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Research Reviews April 2009
Intensive and Critical Care Nursing (2009) 25, 221—222
available 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 Accepted 21 April 2009
1. Turgay AS, Sara D, Genc RE. Physical restraint use in Turkish Intensive Care Units. Clinical Nurse Specialist. 2009;23(2):68—72. Objectives Physical restraint is described as imposing any limitation to a person’s freedom of movement or access to their body by use of a mechanical or other physical device. The use of physical restraint is reported to vary from 24% to 56% across ICU’s and this practice is highly contentious from professional, ethical and legal standpoints. There are also serious implications around patient safety. This paper explored intensive care nurses’ reasons for using physical restraint in Turkey. The aim of this study was to investigate which types of restraints are used and why they are applied. The relationships between the nurses’ characteristics and use of restraint were also explored. Methods The study was conducted using a descriptive and crosssectional research design, and took place in seven ICU’s across Turkey. The sample was 190 ICU nurses. Data were collected by self-administered questionnaires containing open-ended questions. Data were analysed using both descriptive (subject characteristics, frequencies and mean) and inferential statistics (chi square). Findings The majority of participants reported that they initiated restraint without medical consultation. Common reasons for restraint included the maintenance of medical devices and invasive lines (86.8%), restless behaviour (86.3%), impaired mental status (79.5%), treatment (53.7%), and convenience
E-mail address: [email protected]. 0964-3397/$ — see front matter doi:10.1016/j.iccn.2009.04.005
(23.2%). Wrist and ankle ties were the most common forms used (84.7%) and less than half (40.5%) documented that restraint had been used in the nursing notes. Younger nurses (aged 20—30 years) were also more likely to use physical restraint (2 8.46, d.f. = 1, p = 0.04). Conclusion and recommendations The authors make it clear that the focus of the study was not to reduce the use of restraint in ICU but to establish the types of restraint and reasons for its use. The findings do support those of other studies and highlights the common use of physical restraint in Turkey. The results suggest further education is required in this area of practice and that more research is needed to identify appropriate alternatives to restraint. Comment This is an interesting and controversial area of practice that many of us may have historically experienced at some point in the ICU setting. Of particular concern, the majority of nurses took the decision to use constraint independently, without medical consultation, and without documentation. Convenience was also reported as a significant factor. This is an area that requires further research from a national and international perspective in order for suitable alternatives to be found. 2. Forcina MS, Farhat AY, O’Neill WW, Haines DE Cardiac arrest survival after implementation of automated external defibrillator technology in the in-hospital setting. Critical Care Medicine. 2009;37(4):1229—36. Objectives Early defibrillation significantly improves the chance of survival after ventricular fibrillation (VF) or ventricular tachycardia (VT) arrest. The automated external
222 defibrillator (AED) has increased out-of-hospital survival rates post-arrest through early access to defibrillation. The aim of this study was to determine whether the introduction of a hospital-wide biphasic defibrillator with AED capacity would increase survival rates following in-hospital cardiac arrest. Methods The study took place at a large teaching hospital in the USA. Following an initial period of training, all standard defibrillators were replaced with AED’s. The sample size was 561 patients who had suffered a cardiac arrest and resuscitation had been attempted. Data were recorded one year prior to the introduction of AED’s (control group) and one year after the change (intervention group) using a prospective patient database. Primary outcome measures were survival to discharge after initial VF/VT and survival to discharge after initial asystole (AS)/pulseless electrical activity (PEA) arrest. Secondary outcome measures were time to first shock, effectiveness of shock, return of spontaneous circulation and survival. Data were analysed using chi square, fisher’s exact test and Wilcoxon’s rank test. Findings The results showed that AED’s were not associated with improvements in time to first shock in patient’s whose initial rhythm was VF/VT (median time 1 min, p = 0.79 for both intervention and control group). Similarly, no improvements were seen in relation to survival to discharge (31% compared to 29%, p = 0.80) in either groups. In patient’s whose initial rhythm was AS or PEA, AED’s were associated with a significantly worse outcome in terms of survival (15% versus 23%, p = 0.04) compared to standard defibrillators. Overall, no difference in rates of survival to discharge was found between the AED and the standard defibrillator. Conclusion and recommendations The study concluded that replacing standard monophasic defibrillators with biphasic AED’s did not change survival rates following in-hospital VF/VT arrest. Survival rates in patients with AS or PEA arrest were also associated with a worse outcome. The authors themselves state that the study is limited by introducing several interventions at the same time; including an extensive educational campaign to support AED use, and that due to the retrospective nature of the study it is difficult to ascribe any effect to one single intervention. Comment This is an interesting study the results of which are perhaps somewhat surprising. In this particular study, the non-significant results might have been due to an already rapid cardiac arrest response team, as demonstrated by a failure to reduce time to first shock. The authors argued that if AED’s are to be used, they should be primarily deployed to areas where mainly only basic life support facilities are available. However, this is not an issue in most acute care Trusts as access to advanced life support is readily available through cardiac arrest teams.
