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Research reviews
Intensive and Critical Care Nursing (2013) 29, 117—118
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
Research reviews Tina Day James Clerk Maxwell Building, Waterloo Road, London SE1 8WA, United Kingdom
Pattison N, Eastham E. Critical care outreach referrals: a mixed-method investigative study of outcomes and experiences. Nursing in Critical Care 2012;17(2):71—80 Objective The introduction of critical care outreach, now over a decade ago, was heralded as a way of identifying and managing the deteriorating patient. However, there have been many models of outreach and the service itself has not been without problems. Many authors have reported difficulties in evaluating the effectiveness of the service and studies have been confounded by the complex nature of outreach and number of outcome measures. The aim of this study was to examine referrals to a critical care outreach team (CCOT), and the factors associated with patient management and survival. Qualitative data were also collected around referrals and areas for service improvement. Methods This single-centre mixed method study took place in a specialist cancer hospital over an eight month period. The design was Creswell and Plano Clark’s (2007) explanatory design: participant selection model, whereby quantitative data are further explored through qualitative work. Phase 1 were patients (n = 407) referred to CCOT. Phase 2 comprised of a sample of doctors (n = 2) and nurses (n = 7). Phase 1 data were collected prospectively although to avoid missing data there was some retrospective data collection.
E-mail addresses: [email protected], [email protected] 0964-3397/$ — see front matter http://dx.doi.org/10.1016/j.iccn.2012.09.002
Findings Thirty percent of referrals were by medical staff (104/407, 30.5%). For 23.8% of referrals there was a delay between the point of deterioration and referral time. The average delay was 2.96 hours (95%, CI 1.97—3.95, SD 9.56). Of those referred, 26.5% did not survive to discharge and those referred earlier had improved outcomes. Qualitative data analysis identified four themes: indications for referral, facilitating factors for referral, barriers to referral and consequences of referral. Reassurance was seen as a core theory and CCOT seen as an important back up in the support of patients at risk. Conclusion and recommendations The authors conclude that matching outreach referrals with patient care helped them to identify areas for improvement. These were timeliness of referral, education and revision of early warning criteria. Comment The study identified some areas of concern around referral delays of almost 3 hours. Such delays would have had an impact on patient outcome. Important issues have been highlighted and the team have plans to address these. This study is limited to a specialist cancer service and it would be useful to extend to other specialist or generalist areas.
118
Subramanian P, Allcock N, James V, Lathlean J. Challenges faced by nurses in managing pain in a critical care setting. Journal of Clinical Nursing 2011;21:1254—1262
T. Day
Chen JH, Chao YH, Lu SF, Shiung TF, Chao YF. The effectiveness of valerian acupressure on the sleep of ICU patients: a randomised clinical trial. International Journal of Nursing Studies 2012;49:913—920
Objectives Objectives It has long been documented in the literature that pain management is a global issue in healthcare (Brennan et al., 2007). Poorly managed pain is still widely reported across the NHS (Commission of Health Report 2007) and critical care is no exception. This study aimed to explore the challenges faced by nurses in managing pain in a critical care setting. Methods This was a qualitative study which took place by semi structured interviews using a critical incident technique. Twenty-one nurses from critical care settings of one acute UK health care Trust were invited to take part in the study. This was a qualitative prospective exploratory study, designed to understand the interpretative interactions of nurse’s perception of the challenges associated with pain management in this population group. A critical incident interview schedule was developed and used to guide the interviews. Data were analysed by framework analysis. Findings Framework analysis identified four main challenges in managing pain. These included lack of clinical guidelines, lack of a structured pain assessment tool, lack of autonomy in relation to decision making and other factors related to the patient’s condition such as the type of surgery or other interventions. Conclusion and recommendations The authors conclude that structured guidelines are needed to guide pain management in the critically ill. They suggest that as the quality of care given to patients is based on decisions made, it is essential that barriers to pain assessment and management are overcome. Recommendations are also made for further education on pain management in critical care.
Sleep deprivation is a common phenomenon in critical care. Factors such as noise, alarms from monitoring systems and lights can all affect the patient’s ability to sleep. This often leads to sleep deprivation and has a negative effect on recovery. Acupressure and valerian aromatherapy have been reported to be beneficial in promoting sleep. This study aimed to explore the effectiveness of valerian acupressure on sleep in intensive care (ICU) patients. Method The study was a randomised clinical trial which took place in a large intensive care unit in China. Forty-one participants were allocated to the experimental group and 44 to the control group. The treatment group received valerian pressure on three identified acupoints between the hours of 19.00 and 22.00 h. The control group received usual care. Outcome measures were observation and actigraphy measures between 22.00 and 06.00 h, and the Stanford Sleepiness Scale (SSS) the next morning. Heart rate recordings were also taken before and after therapy to evaluate relaxation response. Findings The results demonstrated that patients in the experimental group had more hours of sleep (3.4 hours versus 2.6 hours, p = 0.03) with fewer episodes of waking (14.2 m versus 54.6 m, p < 0.001) than those in the control group. SSS grades were also lower in the treatment group (2.3 versus 3.4 p < 0.001). In addition, the heart rate changes indicated an immediate relaxation response after therapy. Conclusion and recommendations The authors conclude that their study supports the hypothesis that valerian acupressure can improve the quality and duration of sleep for patients in ICU. However, the study is limited in that some errors in actigraph activity have been reported.
Comment
Comment
Managing pain in the critically ill is complex. It is also not easy to assess pain or to evaluate the effectiveness of interventions. This is a useful study, although the authors recognise that it may have limited generalizability to other settings. There is room for further research in this area.
