To promote the use of appropriate testing, and decrease unnecessary treatments, the ABIM Foundation established the Choosing Wisely campaign in 2012. Initially targeting physicians, the campaign has evolved to encourage all providers to promote high-value care; however, information related to critical care nursing is limited. To assess nurses' reports of the use of Choosing Wisely recommendations in critical care settings. Responses from nurses were examined as part of a critical care survey of members of 4 societies in order to assess awareness and use of the Choosing Wisely recommendations. Of the 1651 acute and critical care nurses who were members of the American Association of Critical-Care Nurses and responded to the survey, 632 (38.3%) reported being familiar with the Choosing Wisely campaign. Of these respondents, 200 identified as advanced practice nurses. A total of 620 reported implementing the 5 Critical Care Society Collaborative recommendations, including reducing diagnostic testing (n = 311 [50.2%]), reducing the number of red blood cell transfusions (n = 530 [85.5%]), not using parenteral nutrition in adequately nourished patients (n = 293 [47.3%]), not using deep sedation in patients receiving mechanical ventilation (n = 499 [80.5%]), and offering comfort care for patients at high risk for death (n = 416 [67.1%]). Staff education, specific protocols, electronic medical record alerts, and order sets all raised nurses' awareness of the recommendations. Acute and critical care nurses are directly involved with measures to reduce unnecessary testing and treatments. Greater awareness and championing of the Choosing Wisely recommendations by acute and critical care nurses can help to promote high-value care for acute and critically ill patients.

Despite a lack of data from intensive care patients, bispectral index monitors are often used to measure the depth of sedation for critically ill patients with acute respiratory distress syndrome (ARDS) who require continuous neuromuscular blocking agents. To evaluate differences in the effectiveness and safety of monitoring sedation by using bispectral index or traditional methods in patients with ARDS who are receiving continuous neuromuscular blocking agents. This noninterventional, single-center, retrospective cohort study included adult patients with ARDS who are receiving a neuromuscular blocking agent. Daily sedation and analgesia while a neuromuscular blocking agent was being administered were compared between patients with and patients without orders for titration based on bispectral index values. Clinical outcomes also were evaluated. Overall, sedation and analgesia did not differ between patients with and patients without titration based on bispectral index. Compared with patients without such titration, patients with bispectral index-based titration experienced more dose adjustments for the sedation agent (median [interquartile range], 7 [4-11] vs 1 [0-5], respectively, P < .001) and the analgesic (1 [0-2] vs 0 [0-1], respectively; P = .003) during the first 24 hours of neuromuscular blockade, but this was not associated with any difference in clinical outcomes. Titration based on bispectral index did not result in a significant difference in sedation or analgesia exposure, or clinical outcomes, from that achieved with traditional sedation monitoring in patients with ARDS who were receiving a neuromuscular blocking agent, despite more dose adjustments during the first 24 hours of receiving the neuromuscular blocking agent.

Patient immobility and a lack of physical activity in the intensive care unit results in a myriad of negative patient and hospital outcomes. To report research findings related to the use of exercise physiologists in promoting and providing aggressive and progressive early mobilization within the intensive care unit. This observational cohort study used the researcher-generated 12-point Activity Mobilization Evaluation Scale and delirium prevention bundle in 3 medical-surgical intensive care units to track patients' progress with mobilization. On average, most of the 216 patients in the study population realized a 1.6-point change (P < .001) in activity level with intervention by an exercise physiologist. Almost all of the study population (97%) maintained or increased the level of activity after receiving a minimum of 1 session with an exercise physiologist (mean, 3.5 sessions per day) during the 3-month study period. The introduction of exercise physiologists in the intensive care units proved to be a novel, safe, and effective strategy that maintained or increased the activity level of 97% of study patients.

Pain management in critically ill children is complex. Epidemiological research is needed to identify how often patients in pediatric intensive care units experience pain and the practices being used to lessen pain. To describe pain assessment and intervention practices in pediatric intensive care units, determine the prevalence of pain and painful procedures, and identify characteristics of children with moderate to severe pain. A 24-hour observational cohort study was conducted in 15 units. Nurses completed surveys regarding patients' communicative ability. Patients' records were reviewed for pain assessments, painful procedures, and pharmacologic and nonpharmacologic interventions. For the 220 patients in this study, pain was assessed a median (interquartile range) of 10 (7-13) times, usually with behavioral pain scales. Sixty-eight percent of patients received pharmacologic interventions and 44% received nonpharmacologic interventions. Fentanyl was the most common analgesic provided. Repositioning was the most common nonpharmacologic intervention. Forty-five percent of patients had pain and 24% had moderate to severe pain. Patients experienced a median (interquartile range) of 7 (2-15) painful procedures in 24 hours. More frequent pain assessments and pharmacologic interventions and the ability to communicate were associated with moderate to severe pain. No patient in the moderate to severe pain category received neuromuscular blockers. Critically ill children experience pain and multiple painful procedures daily. Assessment and intervention practices vary considerably. Research is needed to establish best practices for pain assessment in patients with limited communicative ability and to determine which pain management strategies improve patients' outcomes.

