slow to be changed, potentially misleading, and often manifested as late indications of decreased cardiac output. The hemodynamic optimization strategy called stroke volume optimization might provide a proactive guide for clinicians to optimize a patient's status before late indications of a worsening condition occur. The evidence supporting use of the stroke volume optimization algorithm to treat hypovolemia is increasing. Many of the cardiac output monitor technologies today measure stroke volume, as well as the parameters that comprise stroke volume: preload, afterload, and contractility.
Implementing evidence-based practice in areas that consume significant resources may help control... more Implementing evidence-based practice in areas that consume significant resources may help control costs while maintaining care quality.
Background Critical care nurses titrate continuous infusions of medications to achieve clinical e... more Background Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses’ autonomous decision-making. Objectives To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions. Methods A survey of nurses’ experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses. Results The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulti...
AACN Clinical Issues: Advanced Practice in Acute and Critical Care, 2003
The use of capnography has expanded over recent years. Currently, capnography is used in a variet... more The use of capnography has expanded over recent years. Currently, capnography is used in a variety of acute care settings. This article describes what capnography is and how it is used. The normal and abnormal capnogram or waveforms are described to assist in identifying various clinical situations. The multiplicity of clinical indications include detection of pulmonary embolism as well as malpositioned endotracheal/tracheal, gastric, and small bowel tubes. Capnography also provides clinicians with information regarding expiratory breathing patterns and assists in perfusion assessments such as those for cardiopulmonary resuscitation. Finally, case studies are provided to help the reader apply the concepts of capnography to a variety of acute care settings.
Objectives: To provide a series of recommendations based on the best available evidence to guide ... more Objectives: To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis. Design: Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus. Methods: We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding. Results: Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central linerelated, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points. Conclusion: Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NH... more This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Weaning patients from mechanical ventilation by nurses and respiratory therapists using protocol guidelines or by traditional physician-directed procedure. Type of intervention Rehabilitation. Economic study type Cost-effectiveness analysis. Study population The study population was patients receiving mechanical ventilation. All patients aged over 18 years who were in the ICUs and who were receiving mechanical ventilation were eligible to be included in the study sample. The exclusion criteria were as follows: (a) head or facial burns or trauma, (b)transfer from other hospitals with prior mechanical ventilation and (c) a need for mechanical ventilation to allow organ retrieval following brain death. Setting The setting was a teaching hospital ICU. The economic study was carried out in Washington, USA.
To determine whether the use of continuous IV sedation is associated with prolongation of the dur... more To determine whether the use of continuous IV sedation is associated with prolongation of the duration of mechanical ventilation. Design: Prospective observational cohort study. Setting: The medical ICU of Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. Patients: Two hundred forty-two consecutive ICU patients requiring mechanical ventilation. Interventions: Patient surveillance and data collection. Measurements and results: The primary outcome measure was the duration of mechanical ventilation. Secondary outcome measures included ICU and hospital lengths of stay, hospital mortality, and acquired organ system derangements. A total of 93 (38.4%) mechanically ventilated patients received continuous IV sedation while 149 (61.6%) patients received either bolus administration of IV sedation (n)46؍ or no IV sedation (n)58؍ following intubation. The duration of mechanical ventilation was significantly longer for patients receiving continuous IV sedation compared with patients not receiving continuous IV sedation (185؎190 h vs 55.6؎75.6 h; p<0.001). Similarly, the lengths of intensive care (13.5؎33.7 days vs 4.8؎4.1 days; p<0.001) and hospitalization (21.0؎25.1 days vs 12.8؎14.1 days; p<0.001) were statistically longer among patients receiving continuous IV sedation. Multiple linear regression analysis, adjusting for age, gender, severity of illness, mortality, indication for mechanical ventilation, use of chemical paralysis, presence of a tracheostomy, and the number of acquired organ system derangements, found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous IV sedation compared with patients who did not receive continuous IV sedation (148 h [95% confidence interval: 121, 175 h] vs 78.7 h [95% confidence interval: 68.9, 88.6 h]; p<0.001). Conclusion: We conclude from these preliminary observational data that the use of continuous IV sedation may be associated with the prolongation of mechanical ventilation. This study suggests that strategies targeted at reducing the use of continuous IV sedation could shorten the duration of mechanical ventilation for some patients. Prospective randomized clinical trials, using well-designed sedation guidelines and protocols, are required to determine whether patientspecific outcomes (eg, duration of mechanical ventilation, patient comfort) can be improved compared with conventional sedation practices.
Critical care practices have evolved to rely more on physical assessments for monitoring cardiac ... more Critical care practices have evolved to rely more on physical assessments for monitoring cardiac output and evaluating fluid volume status because these assessments are less invasive and more convenient to use than is a pulmonary artery catheter. Despite this trend, level of consciousness, central venous pressure, urine output, heart rate, and blood pressure remain assessments that are slow to be changed, potentially misleading, and often manifested as late indications of decreased cardiac output. The hemodynamic optimization strategy called stroke volume optimization might provide a proactive guide for clinicians to optimize a patient's status before late indications of a worsening condition occur. The evidence supporting use of the stroke volume optimization algorithm to treat hypovolemia is increasing. Many of the cardiac output monitor technologies today measure stroke volume, as well as the parameters that comprise stroke volume: preload, afterload, and contractility.
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Papers by Tom Ahrens