Funding:EAA is funded by the Washington University Department of Anesthesiology's Division of Clinical and Translational Research (DoCTR). Research reported in this publication was supported by the Washington University Institute of Clinical and Translational Sciences grant UL1TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (1). The content is solely the responsibility of the authors and does not necessarily represent the official view of the NIH. KEY POINTS:This hybrid 1 implementation science study investigated the effectiveness of a program to reduce IUC utilization in ICU patients with AKI and ESRD. The DUCKI protocol successfully decreased IUC rates by 67% in the study's targeted group of AKI and ESRD patients within an academic surgical ICU and was maintained over 2 years of follow up. Using implementation science to introduce evidence-based strategies like DUCKI is effective at increasing adoption and sustaining the practice.Oliguric patients offer a path of less resistance in changing catheterization practices.DUCKI can safely minimize IUC use in specific ICU populations.The protocol offers the potential for broader interventions to reduce catheter-associated risks in all ICU patients. BACKGROUND:Indwelling urinary catheter use remains high in the surgical intensive care unit despite targeted, national efforts. When hospital-based initiatives occur, it is unclear if decreases in utilization are sustained. OBJECTIVES:In 2021, we used implementation science to develop the Decreasing Urinary Catheters in Kidney Injury (DUCKI) program, targeting decreased indwelling catheterization in patients with acute kidney injury (AKI) with oliguria or end stage renal disease (ESRD). Three years later, we evaluated the effectiveness of DUCKI. METHODS:This was a hybrid 1 implementation study. Outcomes of DUCKI eligible patients were evaluated through chart review with comparisons made between the 2021 and 2023 cohorts. Physicians and nurses were surveyed on the implementation effort. RESULTS:∼12.5% of patients were eligible for DUCKI. 70 patients in 6 months in 2021 and 19 patients in month in 2023 met DUCKI criteria. The average indwelling catheterization rate in DUCKI patients dropped to 10% from 80% in 2021. In 2023, the catheterization rate in DUCKI patients remains low (9%). Overall rates in the unit declined from 74% pre-implementation to 70% in 2021 and 66% in 2023. There were no serious adverse events associated with the protocol. The acceptability survey was completed by ICU stakeholders pre (n=88) and post (n=77) intervention. Respondents generally rated DUCKI positively, although a minority (26%) reported increased burden to workflow. CONCLUSIONS:Low indwelling catheterization rates in patients with oliguric AKI or ESRD were sustained in the ICU's DUCKI implementation program. This program has contributed to sustained decrease in overall unit catheterization.

BACKGROUND:Critically ill patients may have pressure injuries upon admission, increasing the need for nursing care and resources. LOCAL PROBLEM:An increase in pressure injuries during the COVID-19 pandemic required implementation of 2-nurse skin assessments for pressure injury identification and prevention. METHODS:A quality improvement initiative incorporating tele-intensive care unit (tele-ICU) nurses and wound, ostomy, and continence nurses using camera technology in collaboration with bedside intensive care unit nurses was conducted in 3 intensive care units within a multi-institutional health care system from 2021 through 2023. Sites included an academic medical center and 2 community hospitals. The team implemented the following bundle: (1) tele-ICU nurses provided second skin assessments, (2) tele-ICU and bedside intensive care unit nurses reviewed pressure injury prevention measures on admission, and (3) tele-ICU nurses documented pressure injuries. Customized daily dashboards and automated reporting were implemented. Crude data descriptive analysis and segmented regression analysis were used. RESULTS:For 4723 admissions, 2-nurse skin assessment compliance increased from 46.9% during the 9-month preimplementation period to 80.8% during the 18-month postimplementation period, showing that compliance increased by 72.3%. Overall, 1153 pressure injuries were identified on intensive care unit admission or transfer, a mean of 20.6 per month before implementation and 64.1 per month after implementation. In the segmented regression analysis, the number of pressure injuries identified as present on admission significantly increased after implementation (P = .02). CONCLUSION:Integrating tele-ICU nurses, bedside intensive care unit nurses, and wound, ostomy, and continence nurses with camera technology increased compliance with 2-nurse assessments, leading to identification of present-on-admission pressure injuries, prompt treatment, and preventive interventions.