T. Day 3. Pudas-Tähkä SM, Axelin A, Aantaa R, Lund V, Sälanterä S. Pain assessment tools for unconscious or sedated intensive care patients: a systematic review. Journal of Advanced Nursing. 2009;65(5):946—55. Objectives Pain can play a significant part of the patient’s ICU experience with many unpleasant or uncomfortable procedures. Due to the critical nature of their condition and the use of sedative agents, patients are often unable to communicate, which makes pain recognition and assessment difficult. The aim of this systematic review was to describe tools developed for pain assessment in unconscious, sedated ICU patients. Methods The review followed the framework for systematic review reported by the Centre for Reviews and Dissemination (2001). A systematic literature search was undertaken from 1987 to 2007 by both a reviewer and a librarian. Key words were selected and there is a comprehensive description of the search strategy. The search revealed 1586 papers which were reviewed by two reviewers. Eight papers were included in the final analysis. The papers were analysed using a quality assessment instrument previously developed to evaluate pain assessment tools. Findings The results identified five different pain assessment tools for use in the sedated, unconscious ICU patient. These papers included behavioural indicators such as facial expressions, movement of the upper limbs and compliance with mechanical ventilation. Three of these papers also included physiological indicators, such as heart rate, blood pressure, respiratory rate, perspiration, flushing, etc. The psychometric properties of the instruments were evaluated by quality assessment criteria such as validity and reliability testing and the papers were subsequently allocated scores. Most papers received low scores, demonstrating that further testing is required. Conclusion and recommendations From the pain assessment tools reviewed, it was not possible to fully establish their usefulness in practice as the psychometric properties varied considerably. The authors acknowledge that as the instruments are relatively new, validity and reliability testing is still at an early stage and recommend further testing before any specific tool can be recommended in preference to another. Comment This is a useful review of the literature relating to pain assessment in ICU. The review has highlighted that further research is required and a more rigorous testing of the available tools. Further education about pain assessment and management should also be a priority as this perhaps does not play as important a part in critical care programmes as it should do.
available 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 Accepted 21 April 2009
1. Turgay AS, Sara D, Genc RE. Physical restraint use in Turkish Intensive Care Units. Clinical Nurse Specialist. 2009;23(2):68—72. Objectives Physical restraint is described as imposing any limitation to a person’s freedom of movement or access to their body by use of a mechanical or other physical device. The use of physical restraint is reported to vary from 24% to 56% across ICU’s and this practice is highly contentious from professional, ethical and legal standpoints. There are also serious implications around patient safety. This paper explored intensive care nurses’ reasons for using physical restraint in Turkey. The aim of this study was to investigate which types of restraints are used and why they are applied. The relationships between the nurses’ characteristics and use of restraint were also explored. Methods The study was conducted using a descriptive and crosssectional research design, and took place in seven ICU’s across Turkey. The sample was 190 ICU nurses. Data were collected by self-administered questionnaires containing open-ended questions. Data were analysed using both descriptive (subject characteristics, frequencies and mean) and inferential statistics (chi square). Findings The majority of participants reported that they initiated restraint without medical consultation. Common reasons for restraint included the maintenance of medical devices and invasive lines (86.8%), restless behaviour (86.3%), impaired mental status (79.5%), treatment (53.7%), and convenience
E-mail address: [email protected]. 0964-3397/$ — see front matter doi:10.1016/j.iccn.2009.04.005
(23.2%). Wrist and ankle ties were the most common forms used (84.7%) and less than half (40.5%) documented that restraint had been used in the nursing notes. Younger nurses (aged 20—30 years) were also more likely to use physical restraint (2 8.46, d.f. = 1, p = 0.04). Conclusion and recommendations The authors make it clear that the focus of the study was not to reduce the use of restraint in ICU but to establish the types of restraint and reasons for its use. The findings do support those of other studies and highlights the common use of physical restraint in Turkey. The results suggest further education is required in this area of practice and that more research is needed to identify appropriate alternatives to restraint. Comment This is an interesting and controversial area of practice that many of us may have historically experienced at some point in the ICU setting. Of particular concern, the majority of nurses took the decision to use constraint independently, without medical consultation, and without documentation. Convenience was also reported as a significant factor. This is an area that requires further research from a national and international perspective in order for suitable alternatives to be found. 2. Forcina MS, Farhat AY, O’Neill WW, Haines DE Cardiac arrest survival after implementation of automated external defibrillator technology in the in-hospital setting. Critical Care Medicine. 2009;37(4):1229—36. Objectives Early defibrillation significantly improves the chance of survival after ventricular fibrillation (VF) or ventricular tachycardia (VT) arrest. The automated external
