Background: Breast milk is the preferred source of enteral nutrition for neonates and is particularly important for premature neonates because it promotes growth and development, and reduces the incidence of many diseases to which premature neonates are susceptible. Objectives: To assess the prevalence and duration of breastfeeding among very preterm infants (VPIs) with a gestational age <32 weeks admitted to the neonatal intensive care unit (NICU) of XiJing Hospital. Methods: A retrospective record review was conducted to collect data on clinical characteristics and feeding methods of 235 VPIs born in XiJing Hospital from January 2017 to December 2023 and admitted to the NICU within 24 hours of birth. Results: Of the 235 eligible VPIs, 177 (75.3%) were delivered by cesarean section, 102 (43.4%) did not receive any breast milk during their hospitalization, and 133 (56.6%) received a mixture of breast milk and formula. Compared with the cesarean-section group, the vaginal-delivery group was significantly more likely to breastfeed (12% vs. 0.3%; P =.004) and had a significantly higher median daily breast milk intake (5.81 vs. 0.17 mL/kg; P =.003) during hospitalization; however, the duration of parenteral nutrition did not differ significantly between groups. Discussion: Overall, these results indicate that measures are required to increase breastfeeding among VPIs, particularly those born by cesarean section.
Background: A newly opened Medical Intensive Care Unit identified variation in nursing documentation practices related to titratable medications, with underlying causes initially unclear. Objectives: The primary aim of this quality improvement initiative was to reduce variation in titratable medication documentation practices by identifying and addressing barriers to compliance. Methods: Using an improvement science approach informed by protocol-based care and iterative Plan-Do-Study-Act cycles, the project identified key barriers, including workflow inefficiencies, documentation complexity, and knowledge gaps. A targeted educational intervention was subsequently developed, and auditing tools were used to assess sustainability. Results: Following the intervention, compliance with titratable medication documentation improved from a baseline of 78.5% to 88.7%, as demonstrated by audits conducted 3 months postintervention. Pre- and postclass surveys also showed significant improvements in nurses’ confidence and competence in documenting and managing titratable medications. Discussion: This project provides insight into the development of collaborative, data-driven educational interventions that foster accountability, enhance clinical documentation practices, and ultimately improve patient safety and care quality in critical care settings. Future quality improvement efforts may benefit from incorporating simulation-based strategies.
The ICU often provides aggressive treatments that may be futile for critically ill patients. Palliative care (PC) aims to enhance the quality of life for patients with life-threatening illnesses. Despite recommendations for early PC consultations, delays remain prevalent worldwide. This project aimed to improve the timeliness of PC referrals in a New York City hospital ICU through the implementation of a nurse-driven PC screening tool. Using the Model for Improvement, this quality improvement project was conducted over 7 months, including a 4-month baseline phase and a 3-month implementation phase. ICU nurses used a PC screening tool to evaluate patients within 48 hours of admission. The project aimed to increase PC screenings to 75% and ensure PC referrals within 48 hours. The implementation phase saw a significant increase in PC screenings, with compliance reaching 90.9% after process adjustments. The average time to PC referral decreased from 8.9 days pre-intervention to <2 days in the 3-month implementation phase. Of the patients receiving PC consultations, 46.6% had do not resuscitate and/or intubate status established, and 20% transitioned to hospice or comfort care. The nurse-driven PC screening tool effectively improved the timeliness of PC referrals, demonstrating the importance of standardized screening processes in the ICU.
