American journal of critical care : an official publication, American Association of Critical-Care Nurses
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Pediatric traumatic brain injury (TBI) protocols vary widely among institutions, despite the existence of published guidelines. This study seeks to identify significant differences in management of pediatric TBI across several institutions. Severe pediatric TBI protocols were collected from major US pediatric hospitals through direct communication with trauma staff. ⋯ However, significant variation across institutions was found regarding timing of cerebrospinal fluid drainage, hyperventilation, and neuromuscular blockade. When included in institutional protocols, most therapies are in line with the 2019 guidelines, except for diversion of cerebrospinal fluid, hyperventilation, maintenance of cerebral perfusion pressure, and use of neuromuscular blocking agents. Although these variations may represent differences in style or preference, the optimal timing of these specific treatment variations should be studied to determine the impact of each protocol on clinical outcomes.
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Observational Study
Unplanned Transfers From Intermediate Care Units to Intensive Care Units: A Cohort Study.
This study evaluated unplanned transfers from the intermediate care unit (IMCU) to the intensive care unit (ICU) among urgent admissions. This retrospective, observational study was conducted in 2 ICUs and 1 IMCU. Three patterns of urgent admission were assessed: admissions to the ICU only, admissions to the IMCU only, and admissions to the IMCU with subsequent transfer to the ICU. ⋯ Mortality was higher in patients transferred from the IMCU to the ICU than in the 3900 ICU-only patients (odds ratio, 3.22; 95% CI, 1.52-6.80). Most transfers from the IMCU to the ICU (135; 78.5%) were due to deterioration of the condition for which the patient was admitted. Patient transfers from the IMCU to the ICU were common, were associated with increased hospital mortality, and were mostly due to deterioration in the condition that was the reason for admission.
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The Glasgow Coma Scale was developed in 1974 as an injury severity score to assess and predict outcome after traumatic brain injury. The tool is now used to score depth of impaired consciousness in patients with and without traumatic brain injury. However, evidence supporting the use of the Glasgow Coma Scale in the latter group is limited. ⋯ The Glasgow Coma Scale is not recommended for use in patients without traumatic brain injury; clinicians should use a more appropriate and validated clinical assessment instrument for this patient population.
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For decades, medication titration has been within nurses' scope and practice. In 2017 The Joint Commission (TJC) revised elements for orders for the titration of continuous intravenous medications. ⋯ The standards from TJC impose harm by eroding workplace wellness and introducing moral dilemmas and patient safety concerns. Professionalism is threatened through limits on scope and autonomy. Further advocacy is necessary in order to resolve unanticipated consequences related to the titration standards.
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Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses' autonomous decision-making. ⋯ Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.