Background Changes in healthcare delivery were required during the first year of the COVID-19 pandemic. Objective The purpose of this study was to determine the impact of the approach to care of the COVID-19 patient on nursing sensitive indicators and nutrition therapy and the utilization of rehabilitation services during the first year of the pandemic in the acute care setting. Method A retrospective study of 894 patients admitted with a COVID-19 diagnosis was conducted between March 2020 and February 2021 in 3-month cohorts. All charts were reviewed for general demographics and hospital data, nursing quality indicators, and nutritional and rehabilitation services for the first 30 days of admission. Results Differences in patient characteristics were noted among the cohorts. Variations were observed between time points in hospital-acquired pressure injury occurrence, with mechanical ventilation and proning being independent predictors of hospital-acquired pressure injuries. There were differences noted in the percentage of patients with a central line-associated bloodstream infection among the time points (P < .001), but there were no differences noted in catheter-associated urinary tract infections (P = .20). Overall, 15.5% had a malnutrition diagnosis, with most patients receiving 50% of prescribed calorie and protein needs. Rehabilitation services increased over time with these services being initiated earlier in the later cohorts (P < .001). Discussion The results of this study demonstrated the impact of the pandemic on outcomes in the areas of nursing, nutrition, and rehabilitation, which varied across quarterly cohorts as we learned and developed new practices and adapted to a novel pandemic.

Schmidt, Melissa1; Hudock, Meghan2; Tymkew, Heidi3; Arroyo, Cassandra4; Schallom, Marilyn3; Sitler, Dawn5 Author Information

PURPOSE:Hospitals are implementing a variety of fall prevention programs to reduce the fall rates of hospitalized patients. But if patients don't perceive themselves to be at risk for falling and don't adhere to fall prevention strategies, such programs are likely to be less effective. The purpose of this study was to describe the perceptions of fall risk among hospitalized patients across four acute care specialty services.METHODS:One hundred patients who had been admitted to the study hospital and who had a Morse Fall Scale score over 45 were asked to complete the Patient Perception Questionnaire, a tool designed to explore a patient's confidence regarding their fall risk, fear of falling, and intention to engage in fall prevention activities. Morse Fall Scale scores were collected via retrospective chart review. Data were analyzed using descriptive statistics, Pearson correlation coefficients, and independent sample t tests.RESULTS:Participants' mean age was 65 years; 52% were male, 48% female. Although all 100 participants were deemed at risk for falls per their Morse Fall Scale scores, only 55% considered themselves to be at such risk. As patients' confidence in their ability to perform mobility tasks increased, their intention to ask for help and fear of falling significantly decreased. Patients who had been admitted as the result of a fall demonstrated significantly lower confidence scores and higher fear scores.CONCLUSIONS:Patients who score high on fall risk assessments often don't perceive themselves to be at high risk for falling, and thus might not engage in fall prevention activities. Developing a fall risk assessment method that incorporates both a patient's physiological condition and their perception of their fall risk could help reduce fall rates in the acute care setting.

Schmid, Kristin1; Walsh, Maura1; Robertson, Laurie2; Schallom, Marilyn3; Prentice, Donna3; Sona, Carrie2; Wessman, Brian4; Ablordeppey, Enyo5 Author Information

Background Early mobility benefits include improved strength, decreased length of stay (LOS), and delirium. The impact of an early mobility protocol on return to activities of daily living (ADL) is less studied. Objective The aim of this study was to examine 1-year outcomes including ADL performance after the institution of an ICU early mobility protocol. Methods One year after the initiation of an early mobility protocol in 7 intensive care units (ICUs) at an academic medical center, patients with an ICU stay of 7 days or more were enrolled in a 1-year follow-up phone call study. Baseline demographic data included the following: average ICU mobility and highest ICU mobility level achieved (4 levels), highest ICU mobility score (10 levels) at ICU admission, ICU discharge (DC), hospital DC, LOS, and delirium positive days. At 4 time points after DC (1, 3, 6, 12 months), patients were contacted regarding current residence, employment, readmissions, and current level of ADL from the Katz ADL (scored 0-6) and Lawton instrumental ADL scales (scored 0-8). Results A convenience sample of 106 patients was enrolled with a mean age of 58 ± 15.4 years, ICU LOS of 18 ± 11.5 days, and hospital LOS of 37.5 ± 31 days; 58 (55%) were male; 4 expired before DC. Mobility results included mean mobility level of 1.6 ± 0.8, mean highest mobility level 3.3 ± 0.9; ICU mobility score was 5.9 ± 2.4 at time of ICU DC and 7.3 ± 2.5 at hospital DC. Katz ADL scores improved from 4.8 at 1 month to 5.6 at 12 months (P = .002), and Lawton IADL scores improved from 4.2 to 6.6 (P < .001). Mobility scores were predictors of 1 month Katz (P = .004) and Lawton (P < .001) scores. None of the mobility levels or scores were predictive for readmissions. Most patients were not working before admission, and not all returned to work. Days positive for delirium were predictive of 1 month Katz and Lawton (P = .014, .002) scores. Impact of delirium was gone by 1 year. Discussion In this critically ill patient population followed for 1 year, ICU mobility positively impacted return to ADLs and improved ADLs over time but not readmissions. Delirium positive days decreased ADL scores, but the effect diminished over time.