BACKGROUND:Postoperative patients are at a higher risk for unexpected clinical changes in the immediate postoperative period that may necessitate escalation of care. OBJECTIVE:The study aimed to identify the characteristics, triggers, potential risk factors, and outcomes associated with clinical deterioration necessitating rapid response (RR) activation in post-surgical patients. METHODS:A 5-year retrospective review was performed at a large tertiary academic hospital of clinical characteristics and outcomes of postoperative pediatric surgical patients admitted to the ward who had a RR within 30 days after surgery. The study utilized the National Surgical Quality Improvement Program (NSQUIP) calculator as a predictor tool to compare individual patients' risk to the average population risk. RESULTS:Of the 435 surgical patients, the predominant reasons for RR activation were: multisystem 136 (34.1%) and respiratory 114 (28.6%). Two hundred thirty-eight (55.7%) were elective cases, and the most common surgical category was otolaryngology, 55 (12.8%). Patient comorbidities included: developmental delay (135, 31.5%) and cardiac anomalies (102, 23.8%). After RR, transfer to the PICU occurred in 248 events (57%); 63.7% (158) required intravenous fluid therapy, 19.8% (47) required mechanical ventilation within 24 hours, and 46 (12.3%) underwent reoperation. The median PICU length of stay (LOS) was 2 days (IQR: 0.0, 7.0), and mortality of 23 (5.9%). This patient cohort had a higher NSQUIP risk for any complications, pneumonia, surgical site infection, venous thrombosis, renal failure, and reintubation versus the average population risk. CONCLUSIONS:Postoperative RR activation with PICU transfer is associated with longer LOS, higher rate of reoperation, and higher mortality. The NSQUIP predictor tool should be explored further to guide postoperative clinical management and resource allocation for future surgical patients.
BACKGROUND:Venous thromboembolism (VTE) is a major contributor to morbidity and mortality in severe trauma (ST) patients. Platelet count (PLT), fibrinogen level (FIB), and D-dimer level are important coagulation indicators; however, few studies have described their trajectory in ST and assessed predictive value for VTE in clinical and nursing practice. OBJECTIVE:To describe the trajectories of PLT, FIB, and D-dimer on days 1, 3, 5, and 7 after ST, and to evaluate their predictive value for post-traumatic VTE. METHODS:Clinical data, including PLT, FIB, and D-dimer, were retrospectively collected from 184 ST patients. Univariate analysis and multivariate logistic regression analysis were used to identify independent risk factors for intramuscular venous thrombosis (IMVT), deep vein thrombosis (DVT), and pulmonary embolism (PE) in ST patients. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive performance of these independent risk factors. RESULTS:PLT showed a decreasing trend from day 1 to day 3 after trauma, followed by an increasing trend from day 3 to day 7. FIB dropped sharply to the lowest value on day 1 after trauma and then gradually increased. D-dimer surged sharply to the peak on day 1 after trauma, decreased gradually in the first 3 days, and then increased slowly from day 3 to day 7. Multivariate logistic regression analysis identified D-dimer level on day 5 as an independent risk factor for both IMVT (OR=1.133, 95% CI: 1.032-1.243; P=0.009; AUC=0.561) and PE (OR=1.085, 95% CI: 1.016-1.160; P=0.015; AUC=0.721). PLT and FIB were not identified as independent risk factors for IMVT, DVT, or PE. CONCLUSIONS:This study demonstrated that while the dynamic changes in PLT, FIB, and D-dimer can reflect the transition of coagulation status after ST, their value as independent VTE predictive tools is limited. In clinical and nursing practice, it is crucial to determine the timing of coagulation status transition after trauma and explore the optimal timing for pharmacological prophylaxis.
The COVID‑19 pandemic has had a catastrophic and enduring impact on frontline nurses, contributing to burnout, stress, and widespread workforce disruption. This qualitative study used Thorne's interpretive description methodology to explore the lived experiences of nursing students, new graduate nurses, and nurses who resigned within their first year of practice during the pandemic. Semi‑structured interviews were conducted across multiple US regions to understand how pandemic‑era educational and clinical experiences shaped perceptions of nursing, career trajectories, and readiness for practice. Six themes emerged: (1) the pandemic did not dissuade students from becoming nurses; (2) career trajectories were altered; (3) institutional and peer support were insufficient; (4) practical readiness was diminished; (5) rifts within the nursing workforce intensified; and (6) media shaped perceptions of nursing. Findings highlight the need for robust transition‑to‑practice structures, intentional mentoring, and leadership strategies to support early‑career nurses and mitigate workforce attrition. Implications for nurse leaders and recommendations for future research are discussed.
