Effects of Safety Zone Implementation on Perceptions of Safety and Well-being When Caring for COVID-19 Patients

Background In March 2020, the caseload of patients positive for COVID-19 in hospitals began increasing rapidly, creating fear and anxiety among health care workers and concern about supplies of personal protective equipment. Objectives To determine if implementing safety zones improves the perceptions of safety, well-being, workflow, and teamwork among hospital staff caring for patients during a pandemic. Methods A safety zone process was implemented to designate levels of contamination risk and appropriate activities for certain areas. Zones were designated as hot (highest risk), warm (moderate risk), or cold (lowest risk). Caregivers working in the safety zones were invited to complete a survey regarding their perceptions of safety, caregiver well-being, workflow, and teamwork. Each question was asked twice to obtain caregiver opinions for the periods before and after implementation of the zones. Results Significant improvements were seen in perceptions of caregiver safety (P < .001) and collaboration within a multidisciplinary staff (P < .001). Significant reductions in perceived staff fatigue (P = .03), perceived cross contamination (P < .001), anxiety (P < .001), and fear of exposure (P < .001) were also seen. Teamwork (P = .23) and workflow (P = .69) were not significantly affected. Conclusions Safety zone implementation improved caregivers’ perceptions of their safety, their well-being, and collaboration within the multidisciplinary staff but did not improve their perceptions of teamwork or workflow.

Bereavement Experiences of Families in the Cardiac Intensive Care Unit

Background Losing a loved one in the intensive care unit is associated with complicated grief and increased psychologic distress for families. Providing bereavement support may help families during this time. However, little is known about the bereavement experiences of families of patients in the cardiac intensive care unit. Objective To describe the bereavement experiences of families of patients in the cardiac intensive care unit. Methods In this secondary analysis, an exploratory, descriptive design was used to understand the families’ bereavement experiences. Families from 1 cardiac intensive care unit in a tertiary medical center in the western United States participated. Audiotaped telephone interviews were conducted by using a semistructured interview guide 13 to 15 months after the patient’s death. A qualitative, descriptive technique was used for data analysis. Two independent researchers coded the interview transcripts and identified themes. Results Twelve family members were interviewed. The majority were female (n = 8, 67%), spouses (n = 10, 83%), and White (n = 10, 83%); the mean age (SD) was 58.4 (16.7) years. Five main themes emerged: (1) families’ bereavement work included both practical tasks and emotional processing; (2) families’ bereavement experiences were individual; (3) these families were resilient and found their own resources and coping mechanisms; (4) the suddenness of a patient’s death influenced families’ bereavement experiences; and (5) families’ experiences in the intensive care unit affected their bereavement. Conclusions This study provided insight into the bereavement experiences of families of patients in the cardiac intensive care unit. These findings may be useful for professionals working with bereaved families and for cardiac intensive care units considering adding bereavement support.

Interprofessional, Interdisciplinary, or Multidisciplinary?

As a longtime researcher in interprofessional collaborative care and deputy editor-in-chief of the Journal of Interprofessional Care, I was dismayed by the imprecise use of language in the article by Colbenson et al.1 The title says “interprofessional,” the first sentence of the abstract says “interdisciplinary,” and the abstract also uses the word “multidisciplinary.” These words have different meanings and are not interchangeable. The first implies collaborative interactions, the second is often used by physicians to imply physicians with different specialties interacting (eg, oncologist and pathologist), and the third simply means that persons from different professions are in the same space per- haps working in parallel, perhaps sequentially. Another term the authors use, “ICU [intensive care unit] teams,” may or may not actually be working as teams, but the terms are not defined. The theme “interdisciplinary dynamics” is really about multidisciplinary interactions and is minimally described. If nurses feel devalued and not involved in decision-making, the dynamics are not interprofessional or even interdisciplinary.