Sona, Carrie; Taylor, Beth; Prentice, Donna; Schallom, Marilyn; schepis, Erin; Banaszynski, Stephanie; Wyman, Anna; George, Ramonda; Seley, Angela; willmann, gail Author Information

Schallom, Marilyn; Robertson, Laurie; Prentice, Donna; Schmid, Kristin; Walsh, Maura; Sona, Carrie; Wessman, Brian; Ablordeppey, Enyo Author Information

Many patients with DKA are admitted to Intensive Care Units (ICUs) due to restriction of insulin infusions outside of ICU areas. Our previous retrospective study showed that 37.0% of patients did not require admission to ICUs. Notably, reduced ICU admissions decrease costs and preserve bed availability for critical patients. Aim: To compare the clinical characteristics and hospital care among patients with DKA admitted to the ICU to those admitted to the non-ICU areas. Methods: A secondary analysis of collected data from the previous DKA study included 170 patients admitted from April-December 2017. Results: Of 170 emergency department (ED) patients, 96 (56.5%) were admitted to an ICU and 74 (43.5%) to non-ICUs; 72 (42.4%) had T1D, 82 (48.2%) had T2D, and 16 (9.4%) had other types of DM. Mean age was 46.9±16.0 years old. The length of ED stay was significantly shorter (4.68±2.4 vs. 9.5±4.4 hours, p<0.001) and the length of hospital stay significantly longer (6.2±11.2 vs. 3.1±3.9 days, p=0.03) in the ICU group than in the non-ICU group. Acute kidney injury (p=0.01), stroke and deep vein thrombosis (p=0.05), and substance abuse (p=0.03) were more common in the ICU group. Mean blood glucose, pH, anion gap, ketone, potassium, and lactate levels were significantly higher, while bicarbonate levels were significantly lower in the ICU group. Insulin (96.9%) and fluid (97.9%) infusions were more commonly used in the ICU group. Patients in the ICU group received more endocrine (p<0.001) and dietitian (p<0.006) consultations than those in the non-ICU group. Conclusions: Patients in the ICU group had more severe metabolic acidosis and other critical illnesses. Patients with uncomplicated DKA can be safely treated in the ED. Insulin drips should not be the criteria for ICU admission. Further study along with these data can help with the development of a severity scoring tool to identify the appropriate patients for ICU admissions. Disclosure A. Liu: None. K. Carmichael: None. M. Schallom: None. C. Arroyo: None.

