Awake and Walking Approach Improved ICU Outcomes
Prioritizing patients’ wakefulness can improve mobility and lead to better outcomes.
The ABCDEF bundle and an Awake and Walking approach can decrease delirium and improve cognitive function for mechanically ventilated patients through early mobilization and reduced sedation.
“Creating a Culture of an Awake and Walking Intensive Care Unit: In-Hospital Strategies to Mitigate Post-Intensive Care Syndrome,” in Critical Care Clinics, details how prioritizing patients’ wakefulness can improve mobility and lead to better short- and long-term outcomes. This approach views mechanical ventilation as a tool to mobility rather than a barrier.
The case of a 59-year-old man with acute respiratory distress syndrome illustrates how a 16-bed ICU successfully implements the Awake and Walking and ABCDEF bundle protocols, emphasizing minimal sedation and initiating mobilization within 12 hours of ICU admission. The care team helps patients achieve their highest level of mobility three times daily, with each team member fulfilling their role in managing delirium, pain, sedation and mobility.
An AACN blog highlights elements of the ABCDEF bundle and the interdisciplinary teamwork required:
- Assess, prevent and manage pain
- Both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs)
- Choice of analgesia and sedation
- Delirium: assess, prevent and manage
- Early mobility and exercise
- Family engagement and empowerment
“Further, not implementing this bundle puts more strain on staff through increased time on the ventilator, time in the hospital, staff to care for patients, readmissions to the ICU and hospital, healthcare costs and, ultimately, nurse burnout,” the blog notes.
While the ABCDEF bundle underscores the importance of early mobilization, also consider a study in JAMA: The Journal of the American Medical Association that examined another critical component: screening frequency and SBT techniques. For critically ill adults on mechanical ventilation for more than 24 hours, neither the frequency of screenings (once daily vs. more frequently) nor the SBT technique (pressure-supported vs. T-piece) significantly affected time to extubation. However, combining more frequent screenings with pressure-supported SBTs led to an unexpected interaction, increasing the time to the first successful extubation.
Tech for Teamwork: App Boosts Nurse Satisfaction
The findings support environments where nurses feel heard and valued – and open communication.
A mobile app for front-line nurses to provide immediate feedback to leadership significantly improved workplace communication in a large U.S. hospital, leading to lower turnover rates and greater job satisfaction.
“Enhancing Nurse Satisfaction and Retention Through Real-Time Feedback: A Case Study at Los Angeles General Medical Center,” in Nurse Leader, suggests the findings support broader implementation of technology that facilitates open communication and fosters environments where nurses feel heard and valued.
In the six-month study, 321 nurses used the Joslin Insight app to provide immediate and ongoing feedback to the chief nursing officer (CNO). In turn, the CNO provided same-day responses and monthly emails updating nurses on plans to resolve issues or commend their successes.
During the study, the nurse turnover rate at Los Angeles General decreased by 9% compared with the previous year, and 90% of participants felt the app either improved or potentially improved communication with leaders. In addition, nurses felt more empowered and involved in decision making, and that leaders were more responsive to their concerns.
“As nurse leaders, it is essential to spearhead the adoption of similar technologies and practices within institutions,” the study notes, adding that leaders seeking to replicate this success should consider some key actions.
Leaders should:
- Prioritize using technologies that empower nurses to provide anonymous, real-time feedback to leadership.
- Increase their accessibility to nursing staff through digital and personal interactions.
- Encourage nurses to use feedback tools, and emphasize the importance of their input on organizational changes.
- Respond promptly with updates about actions taken in response to staff feedback.
- Understand how to manage feedback systems and respond constructively.
- Prioritize ongoing evaluation of the feedback system and be open to adjustments.
- Champion engagement, so nurses feel empowered to share their insights and participate in decisions affecting the workplace and patient care.
Nurses’ Healthy Work Environments Improved Patients’ Mortality Rate
Improving nurse work environments may help reduce health disparities.
Socially vulnerable Medicare patients were more likely to survive COVID-19 hospitalization in 2020 – an over 20% reduction in the odds of mortality – if the facilities had high ratings for nurse work environments.
“COVID-19 Mortality Disparities Among Socially Vulnerable Medicare Beneficiaries Associated With the Quality of Nurse Work Environments in U.S. Hospitals,” in Inquiry, notes that 585 patient deaths in two states could have been avoided had all the studied patients been admitted to hospitals with high-quality work environments for nurses. “Strengthening the quality of nurse work environments may help to reduce health disparities and should be considered in public health emergency planning, specifically in hospitals serving socially vulnerable communities,” the study adds.
The study used data from over 105,000 Medicare patients with COVID-19 admitted to 238 hospitals in Illinois and New York from communities identified through the Social Vulnerability Index. The findings note that “adults admitted to hospitals from the most socially vulnerable communities experienced nearly 50% higher risk of death compared to those in the least.” The probability of death for patients in the highest SVI quartile dropped from 30% at hospitals with the lowest ratings for a healthy work environment (HWE) to 22% at hospitals with the highest ratings.
The study used a five-element survey to measure the work environment, the short form of the Practice Environment Scale of the Nursing Work Index, which has five items: “(1) administration that listens and responds to employee concerns; (2) a nurse manager who is a good manager and leader; (3) a lot of team work between nurses and physicians; (4) enough staff to get the work done; and (5) a clear philosophy of nursing that pervades the patient care environment.”
AACN developed six HWE standards: skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition and authentic leadership. Creating and sustaining an HWE helps nurses provide the highest standards of compassionate care.
Benefits of Early Mechanical Ventilation for Patients With Sepsis
The cohort was composed of 2,527 ICU patients in Korea.
