Necrotizing enterocolitis (NEC) remains one of the most catastrophic comorbidities associated with prematurity. In spite of extensive research, the disease remains unsolved. The aims of this paper are to present the current state of the science on the pathogenesis of NEC, summarize the clinical presentation and severity staging of the disease, and highlight the nursing assessments required for early identification of NEC and ongoing care for infants diagnosed with this gastrointestinal disease. The distributions of systemic and intestinal clinical signs that are most sensitive to nursing assessment and associated with Bell Staging Criteria are presented. This descriptive data is representative of 117 cases of NEC diagnosed in low gestational age infants (<29 weeks gestation). The data highlights the clinical signs most commonly observed in infants with NEC, and thus, provides NICU nurses an evidence-based guide for assessment and care of infants with NEC.

Background Delirium is a common, underdetected problem that has short- and long-term negative sequelae for critically ill patients. Prompt and accurate delirium identification by nurses can ensure early intervention and treatment to help minimize adverse outcomes. Objectives To evaluate the relationship between an educational program and the accuracy of registered nurses' (RNs') documentation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a delirium screening tool. Methods In a medical ICU at a tertiary academic medical center from September 2015 to March 2016, RNs were reinstructed on use of the CAM-ICU. Registered nurse assessment data were collected retrospectively for 12 months before and after intervention and were compared against the CAM-ICU algorithm using χ2 analysis. Results A total of 10 736 RN assessments in 1020 patients preintervention and 11 068 in 951 patients postintervention were evaluated. Overall RN accuracy improved from 78% to 80% (P = .054). The algorithm determined delirium to be present in 32% versus 30% of all patients preintervention and postintervention, respectively; there was no difference in rate of nurse detection of delirium preintervention and postintervention (54% vs 55%, not statistically significant). The percentage of “inappropriate unable to assess” ratings by nurses decreased from 42% to 37% postintervention (P < .05). Conclusions After a comprehensive training initiative, there was no significant improvement in CAM-ICU documentation and no improvements in patient delirium identification. Future quality improvement efforts should target reducing the number of assessments that RNs judge to be “unable to assess.” Clinical practice must evolve to routinely incorporate RN delirium assessments into the patient's plan of care.

OBJECTIVES: Evaluate the efficacy of interventions to improve symptoms for ICU surrogates at highest risk of developing psychologic distress: those facing end-of-life care decisions. DATA SOURCES: MEDLINE, CINAHL, PsycInfo, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched through April 16, 2022. STUDY SELECTION: Following an a priori protocol, randomized trials of interventions delivered to surrogates of adult ICU patients who died or had high likelihood of mortality evaluating surrogate symptoms were identified. DATA EXTRACTION: Two reviewers performed screening and data extraction and assessed risk of bias (Cochrane Risk of Bias [RoB] 2 tool). Trials were eligible for meta-analysis if group mean symptom scores were provided at 3 or 6 months. Pooled effects were estimated using a random effects model. Heterogeneity was assessed (Cochrane Q, I2). Certainty of evidence was assessed (Grading of Recommendations Assessment, Development and Evaluation). DATA SYNTHESIS: Of 1,660 records, 10 trials met inclusion criteria representing 3,824 surrogates; eight were included in the meta-analysis. Overall RoB was rated Some Concerns. Most (n = 8) interventions focused on improving communication and enhancing psychologic support in the ICU. All trials measured anxiety, depression, and posttraumatic stress. Significant improvement was seen at 3 months (depression, mean difference [MD], –0.68; 95% CI, –1.14 to –0.22, moderate certainty; posttraumatic stress, standardized MD, –0.25; 95% CI, –0.49 to –0.01, very low certainty) and 6 months (anxiety, MD, –0.70; 95% CI, –1.18 to –0.22, moderate certainty). Sensitivity analyses suggest significant findings may be unstable. Subgroup analyses demonstrated differences in effect by trial location, interventionist, and intervention dose. CONCLUSIONS: Communication and psychological support interventions in the ICU yielded small but significant improvement in psychological symptoms with moderate to very low certainty evidence in a prognostically-enriched sample of ICU surrogates facing end-of-life care decisions. A new approach to interventions that extend beyond the ICU may be needed.

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Background Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. Review of Evidence A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. Implementation An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. Evaluation This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. Sustainability Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. Conclusions Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

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Background Antibiotics are commonly used in the nursing home (NH) setting and increase residents’ risk for opportunistic and painful infections. Existing evidence of NH residents’ experiences and attitudes towards antibiotic use is limited. We aimed to explore NH residents’ experiences and perceptions of the benefits and risks to antibiotic treatment. Methods Two researchers conducted one-on-one semi-structured interviews with residents residing in a large not-for-profit NH in New York City. Interviews were audio-recorded and transcribed verbatim. Researchers coded the transcripts using thematic analysis in NVivo 12. Results A total of 26 residents engaged in individual interviews. Participants had a mean age of 76. Most were white (81%), female (58%) and had attended college (58%). Four thematic findings emerged: 1) participants’ involvement in antibiotic treatment decisions; 2) perceived benefits and risks to antibiotics; 3) unmet informational needs; and 4) suggestions to overcome informational needs. Participants described varied involvement in antibiotic treatment decisions, in which some participants described insisting antibiotics from their clinicians and others described leaving antibiotic treatment decisions entirely to the judgement of clinicians. Benefits of antibiotics were well-articulated, yet risks (side effects including antibiotic resistance) to antibiotics were poorly described. Participants reported unmet information needs, including concerns regarding potential drug interactions. Information needs were described to result from a lack of communication with NH staff and/or poor memory among NH residents. Participants suggested that NH residents receive written material regarding their antibiotic prescriptions and provided the types of information that would be helpful for NH residents to know. Descriptions of themes and representative quotes are provided in Figure. Table. Thematic Findings and Representative Quotes Conclusion NH residents expressed a lack of understanding of risks to antibiotic use, unmet informational needs regarding their antibiotic treatments and articulated suggestions to address these information needs. Disclosures All Authors: No reported disclosures