Supplemental digital content is available in the text. GENERAL PURPOSE To outline a conceptual schema describing the relationships among the empirically supported risk factors, the etiologic factors, and the mitigating measures that influence pressure injury (PI) development in the critical care population. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will: 1. Choose a static intrinsic factor that increases the risk for the development of PI. 2. List several dynamic intrinsic risk factors for developing a PI. 3. Identify dynamic extrinsic risk factors that may predispose a patient to developing a PI. 4. Explain the pathophysiology of PI development. ABSTRACT BACKGROUND The first step in successful pressure injury (PI) prevention is to determine appropriate risk factors. In patients who are critically ill, PI risk is multietiologic, including the pathophysiologic impacts associated with a critical illness, concomitant preexisting comorbid conditions, and treatment-related factors that are essential in the ongoing management of a critical illness. OBJECTIVE To outline a conceptual schema describing the relationships among the empirically supported risk factors, the etiologic factors, and the mitigating measures that influence PI development in the critical care population. METHODS Risk factors for PI included in the conceptual schema were identified after a comprehensive review of the literature. Risk factors were categorized as static intrinsic factors, dynamic intrinsic factors, or dynamic extrinsic factors. RESULTS The schema illustrates the complex relationships between risk factor duration and intensity and the underlying etiology of PI development. The relationships among cumulative risk factors, etiologic factors, and mitigating measures for PI prevention are also outlined in the schema within the context of potentially unavoidable PI development. CONCLUSION Examining PI development in patients who are critically ill through the lens of a conceptual schema may guide future research endeavors focusing on the etiologic bases for PI development. It may also provide a framework to explore alternatives to current formal PI risk assessment in this unique subset of hospitalized patients.

Neumann, Larissa; Bulgarelli, Lucas; Barnes, Juan Alfonso Soler; Nabulsi, Hamza; Pollard, Tom; Schallom, Marilyn; Celi, Leo; Nazer, Lama Author Information

BACKGROUND:Removal of urinary catheters depends on accurate noninvasive measurements of bladder volume. Patients with acute kidney injury often have low bladder volumes/ascites, possibly causing measurement inaccuracy.OBJECTIVE:To evaluate the accuracy of bladder volumes measured with bladder scanning and 2-dimensional ultrasound (US) compared with urinary catheterization among different types of clinicians.METHODS:Prospective correlational descriptive study of 73 adult critical care patients with low urine output receiving hemodialysis or unable to void. Bladder volumes were independently measured by (1) a physician and an advanced practice registered nurse using US, (2) an advanced practice registered nurse and a bedside nurse using bladder scanning, and (3) urinary catheterization (cath). Bland-Altman and χ2 analyses were conducted.RESULTS:Mean (SD) cath volume was 171.7 (269.7) mL (range, 0-1100 mL). Abdominal fluid was observed in 28% of patients. Bias was -1.3 mL for US vs cath and 3.3 mL for bladder scanning vs cath. For patients with abdominal fluid and cath volume less than 150 mL, decisions to not catheterize patients were accurate more often when based on US measurements (97%-100%) than when based on bladder scanning measurements (86%-89%; P = .02). In patients with cath volume of 300 mL or more, decisions to catheterize patients were accurate more often when based on bladder scanning measurements (94%-100%) than when based on horizontal US measurements (50%-56%; P = .001).CONCLUSIONS:Bladder volume can be measured accurately with bladder scanning or US, but abdominal fluid remains a confounding factor limiting accuracy of bladder scanning.

As health IT has become overloaded with patient information, provider burnout and stress has accelerated. Studies have shown that EHR usage leads to heightened cognitive workload for nurses, and increases in cognitive workload can result in stronger feelings of exhaustion and burnout. We conducted a time motion study in an oncology division to examine the relationships between nurses' perceived workload, stress measured by blood pulse wave (BPw), and their time spent on nursing activities, and to identify stress associated with EHR use. We had a total of 33 observations from 7 nurses. We found that EHR-related stress is associated with nurses' perceived physical demand and frustration. We also found that nurses' perceived workload is a strong predictor of nurses' stress as well as how they spent time with their patients. They also experienced higher perceived mental demand, physical demand, and temporal demand when they were assigned to more patients, regardless of patient acuity. Our study presents a unique data triangulation approach from continuous stress monitoring, perceived workload, and a time motion study.