Delivery of patient education materials to promote health literacy is a vital component of patient-centered care, which improves patients' decision-making, reduces patients' anxiety, and improves clinical outcomes. To evaluate perceptions of television-based patient education among patients, caregivers, nurses, and other care providers (attending physicians, advanced practice nurses, physician assistants, and resident fellows) in the intensive care unit. A Likert-scale survey of the perceptions of patients, caregivers, nurses, and other care providers in the medical and cardiovascular intensive care units of a large academic medical center. Perceptions of the effects of television-based education on anxiety, knowledge, and health-related decision-making were assessed. A total of 188 participants completed the survey. Among them, 75% of nurses and 76% of other providers agreed or strongly agreed that television-based education improved patients' and caregivers' knowledge (P = .95). More nurses (47%) than other providers (29%) agreed that television-based education would lead to more informed health decisions by patients (P = .04). Patients and caregivers are 23 times more likely than providers to strongly agree that television-based education reduces anxiety, and they are more optimistic regarding the benefits of television-based education (relative risk ratio 23.47; 95% CI 9.75-56.45; P < .001). Patients and caregivers strongly suggested that television is a useful tool for providing health literacy education in an intensive care unit.

Approximately half of hospital-acquired pressure injuries identified among critical care patients are stage 1. Although stage 1 injuries are common, outcomes associated with them among critical care patients have not been examined. To examine the outcomes of stage 1 pressure injuries among critical care patients and to identify factors associated with worsening of pressure injuries. Electronic health records were used to determine which surgical critical care patients at a level I trauma center and academic medical center had stage 1 pressure injuries. Competing risk survival analysis was used to identify factors associated with worsening of pressure injuries. Review of 6377 patient records indicated that 259 patients (4.1%) experienced stage 1 injuries. The injuries persisted until discharge from the hospital in 92 patients (35.5%), worsened into injuries of stage 2 or greater in 84 (32.4%), and healed in 83 (32.0%). Patients whose pressure injuries worsened were more likely to be older (subdistribution hazard ratio [SHR], 1.02; 95% CI, 1.01-1.03; P = .002), or to have higher levels of serum lactate (SHR, 1.06; 95% CI, 1.02-1.10; P = .007), lower levels of hemoglobin (SHR, 0.82; 95% CI, 0.71-0.96; P = .01), or decreased oxygen saturation by pulse oximetry (< 90%; SHR, 1.50; 95% CI, 1.00-2.25; P = .05). Stage 1 pressure injuries worsen in about one-third of patients (32.4%). Nurses should consider maximal treatment for patients who are older or who experience alterations in oxygen delivery or perfusion.

Older adults account for more than half of all admissions to intensive care units; most remain alive at 1 year, but with long-term sequelae. To explore geriatric-focused practices and associated outcomes in older intensive care survivors. In a 1-year, retrospective, cohort study of patients admitted to the medical intensive care unit and subsequently transferred to the medicine service, adherence to geriatric-focused practices and associated clinical outcomes during intensive care were determined. A total of 179 patients (mean age, 80.5 years) met inclusion criteria. Nonadherence to geriatric-focused practices, including nothing by mouth (P = .004), exposure to benzodiazepines (P = .007), and use of restraints (P < .001), were associated with longer stay in the intensive care unit. Nothing by mouth (P = .002) and restraint use (P = .003) were significantly associated with longer hospital stays. Bladder catheters were associated with hospital-acquired pressure injuries (odds ratio, 8.9; 95% CI, 1.2-67.9) and discharge to rehabilitation (odds ratio, 8.9; 95% CI, 1.2-67.9). Nothing by mouth (odds ratio, 3.2; 95% CI, 1.2-8.0) and restraints (odds ratio, 2.8; 95% CI, 1.4-5.8) were also associated with an increase in 30-day readmission. Although 95% of the patients were assessed at least once by using the Confusion Assessment Method for the Intensive Care Unit (overall 2334 assessments documented), only 3.4% had an assessment that indicated delirium; 54.6% of these assessments were inaccurate. Although initiatives have increased awareness of the challenges, implementation of geriatric-focused practices in intensive care is inconsistent.

Health care work environments affect patient outcomes, staff satisfaction and retention, and organizational financial viability. The American Association of Critical-Care Nurses (AACN) Healthy Work Environment Assessment Tool (HWEAT) is a resource for patient care units and organizations to assess the work environment and track progress on their journey to excellence. To validate interprofessional use of the AACN HWEAT across a large free-standing children's hospital. The AACN HWEAT was administered to staff members across professional categories. Responses were averaged to achieve an overall score and a score for each standard included in the instrument. Nurses' and physicians' scores were further stratified. Test-retest reliability and internal consistency were assessed. Construct validity was measured by correlating the AACN HWEAT and the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (H-SOPS). Of 2621 AACN HWEAT surveys, 1030 (39.3%) were returned for review. The organization-wide HWEAT mean overall score was 3.58 (3.87 for physicians vs 3.54 for nurses, P= .02). Test-retest reliability was indicated by Spearman correlation coefficients of 0.50 to 0.68. Internal consistency was shown by a Cronbach α of 0.77 overall (range for standards, 0.77-0.81). Convergent validity between AACN HWEAT standards and AHRQ H-SOPS items was shown by correlation coefficients of 0.30 to 0.52. The AACN HWEAT was both reliable and valid, supporting its interprofessional use as an organizational measure. Active evaluation of health care environments is critical to achieving optimal patient outcomes.