BACKGROUND:Liquid pharmaceutical residues (LPR) released into the environment are micropollutants that may exert toxic effects on wildlife. Appropriate LPR management therefore represents a pollution hotspot in healthcare facilities, although data on their management by healthcare providers are scarce. The primary endpoint was to investigate whether nurses' knowledge of their workplace enabled them to appropriately dispose of LPR in the intensive care unit (ICU). METHODS:As part of the one-day multicenter observational prospective GAME-OVER study, which enrolled 81 French ICUs a day of choice between November 2022 and March 2023, an ancillary survey was conducted in nurses working in the ICU on the study day. The multiple-choice survey aimed to assess practices regarding LPR and medical waste (MW) management. Based on the submitted responses and the non-hazardous MW disposal route in each facility, LPR disposal route was either considered 'appropriate', 'wrong' or 'appropriate but optimizable'. RESULTS:Among the 988 nurses working on the study day, 823 (83%) completed the survey. Overall, 374 registered nurses (44%) chose an improper LPR disposal route in their survey responses. Among the 801 nurses who reported disposing of syringes containing LPR, 253 (32%) chose a wrong LPR disposal route. Moreover, 214 nurses declared emptying syringes containing LPR before disposal, of which 155 (72%) did not use the appropriate LPR pathway, leading to theoretical environmental contamination. Importantly, 359 (44%) nurses were not aware of which non-hazardous MW disposal pathway was used in their facility, namely by incineration (65%), or burial (33%), partly explaining improper LPR management. CONCLUSIONS:This study demonstrated that knowledge on LPR management among registered nurses in French ICUs was limited, leading to theoretical environmental contamination. IMPLICATIONS FOR CLINICAL PRACTICE:This study highlights the need to provide specialized training on LPR management for healthcare providers, which may help decreasing pharmaceutical environmental contamination by implementing ecodesign of healthcare in the ICU. TRIAL REGISTRATION:NCT05553054.
BACKGROUND:Left ventricular assist devices (LVADs) prolong survival in end-stage heart failure, and warfarin thromboprophylaxis is recommended to prevent device thrombosis and thromboembolic complications. When bleeding occurs or emergency surgery is required, rapid anticoagulation reversal is critical. Prothrombin complex concentrate (PCC) provides rapid reversal; however, its risk-benefit profile in LVAD recipients remains unclear. We conducted a systematic review and meta-analysis comparing PCC with non-PCC strategies for warfarin reversal in LVAD recipients. METHODS:MEDLINE, Embase, and Scopus were searched through June 2025 for studies of PCC versus non-PCC strategies for warfarin reversal in LVAD recipients. Two reviewers independently extracted data. Random-effects models were used to pool arm-level estimates and to pool head-to-head comparisons using mean differences or risk ratios (RRs). RESULTS:Eighteen studies involving 779 patients were included. Arm-level pooled estimates for PCC versus non-PCC comparators were 24.0% versus 15.8% for mortality, 16.5% versus 12.1% for thrombotic events, and 3.1 versus 5.7 for FFP units. Arm-level time to INR correction was longer with PCC overall (16.5 versus 13.6 h), driven by one elective cohort, but faster within the ICH subgroup (6.0 versus 13.7 h). In head-to-head comparisons, PCC achieved faster INR correction than non-PCC comparators (mean difference - 7.6 h; p = 0.001) and required fewer FFP units (-2.6 units; p = 0.019), with no significant difference in all-cause mortality (RR 1.14; p = 0.490) or thrombotic events (RR 1.43; p = 0.176). CONCLUSIONS:In head-to-head studies, PCC was associated with faster INR correction and lower FFP requirements than non-PCC strategies, whereas mortality and thrombotic events did not differ significantly. Given the observational evidence, wide confidence intervals, and heterogeneity, equivalent safety cannot be established, and prospective studies are needed to define the relative safety and effectiveness of the two approaches. IMPLICATIONS FOR CLINICAL PRACTICE:PCC-based strategies may be considered for urgent warfarin reversal in LVAD recipients, particularly when rapid INR reduction or avoidance of large-volume plasma transfusion is clinically important. Treatment decisions should account for the indication, bleeding severity, and underlying thrombotic risk. TRIAL REGISTRATION:CRD42024573925.