BACKGROUND Increasing mobility in the intensive care unit is an important part of the ABCDEF bundle. Objective To examine the impact of an interdisciplinary mobility protocol in 7 specialty intensive care units that previously implemented other bundle components. METHODS A staggered quality improvement project using the American Association of Critical-Care Nurses mobility protocol was conducted. In phase 1, data were collected on patients with intensive care unit stays of 24 hours or more for 2 months before and 2 months after protocol implementation. In phase 2, data were collected on a random sample of 20% of patients with an intensive care unit stay of 3 days or more for 2 months before and 12 months after protocol implementation. RESULTS The study population consisted of 1266 patients before and 1420 patients after implementation in phase 1 and 258 patients before and 1681 patients after implementation in phase 2. In phase 1, the mean (SD) mobility level increased in all intensive care units, from 1.45 (1.03) before to 1.64 (1.03) after implementation (P < .001). Mean (SD) ICU Mobility Scale scores increased on initial evaluation from 4.4 (2.8) to 5.0 (2.8) (P = .01) and at intensive care unit discharge from 6.4 (2.5) to 6.8 (2.3) (P = .04). Complications occurred in 0.2% of patients mobilized. In phase 2, 84% of patients had out-of-bed activity after implementation. The time to achieve mobility levels 2 to 4 decreased (P = .05). Intensive care unit length of stay decreased significantly in both phases. CONCLUSIONS Implementing the American Association of Critical-Care early mobility protocol in intensive care units with ABCDEF components in place can increase mobility levels, decrease length of stay, and decrease delirium with minimal complications.

Although the mortality rate associated with DKA has significantly reduced, hospitalizations for DKA are increasing. Identifying contributing factors for DKA admission could help target prevention efforts. Aims: To explore risk factors for DKA admissions, investigate clinical characteristics of DKA among hospitalized patients, and describe inpatient DKA management and discharge plan. Methods: We performed a retrospective analysis of adult patients’ medical records for DKA admissions from April-December 2017. Admission records from the year prior to 2017 review time period were also reviewed. Results: Of 200 patients, 79 (39.5%) had pre-existing T1D, 94 (47%) had pre-existing T2D, 12 (6%) had new-onset DM, and 15 (7.5%) had other type of diabetes. Metabolic acidosis was more severe in patients with T1D than in those with T2D. Most patients (61.8%) were admitted to ICU. Mean ICU stay was 1.6±3.1 days, and mean hospital stay was 5.4±9.0 days. Insulin (93%) and fluid (95%) infusion were used for initial DKA treatment. Sixty-four (35%) had ≥1 hypoglycemic event, and 29 (14.5%) had a recurrent DKA event during hospitalization. Mortality rate was 2.5% (n=5); 1 patient death (0.5%) was directly related to DKA. Prior DKA admission was observed in 62 (31%) with mean of 2.1±3.9 admissions and were more common in African Americans, patients 18-39 years of age, and those with a history of bipolar disorder or pancreatitis. Nonadherence to home insulin regimen was the predominant precipitating cause of prior DKA admissions. Majority of patients (84.5%) were discharged to home, of whom 41% received medication delivery, 64.2% had a scheduled follow-up appointment, and 21% had a home healthcare referral. Conclusions: Although patients with T1D had more severe acidosis, DKA admission in patients with T2D is as common as in those with T1D. Nonadherence is the leading precipitating factor of DKA readmissions. Future efforts should focus on reducing DKA recurrence and admission among vulnerable populations. Disclosure A. Liu: None. K. Carmichael: None. M. Schallom: None. C. Arroyo: None.

Objectives: To establish cutoff values for making recommendations for discharge to the home setting using standardized physical therapy assessments. Design: Retrospective study. Setting: Five ICUs at a large academic medical center. Patients: 1,203 ICU patients. Intervention: None. Measurements and Main Results: The Functional Status Score for the ICU and the ICU Mobility Scale were collected during the initial physical therapy assessment, at ICU discharge, and prior to hospital discharge. The Activity Measure for Post-Acute Care—Inpatient Mobility Short Form “6 clicks” was only collected during the initial physical therapy assessment. Receiver Operating Characteristic curves were used to determine a potential cutoff value for discharge home. The Receiver Operating Characteristic was adjusted for ICU and hospital length of stay along with mobility status prior to hospital admission. Cutoff values were then determined by using Youden’s Index. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated based on these cut off values. The Functional Status Score for the ICU at ICU discharge was the best predictor of a discharge to the home setting in patients who had an ICU admission. The area under the curve for the Functional Status Score for the ICU at ICU discharge was 0.80. A Functional Status Score for the ICU score at ICU discharge of 19 or higher predicted discharge to home with a sensitivity of 82.9% and specificity of 73.6% Conclusions: The Functional Status Score for the ICU at ICU discharge provided the best accuracy for making a timely recommendation for discharge home in patients who had an ICU admission.