Individualized Family-Centered Developmental Care for Infants With Congenital Heart Disease in the Intensive Care Unit

Background Individualized family-centered developmental care (IFDC) is considered the standard of care for premature/medically fragile newborns and their families in intensive care units (ICUs). Such care for infants with congenital heart disease (CHD) varies. Objective The Consortium for Congenital Cardiac Care– Measurement of Nursing Practice (C4-MNP) was surveyed to determine the state of IFDC for infants younger than 6 months with CHD in ICUs. Methods An electronic survey was disseminated to 1 nurse at each participating center. The survey included questions on IFDC-related nursing practice, organized in 4 sections: demographics, nursing practice, interdisciplinary practice, and parent support. Data were summarized by using descriptive statistics. Differences in IFDC practices and IFDC-related education were assessed, and practices were compared across 3 clinical scenarios of varying infant acuity by using the χ2 test. Results The response rate was 66% (25 centers). Most respondents (72%) did not have IFDC guidelines; 63% incorporated IFDC interventions and 67% documented IFDC practices. Only 29% reported that their ICU had a neurodevelopmental team. Significant differences were reported across the 3 clinical scenarios for 11 of 14 IFDC practices. Skin-to-skin holding was provided least often across all levels of acuity. Nurse education related to IFDC was associated with more use of IFDC (P < .05). Conclusion Practices related to IFDC vary among ICUs. Opportunities exist to develop IFDC guidelines for infants with CHD to inform clinical practice and nurse education. Next steps include convening a C4-MNP group to develop guidelines and implement IFDC initiatives for collaborative evaluation.

Psychometric Properties of the Barthel Index Used at Intensive Care Unit Discharge

Background The Barthel Index, originally developed and validated to assess activities of daily living in patients with neuromuscular disorders, is commonly used in research and clinical practice involving critically ill patients. Objectives To evaluate the internal consistency, reliability, measurement error, and construct validity of the Barthel Index used at intensive care unit discharge. Methods In this observational study, 2 physiotherapists measured the physical functioning of 122 patients at intensive care unit discharge, using the Barthel Index and other measurement instruments. Results The patients had a median (IQR) age of 56 (47-66) years, and 62 patients (51%) were male. The primary reason for intensive care unit admission was sepsis (28 patients [23%]), and 83 patients (68%) were receiving mechanical ventilation. The Cronbach α value indicating internal consistency was 0.81. For interrater reliability, the intraclass correlation coefficient for the total score was 0.98 (95% CI, 0.97-0.98; P < .001) and the κ statistic for the individual items was 0.54 to 0.94. The standard error of measurement was 7.22, the smallest detectable change was 20.01, and the 95% limits of agreement were –10.3 and 11.8. The Barthel Index showed moderate to high correlations with the other physical functioning measurement instruments (ρ = 0.57 to 0.88; P < .001 for all). Conclusion The Barthel Index is a reliable and valid instrument for assessing physical functioning at intensive care unit discharge.

Using Telehealth to Improve the Accuracy of Delirium Screening by Bedside Critical Care Nurses

Background Delirium affects up to 80% of patients in the intensive care unit (ICU) but is missed in up to 75% of cases. Telehealth in the ICU (tele-ICU) has become the standard for providing timely, expert care to remotely located ICUs. Objectives This pilot study assessed the feasibility and acceptability of using tele-ICU to increase the accuracy of delirium screening and recognition by ICU nurses. Methods The pilot sites included 4 ICUs across 3 hospitals. A geriatrician with delirium expertise remotely observed 13 bedside ICU nurses administering the Confusion Assessment Method for the ICU (CAM-ICU) to patients in real time via the tele-ICU platform and subsequently provided training on CAM-ICU performance and delirium management. Training evaluation consisted of a validated spot check form, a 2-item satisfaction/change-of-practice survey, and a qualitative question on acceptability. Results Thirteen ICU nurses were observed performing 26 bedside delirium assessments. The top observed barriers to accurate delirium screening were CAM-ICU knowledge deficits, establishment of baseline cognition, and inappropriate use of the “unable to assess” designation. The mean percentage of correct observations improved from 40% (first observation) to 90% (second observation) (P < .001). All 13 nurses strongly agreed that the training was beneficial and practice changing. Conclusions The use of tele-ICU to improve the accuracy of delirium screening by ICU nurses appears to be feasible and efficient for leveraging delirium expertise across multiple ICUs. Future studies should evaluate the effects of tele-ICU delirium training on patient-centered outcomes.