OBJECTIVE:To investigate the long-term outcomes and prognostic factors of critically ill patients undergoing tracheostomy for prolonged mechanical ventilation within the specific sociocultural and healthcare context of the Middle East. DESIGN:A retrospective observational study of patients who underwent tracheostomy between January 1, 2017, and December 31, 2020. SETTING:Medical ICU of Hamad General Hospital, a tertiary academic healthcare institution in Doha, Qatar. PATIENTS:Adult critically ill patients requiring tracheostomy for prolonged mechanical ventilation. INTERVENTIONS AND MEASUREMENTS:Tracheostomies were performed via percutaneous or open surgical techniques. Primary outcomes included neurological status (Cerebral Performance Category) and functional disability (Modified Rankin Scale) at hospital discharge. Secondary outcomes included survival rates at ICU discharge, hospital discharge, and one-year post-discharge, as well as lengths of stay. Multivariable logistic regression was utilized to identify independent prognostic factors for mortality. RESULTS:The study included 395 patients with a mean age of 55 ± 17.4 years. The percutaneous technique was more prevalent (61.3%) and accompanied by a higher proportion of good neurological outcomes; however, this likely reflects patient selection bias rather than procedural superiority. Survival rates were 82.8% at ICU discharge, 63% at hospital discharge, and 29% at one year. Multivariate analysis revealed that septic shock and higher SOFA scores were independent predictors of ICU mortality. Diverging from Western literature, age and most comorbidities were not independent predictors of long-term mortality. Instead, mortality was primarily driven by acute physiological severity (higher APACHE II and SOFA scores) and specific admission diagnoses such as ARDS and stroke. CONCLUSIONS:This study highlights a distinct epidemiological profile in the Middle East, where outcomes are driven more by acute illness severity than by age or chronic frailty. The findings underscore the unique family-anchored post-discharge care model in this region, necessitating culturally adapted strategies to manage the long-term burden of tracheostomy. IMPLICATIONS FOR CLINICAL PRACTICE:Healthcare planning in this region must account for the younger patient demographic and the heavy reliance on family caregivers. Policy reforms should focus on strengthening home-based professional support to complement family involvement and improve long-term survival.
OBJECTIVES:To map evidence on missed continuity of nursing and therapy care during ICU step-down, including how continuity is conceptualised, what care is lost, contributing factors, consequences, and strategies to support continuity. METHODS:We conducted a scoping review in accordance with Joanna Briggs Institute methodology and reported using PRISMA-ScR. MEDLINE, Embase, CINAHL, Scopus, Web of Science and grey literature sources were searched from 1998 to October 2025. Eligible studies reported adult ICU-to-ward transitions involving nursing and/or therapy care continuity or missed care. Two authors independently screened and charted data. Findings were analysed through descriptive mapping and thematic synthesis. RESULTS:Of 3021 records identified, 27 studies met the inclusion criteria. The evidence was mainly qualitative and nursing-focused, with limited inclusion of therapy professionals. Continuity was most often conceptualised as informational, with evidence of incomplete handover, poor documentation, and loss of clinically relevant detail. Management continuity failures included missed monitoring, delayed review, medication discontinuity, and poor follow-through of care plans. Relational continuity involved inadequate preparation of patients and families and limited interprofessional communication. Functional continuity, including rehabilitation and mobilisation, was less frequently examined but commonly disrupted. Four themes were identified: continuity breakdown between handover and ward enactment; structural mismatch between ICU and ward environments; patient safety risks linked to missed continuity; and under-recognition of relational continuity. Findings supported a continuity cascade model in which breakdown begins before transfer and progresses across interrelated domains. CONCLUSIONS:Missed continuity of nursing and therapy care at ICU step-down is a multifaceted and under-conceptualised problem extending beyond handover. The proposed continuity cascade model suggests that breakdown occurs across anticipatory, informational, interprofessional, management, and functional/relational domains. IMPLICATIONS FOR CLINICAL PRACTICE:Interventions should address care enactment, interprofessional coordination, rehabilitation continuity, and patient and family preparation. ICU step-down should be recognised as a high-risk transition requiring structured, multidisciplinary continuity systems.