BACKGROUND:Glycemic control involves methods for measuring, evaluating, and correcting blood glucose levels to maintain glucose homeostasis. It is essential to reduce hyperglycemia-related complications while minimizing the risk of hypoglycemia, and registered nurses (RNs) play a key role in blood glucose monitoring and insulin therapy management in the intensive care unit (ICU).. OBJECTIVES:To provide a thorough synthesis of nursing perspectives on glycemic control practices for critically ill adult patients admitted to the ICU. METHODS:We conducted a narrative review of the literature using PubMed, Scopus, CINAHL, and Google Scholar, complemented by manual searches of relevant scientific society websites, textbooks, and reference lists. RESULTS:Available evidence suggests initiating glycemic control for persistent hyperglycemia at ≥180 mg/dL (10 mmol/L) and titrating therapy to an individualized target based on patient evaluation. Arterial blood samples should be prioritized for glucose measurement when available, followed by venous and capillary sampling, individualizing the monitoring frequency. Continuous intravenous insulin infusion is generally recommended, guided by a standardized protocol specifying treatment thresholds, target ranges, insulin infusion adjustments, and monitoring frequency. CONCLUSIONS:This narrative review summarizes nursing perspectives on glycemic control in critically ill adult ICU patients, including glucose measurement, individualized monitoring frequency, and protocol-based intravenous insulin infusion management. Evidence gaps remain regarding the optimal application of these approaches, and nursing research should focus on both patient-centered and organizational outcomes.
BACKGROUND:Patients with cirrhosis requiring liver transplant often suffer from frailty, sarcopenia, and malnutrition. As their disease progresses, their complex and acute pretransplant state usually leads to longer, more complicated recoveries in the posttransplant setting. OBJECTIVE:Standard care for mobilizing high-acuity intensive care unit (ICU) patients before and after liver transplantation is mobilization at least twice daily. This quality improvement initiative sought to increase adherence to this standard. METHODS:The mobility champion role was established to support early mobilization efforts. Mobility champions consist of a multidisciplinary team of registered nurses (RNs) and restorative care assistants (RCAs) who provide staff education and led the implementation of an early mobilization program. Team-based mobility initiatives have been shown to be effective in improving mobilization among high-acuity patient populations. RESULTS:Following the implementation of the mobility champions, more than 88% of patients were mobilized at least twice per day; additional analysis correlated mobility frequency with improved disposition after hospitalization. Using mobility champions led to increased compliance with patient mobilization standards. CONCLUSION:Although this quality improvement initiative demonstrated promising early results, additional study is needed to assess the effectiveness and sustainability of mobility champions in the liver transplant population.
BACKGROUND:The recommendations to leave the lights on or turn the lights off before testing the pupillary light reflex (PLR) are primarily based on historical precedent. There is a lack of evidence to determine the best practice regarding adjusting ambient light when obtaining pupil measurements using a quantitative pupillometer (QP). OBJECTIVES:To examine the difference in QP measurements taken from the same subject in bright light versus in a darkened room. METHOD:Before the human subject study, light readings were obtained with a lux meter to identify the range and central tendency for light in an intensive care unit. A set of 4, paired-sample within-subjects QP measurements was obtained in alternating bright and dark rooms. RESULTS:Among 32 healthy volunteers, we found neither statistical nor clinically relevant differences in the neurological pupil index score in paired observations (P = .12) taken in bright light [mean = 561.5 (37.3) lux] or dark conditions [mean = 0.9 (0.3) lux]. This remained true in a mixed model controlling for repeated observations (P = .25). DISCUSSION:Pupil size was larger in dark conditions. But the finding that the pupillary light reflex functions normally despite fluctuating light levels is not unexpected. CONCLUSION:The evidence does not support a need for nurses to adjust light levels before measuring the PLR with a pupillometer.
Background:Frequent intravenous smart-pump (IVSP) alarms can disrupt workflow, increase alarm fatigue, and threaten patient safety.Objectives:To describe the frequency, distribution, and care-area variation of IVSP alarms from the Baxter Sigma Spectrum IVSP over a 2-year period at a large academic medical center.Methods:A retrospective study of IVSP alarms was performed for all inpatient areas at a US academic medical center. Alarm events and infusion starts were extracted using the Care Everywhere analytics platform and aggregated by frequency of alarms, number of infusions, alarm type, and care area. Analyses were done using descriptive statistics.Results:A total of 5,129,505 alarms were linked to 1,102,303 infusion starts (mean = 4.65 alarms per infusion). Four alarm categories accounted for 86.5% of events: downstream occlusion (42.5%), air-in-line (15.5%), infusion complete (14.4%), and upstream occlusion (14.1%). Although they accounted for only 6% of total infusion starts, the NICU, pediatrics, and pediatric intensive care unit (PICU) had the highest alarm rates, averaging 28.6, 9.0, and 7.7 alarms per infusion, respectively. Downstream occlusion rates peaked in Pediatrics (696/100 starts) and PICU (536/100), while upstream occlusions were highest in the NICU (337/100). Air-in-line alarms were greatest in Oncology (103/100).Conclusion:Downstream occlusion, air-in-line, infusion-complete, and upstream occlusion alarms dominated the 2 years of alarm data, generating the majority of the 5 million IVSP alarms. Although adult medical-surgical (Med/Surg) and critical care generated the most alarms overall, pediatric and neonatal areas experienced the highest number of alarms per infusion, placing them at the greatest risk for alarm fatigue.