222 defibrillator (AED) has increased out-of-hospital survival rates post-arrest through early access to defibrillation. The aim of this study was to determine whether the introduction of a hospital-wide biphasic defibrillator with AED capacity would increase survival rates following in-hospital cardiac arrest. Methods The study took place at a large teaching hospital in the USA. Following an initial period of training, all standard defibrillators were replaced with AED’s. The sample size was 561 patients who had suffered a cardiac arrest and resuscitation had been attempted. Data were recorded one year prior to the introduction of AED’s (control group) and one year after the change (intervention group) using a prospective patient database. Primary outcome measures were survival to discharge after initial VF/VT and survival to discharge after initial asystole (AS)/pulseless electrical activity (PEA) arrest. Secondary outcome measures were time to first shock, effectiveness of shock, return of spontaneous circulation and survival. Data were analysed using chi square, fisher’s exact test and Wilcoxon’s rank test. Findings The results showed that AED’s were not associated with improvements in time to first shock in patient’s whose initial rhythm was VF/VT (median time 1 min, p = 0.79 for both intervention and control group). Similarly, no improvements were seen in relation to survival to discharge (31% compared to 29%, p = 0.80) in either groups. In patient’s whose initial rhythm was AS or PEA, AED’s were associated with a significantly worse outcome in terms of survival (15% versus 23%, p = 0.04) compared to standard defibrillators. Overall, no difference in rates of survival to discharge was found between the AED and the standard defibrillator. Conclusion and recommendations The study concluded that replacing standard monophasic defibrillators with biphasic AED’s did not change survival rates following in-hospital VF/VT arrest. Survival rates in patients with AS or PEA arrest were also associated with a worse outcome. The authors themselves state that the study is limited by introducing several interventions at the same time; including an extensive educational campaign to support AED use, and that due to the retrospective nature of the study it is difficult to ascribe any effect to one single intervention. Comment This is an interesting study the results of which are perhaps somewhat surprising. In this particular study, the non-significant results might have been due to an already rapid cardiac arrest response team, as demonstrated by a failure to reduce time to first shock. The authors argued that if AED’s are to be used, they should be primarily deployed to areas where mainly only basic life support facilities are available. However, this is not an issue in most acute care Trusts as access to advanced life support is readily available through cardiac arrest teams.
T. Day 3. Pudas-Tähkä SM, Axelin A, Aantaa R, Lund V, Sälanterä S. Pain assessment tools for unconscious or sedated intensive care patients: a systematic review. Journal of Advanced Nursing. 2009;65(5):946—55. Objectives Pain can play a significant part of the patient’s ICU experience with many unpleasant or uncomfortable procedures. Due to the critical nature of their condition and the use of sedative agents, patients are often unable to communicate, which makes pain recognition and assessment difficult. The aim of this systematic review was to describe tools developed for pain assessment in unconscious, sedated ICU patients. Methods The review followed the framework for systematic review reported by the Centre for Reviews and Dissemination (2001). A systematic literature search was undertaken from 1987 to 2007 by both a reviewer and a librarian. Key words were selected and there is a comprehensive description of the search strategy. The search revealed 1586 papers which were reviewed by two reviewers. Eight papers were included in the final analysis. The papers were analysed using a quality assessment instrument previously developed to evaluate pain assessment tools. Findings The results identified five different pain assessment tools for use in the sedated, unconscious ICU patient. These papers included behavioural indicators such as facial expressions, movement of the upper limbs and compliance with mechanical ventilation. Three of these papers also included physiological indicators, such as heart rate, blood pressure, respiratory rate, perspiration, flushing, etc. The psychometric properties of the instruments were evaluated by quality assessment criteria such as validity and reliability testing and the papers were subsequently allocated scores. Most papers received low scores, demonstrating that further testing is required. Conclusion and recommendations From the pain assessment tools reviewed, it was not possible to fully establish their usefulness in practice as the psychometric properties varied considerably. The authors acknowledge that as the instruments are relatively new, validity and reliability testing is still at an early stage and recommend further testing before any specific tool can be recommended in preference to another. Comment This is a useful review of the literature relating to pain assessment in ICU. The review has highlighted that further research is required and a more rigorous testing of the available tools. Further education about pain assessment and management should also be a priority as this perhaps does not play as important a part in critical care programmes as it should do.