This is a useful study and an intervention that could potentially be introduced, with training, within the critical care environment. However, in this study the inclusion criteria was for patients to be able to fully communicate, to be stable and not sedated, which is unusual for many ICU patients.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
Research reviews Tina Day James Clerk Maxwell Building, Waterloo Road, London SE1 8WA, United Kingdom
Pattison N, Eastham E. Critical care outreach referrals: a mixed-method investigative study of outcomes and experiences. Nursing in Critical Care 2012;17(2):71—80 Objective The introduction of critical care outreach, now over a decade ago, was heralded as a way of identifying and managing the deteriorating patient. However, there have been many models of outreach and the service itself has not been without problems. Many authors have reported difficulties in evaluating the effectiveness of the service and studies have been confounded by the complex nature of outreach and number of outcome measures. The aim of this study was to examine referrals to a critical care outreach team (CCOT), and the factors associated with patient management and survival. Qualitative data were also collected around referrals and areas for service improvement. Methods This single-centre mixed method study took place in a specialist cancer hospital over an eight month period. The design was Creswell and Plano Clark’s (2007) explanatory design: participant selection model, whereby quantitative data are further explored through qualitative work. Phase 1 were patients (n = 407) referred to CCOT. Phase 2 comprised of a sample of doctors (n = 2) and nurses (n = 7). Phase 1 data were collected prospectively although to avoid missing data there was some retrospective data collection.
E-mail addresses: [email protected], [email protected] 0964-3397/$ — see front matter http://dx.doi.org/10.1016/j.iccn.2012.09.002
Findings Thirty percent of referrals were by medical staff (104/407, 30.5%). For 23.8% of referrals there was a delay between the point of deterioration and referral time. The average delay was 2.96 hours (95%, CI 1.97—3.95, SD 9.56). Of those referred, 26.5% did not survive to discharge and those referred earlier had improved outcomes. Qualitative data analysis identified four themes: indications for referral, facilitating factors for referral, barriers to referral and consequences of referral. Reassurance was seen as a core theory and CCOT seen as an important back up in the support of patients at risk. Conclusion and recommendations The authors conclude that matching outreach referrals with patient care helped them to identify areas for improvement. These were timeliness of referral, education and revision of early warning criteria. Comment The study identified some areas of concern around referral delays of almost 3 hours. Such delays would have had an impact on patient outcome. Important issues have been highlighted and the team have plans to address these. This study is limited to a specialist cancer service and it would be useful to extend to other specialist or generalist areas.
118
Subramanian P, Allcock N, James V, Lathlean J. Challenges faced by nurses in managing pain in a critical care setting. Journal of Clinical Nursing 2011;21:1254—1262
T. Day
Chen JH, Chao YH, Lu SF, Shiung TF, Chao YF. The effectiveness of valerian acupressure on the sleep of ICU patients: a randomised clinical trial. International Journal of Nursing Studies 2012;49:913—920
Objectives Objectives It has long been documented in the literature that pain management is a global issue in healthcare (Brennan et al., 2007). Poorly managed pain is still widely reported across the NHS (Commission of Health Report 2007) and critical care is no exception. This study aimed to explore the challenges faced by nurses in managing pain in a critical care setting. Methods This was a qualitative study which took place by semi structured interviews using a critical incident technique. Twenty-one nurses from critical care settings of one acute UK health care Trust were invited to take part in the study. This was a qualitative prospective exploratory study, designed to understand the interpretative interactions of nurse’s perception of the challenges associated with pain management in this population group. A critical incident interview schedule was developed and used to guide the interviews. Data were analysed by framework analysis. Findings Framework analysis identified four main challenges in managing pain. These included lack of clinical guidelines, lack of a structured pain assessment tool, lack of autonomy in relation to decision making and other factors related to the patient’s condition such as the type of surgery or other interventions. Conclusion and recommendations The authors conclude that structured guidelines are needed to guide pain management in the critically ill. They suggest that as the quality of care given to patients is based on decisions made, it is essential that barriers to pain assessment and management are overcome. Recommendations are also made for further education on pain management in critical care.
Sleep deprivation is a common phenomenon in critical care. Factors such as noise, alarms from monitoring systems and lights can all affect the patient’s ability to sleep. This often leads to sleep deprivation and has a negative effect on recovery. Acupressure and valerian aromatherapy have been reported to be beneficial in promoting sleep. This study aimed to explore the effectiveness of valerian acupressure on sleep in intensive care (ICU) patients. Method The study was a randomised clinical trial which took place in a large intensive care unit in China. Forty-one participants were allocated to the experimental group and 44 to the control group. The treatment group received valerian pressure on three identified acupoints between the hours of 19.00 and 22.00 h. The control group received usual care. Outcome measures were observation and actigraphy measures between 22.00 and 06.00 h, and the Stanford Sleepiness Scale (SSS) the next morning. Heart rate recordings were also taken before and after therapy to evaluate relaxation response. Findings The results demonstrated that patients in the experimental group had more hours of sleep (3.4 hours versus 2.6 hours, p = 0.03) with fewer episodes of waking (14.2 m versus 54.6 m, p < 0.001) than those in the control group. SSS grades were also lower in the treatment group (2.3 versus 3.4 p < 0.001). In addition, the heart rate changes indicated an immediate relaxation response after therapy. Conclusion and recommendations The authors conclude that their study supports the hypothesis that valerian acupressure can improve the quality and duration of sleep for patients in ICU. However, the study is limited in that some errors in actigraph activity have been reported.
Comment
Comment
Managing pain in the critically ill is complex. It is also not easy to assess pain or to evaluate the effectiveness of interventions. This is a useful study, although the authors recognise that it may have limited generalizability to other settings. There is room for further research in this area.
This is a useful study and an intervention that could potentially be introduced, with training, within the critical care environment. However, in this study the inclusion criteria was for patients to be able to fully communicate, to be stable and not sedated, which is unusual for many ICU patients.