Background:Critical care nurse moral distress seriously affects the quality of care. Although there are quantitative studies in Japan, few have explored Japanese critical care nurses' (CCNs) experiences, necessitating a contextualized understanding.Objective:To explore Japanese CCNs' descriptions of the causes of their moral distress.Method:A descriptive qualitative study using semistructured interviews was conducted on 10 CCNs working in intensive care units (ICUs) in Japan's Tokai region. Participants were recruited via purposive and snowball sampling. Inclusion criteria were at least 3 years of working in the ICU and 5 years' nursing experience. Data were analyzed using Tesch's eight-step content analysis.Results:Five categories and 17 subcategories were identified as constraints preventing nurses from acting in accordance with their personal values and ethical standards: (1) difficulty in achieving common understanding between patients/family members in crisis and medical professionals; (2) insufficiencies in the therapy/treatment/care centered on patients and families; (3) physician attitudes that communicate superiority and higher status; (4) work environments that make expressing differences in values difficult; and (5) tension between one's professional and moral responsibilities.Discussion:This study provides empirical evidence of situations where moral distress arises among Japanese CCNs in ICUs, emphasizing the influence of cultural norms (conformity and harmony). A cross-cutting theme of silence emerged, as nurses often chose not to voice concerns to maintain harmony, contributing to moral distress. These findings highlight the need for strategies supporting ethical dialogue and culturally sensitive interventions.
Background:A newly opened Medical Intensive Care Unit identified variation in nursing documentation practices related to titratable medications, with underlying causes initially unclear.Objectives:The primary aim of this quality improvement initiative was to reduce variation in titratable medication documentation practices by identifying and addressing barriers to compliance.Methods:Using an improvement science approach informed by protocol-based care and iterative Plan-Do-Study-Act cycles, the project identified key barriers, including workflow inefficiencies, documentation complexity, and knowledge gaps. A targeted educational intervention was subsequently developed, and auditing tools were used to assess sustainability.Results:Following the intervention, compliance with titratable medication documentation improved from a baseline of 78.5% to 88.7%, as demonstrated by audits conducted 3 months postintervention. Pre- and postclass surveys also showed significant improvements in nurses' confidence and competence in documenting and managing titratable medications.Discussion:This project provides insight into the development of collaborative, data-driven educational interventions that foster accountability, enhance clinical documentation practices, and ultimately improve patient safety and care quality in critical care settings. Future quality improvement efforts may benefit from incorporating simulation-based strategies.
BACKGROUND:A newly opened Medical Intensive Care Unit identified variation in nursing documentation practices related to titratable medications, with underlying causes initially unclear. OBJECTIVES:The primary aim of this quality improvement initiative was to reduce variation in titratable medication documentation practices by identifying and addressing barriers to compliance. METHODS:Using an improvement science approach informed by protocol-based care and iterative Plan-Do-Study-Act cycles, the project identified key barriers, including workflow inefficiencies, documentation complexity, and knowledge gaps. A targeted educational intervention was subsequently developed, and auditing tools were used to assess sustainability. RESULTS:Following the intervention, compliance with titratable medication documentation improved from a baseline of 78.5% to 88.7%, as demonstrated by audits conducted 3 months postintervention. Pre- and postclass surveys also showed significant improvements in nurses' confidence and competence in documenting and managing titratable medications. DISCUSSION:This project provides insight into the development of collaborative, data-driven educational interventions that foster accountability, enhance clinical documentation practices, and ultimately improve patient safety and care quality in critical care settings. Future quality improvement efforts may benefit from incorporating simulation-based strategies.