Patients with sepsis who received mechanical ventilation (MV) on the first day of ICU admission had better outcomes for ICU and in-hospital mortality and shorter hospital stays compared with patients starting MV later.
“Impact of the Timing of Invasive Mechanical Ventilation in Patients With Sepsis: A Multicenter Cohort Study,” in Critical Care, notes that early MV also was associated with less need for tracheostomy or renal replacement therapy, according to a previous retrospective review. “Our study, along with the previous studies, suggests the prompt cardiorespiratory stabilization provided by early MV may outweigh potential disadvantages in terms of ICU stay.”
The cohort included 2,527 patients with in Korea between 2019 and 2021 who were admitted to the ICU with sepsis and received MV. Those beginning MV the first day of ICU admission were referred to as early MV and all others were in the delayed MV group. There were 2,119 early MV and 321 delayed MV patients, with a propensity score matching for 295 patients in each group.
Among the propensity matched groups, ICU mortality was lower in the early MV group (38.4% vs. 45.2%), as were in-hospital mortality (47.7% vs. 54.8%), hospital duration (19 days vs. 24) and duration of ICU stay (7 days vs. 12). The early MV group also had less need for renal replacement therapy at ICU discharge.
The study notes that concerns over prolonged ICU stay may lead clinicians to delay MV because of the need for sedatives and paralyzing agents. “Contrary to this popular belief, early application of MV was associated with reduced length of ICU stay in our propensity score-matched cohorts.”
Study limitations include not being randomized, significantly fewer patients in the delayed MV group, and lack of precise timing for intubation. The study did not analyze the reason for intubation, which is “a complex process involving many factors such as clinical parameters, personal biases, and institutional policies/resources.”
AACN offers a dedicated webpage about nursing care of patents with sepsis, including guidelines and key resources.
Update on Treating ED Patients With Hypertension
The statement addresses the evidence for managing elevated inpatient BP (asymptomatic and hypertensive emergency).
Treating asymptomatic elevated blood pressure (BP) for patients in the emergency department (ED) should be the exception not the rule due to many risks, notes a scientific statement from the American Heart Association (AHA).
“The Management of Elevated Blood Pressure in the Acute Care Setting,” in Hypertension, notes the evidence gaps in understanding the benefits of antihypertensive medication for acute care patients who are asymptomatic despite elevated BP. “In the meantime, the best available evidence suggests a practical, common-sense approach to treatment of asymptomatic elevated inpatient BP, including repeating the BP measurement with a proper measurement technique and addressing all underlying conditions such as pain, anxiety, or other underlying illnesses, rather than focusing primarily on pharmacological interventions,” the statement adds.
Referring to guidance from the 2017 Hypertension Clinical Practice Guidelines, the new statement continues to recommend treatment for patients with hypertensive emergencies. Defining an inpatient’s asymptomatic elevated BP as SBP/DBP ≥ 130/80 mm Hg without evidence of new or worsening target-organ damage, the statement recommends looking for reversible causes, including medications and both legal and illegal substances.
Without any randomized trials on treating these patients, the risks of treatment include acute kidney injury, myocardial infarction and stroke. “Future studies are needed to further clarify whether there is clinical benefit for patients with markedly elevated hypertension without evidence of new or worsening target-organ damage,” the statement adds, suggesting multiple avenues of research.
Discharging patients who may need to manage hypertension should include “performing assessments to determine discharge readiness, educating patients and their families to encourage self-management, providing high-quality pharmaceutical care, and facilitating outpatient team-based care and home BP monitoring.” With data indicating that adherence to post-discharge medication is low, the statement encourages timely follow-up appointments and referrals to specialty care.
Transfusion Strategies for Patients With Acute Brain Injury
The trial included 72 ICUs in 22 countries from 2017 to 2022.
Intensive care patients with acute brain injuries who had a liberal blood transfusion strategy had lower rates of unfavorable neurological outcomes than patients with a restrictive strategy.
“Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury: The TRAIN Randomized Clinical Trial,” in JAMA: The Journal of the American Medical Association, notes that patients in the liberal strategy group had 10% fewer unfavorable outcomes at 180 days than those in the restrictive strategy group and were less likely to have at least one cerebral ischemic event. In addition to related trials, “these findings suggest that a liberal transfusion strategy in patients with acute brain injury might be associated with improved neurological outcome,” the trial notes.
The trial included 72 ICUs in 22 countries from 2017 to 2022. Patients with traumatic brain injury or hemorrhage received transfusions when their hemoglobin concentration reached less than 7 g/dL for the restrictive group and less than 9 g/dL for the liberal group. Of the 397 patients in the liberal group, 89.9% received at least one transfusion with 910 administered overall; of the 423 in the restrictive group, 205 received at least one transfusion, with 373 administered overall.
Unfavorable neurological outcomes occurred in 62.6% of patients in the liberal group and 72.6% in the restrictive group within 180 days, but there was an insignificant difference in 28-day mortality. At least one cerebral ischemic event occurred in 8.8% of patients in the liberal group and 13.5% in the restrictive group.
The Transfusion Strategies in Acute Brain Injured Patients (TRAIN) trial differs from other recent trials in its transfusion threshold, and the trial acknowledges that other triggers could be more effective in determining transfusion timing. “As such, given these limitations, these results remain exploratory and should be interpreted with caution,” the trial adds, while noting the potential introduction of bias.
Filipino Nurses: A Legacy Honored
A new documentary, “Nurse Unseen,” tells the history of often unsung Filipino nurses in the U.S. It also examines the impact and sacrifices they made during the COVID-19 pandemic. Read and watch Michele Josue, the film’s producer/director; and co-producer Arlyn Dela Pena Medendorp, an Army veteran and ICU nurse, share their filmmaking experiences and inspirations.