OBJECTIVES:Although negative inspiratory force (NIF) has been studied in relation to weaning failure, evidence addressing extubation failure after a successful spontaneous breathing trial (SBT) remains limited. In standardized, protocol-based weaning programs, ventilator-measured NIF may offer information for extubation decisions, but prospective data are scarce. METHODS:We performed a prospective observational cohort study in medical ICUs using a respiratory care practitioner-driven, standardized weaning program. Adult patients receiving invasive mechanical ventilation for ≥2 calendar days were enrolled between November 2017 and February 2022. Planned extubation episodes after a successful SBT were analyzed. NIF was measured at the bedside by respiratory care practitioners using the ventilator's built-in function and categorized a priori. The primary outcome was extubation failure, defined as reintubation within 48 h after extubation. RESULTS:Among 622 planned extubation episodes, extubation failure occurred in 97 (15.6%). Extubation failure rates decreased stepwise across increasing NIF categories (35.7% for NIF <15 cmH₂O vs. 11.2% for NIF ≥25 cmH₂O; P for trend <0.001). In the fully adjusted model, compared with NIF <15 cmH₂O, NIF 20-24 cmH₂O and ≥25 cmH₂O were independently associated with lower odds of extubation failure (adjusted odds ratios of 0.29 and 0.25, respectively). Hypercapnic or hypoxemic respiratory failure, deep sedation, thick secretions, higher non-neurologic Sequential Organ Failure Assessment score, and delirium were also independently associated with extubation failure. Extubation failure was associated with a higher rate of tracheostomy before ICU discharge (66.0% vs. 5.0%) and higher ICU mortality (10.3% vs. 3.2%). CONCLUSIONS:In medical ICU patients undergoing planned extubation after a successful SBT, higher NIF was independently associated with lower odds of extubation failure. IMPLICATIONS FOR CLINICAL PRACTICE:These findings support the use of ventilator-measured NIF as a practical adjunct to the multifactorial extubation assessment within standardized weaning programs.
AIM:To describe and categorize the thematic content emerging from narrative diaries in Neonatal Intensive Care Unit (NICU) written by parents and healthcare providers. METHODS:A qualitative study of NICU diary writings, provided for a feasibility study, was conducted at a tertiary-care hospital in Central Italy. Parents of neonates admitted to a 22-bed NICU, who underwent intubation and sedation for at least 48 h, were enrolled. Parents, relatives, visitors, and healthcare professionals were invited to write about their experiences, emotions, reflections, along with drawings, or photographs in the NICU narrative diary during the hospitalization. Narrative data were analyzed using thematic analysis following Braun and Clarke's approach. FINDINGS:Twenty-one NICU narrative diaries were collected between January 2024 and January 2025. Each diary contained a median of 22 entries (IQR = 12-28), and the majority of which were written by mothers (91%). Thematic analysis of diaries revealed 15 subthemes, which were then categorized into three overarching themes: 1) the NICU journey, reporting the newborn's clinical course and development, the first-time experience, the NICU environment, and parents' involvement in care; 2) parenthood, encompassing emotions, parental identity, bonding and separation, partner mutual support, and relationships with siblings; and 3) resilience and coping, highlighting narratives of communicating with the newborn, gratitude, support from relatives and peers, spirituality and the role of the narrative diary. CONCLUSIONS:NICU narrative diaries provide valuable insight into the clinical, emotional, and relational dimensions of the NICU experience. Clear communication, recognition of meaningful moments, and structured opportunities for parental participation and narrative expression may foster bonding, resilience, and overall quality of care. IMPLICATIONS FOR CLINICAL PRACTICE:NICU narrative diaries promote a more humane and participatory care environment by supporting parental involvement, caregiver emotional well-being, and a relationship-oriented care culture.
BACKGROUND & OBJECTIVES:The Footprints Project is a humanizing initiative that elicits and displays personal information from patients and families about a patient's life before illness. Key details recorded on a form are then written on a whiteboard in the patient's room to support person-centered care. The whiteboard keeps personal identity, preferences, and daily plans visible. The objective of this study was to explore how the Footprints Project evolved over time and to identify contextual determinants and practical strategies that may support its ongoing sustainability from the perspectives of patients, families, and clinicians. METHODS:This qualitative descriptive study was co-designed with patients and families in a 23-bed university-affiliated medical-surgical Intensive Care Unit (ICU). Implementation followed a preparatory audit, staff surveys, multi-directional communication, and volunteer integration. We enrolled survivors of critical illness, family members of ICU patients, and clinicians to participate in focus groups and individual interviews. Transcripts were analyzed using conventional qualitative content analysis and interpreted with attention to constructs within the Clinical Sustainability Framework as a sensitizing lens. FINDINGS:Participant interviews and focus groups with 7 patients, 19 family members and 40 clinicians identified four transitions reflecting the evolution and embedding of the Footprints Project: 1) transition from a nurse-led tool to an intentional interprofessional intervention; 2) transition from a patient-centered tool to a patient and family-partnered intervention; 3) transition from a stand-alone intervention to one embedded into daily workflows; and 4) transition in the format and content of the form and whiteboard. CONCLUSIONS:In this qualitative study, patients, families, and clinicians identified practical strategies and contextual features that supported the evolution and ongoing use of the Footprints Project through interprofessional and family-partnered efforts, workflow alignment and refreshed tools. IMPLICATIONS FOR CLINICAL PRACTICE:Embedding Footprints into daily ICU workflows may strengthen person-centered care by making patient identity visible at the bedside. Interprofessional ownership and explicit family partnership can enhance consistency and sustainability. Updating and intentionally embedding tools may support staff engagement in high-acuity environments. These strategies may help ICUs to operationalize other humanizing practices in practice.
OBJECTIVES:To map the existing knowledge in literature on the use of point-of-care ultrasound by critical care nurses in intensive and critical care settings, and to describe current practices, and examine reported training programme characteristics and outcomes. METHODS:This scoping review followed the Levac et al. framework, building on Arksey and O'Malley, and adhered to the PRISMA-ScR guideline. A systematic literature search was conducted without any time restriction until October 2025 across PubMed/MEDLINE, Scopus, CINAHL, Web of Science, and Embase. Data were extracted, collated, and classified to identify key patterns. Findings were synthesised through tabulation and a narrative summary to map the evidence comprehensively. RESULTS:A total of 305 records were identified, of which 17 studies were included. Across the included studies, nurse-performed point-of-care ultrasound in critical care settings was applied within three overarching domains of patient care: 'verification and guidance of clinical procedures', 'cardiopulmonary assessment', and 'additional diagnostic purposes'. Training programmes for critical care nurses varied widely in duration, content, delivery methods, and assessment strategies, and reported outcomes were related to clinical practice, patient experience, and professional development. CONCLUSIONS:Nurse-performed point-of-care ultrasound is increasingly incorporated into intensive and critical care settings suggesting potential clinical and professional benefits. Persistent heterogeneity in training models, competency assessment, and defined scope of practice reveals an absence of standardised frameworks necessary for consistent and sustainable adoption. IMPLICATIONS FOR CLINICAL PRACTICE:Policies are needed to standardise scope of practice, training, and competency assessment for critical care nurses using point-of-care ultrasound. Integration of point-of-care ultrasound into critical care nursing education should be supported to ensure consistent preparation and skill development. Clear oversight and competency processes are needed to promote patient safety and sustainable implementation. Policy frameworks should also recognise point-of-care ultrasound as a pathway for professional development and role advancement among critical care nurses.
