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A Nurse-Teacher’s Thanksgiving Reflections

By: Fidelindo Lim, DNP, CCRN
Clinical Assistant Professor
New York University College of Nursing

         The nursing profession continues to evolve. My role as a nursing faculty allows me the privilege to see future nurses embrace what is yet to be, beyond the linear columns of the nursing care plan. What I see students do in clinical, outside the bulleted educational outcomes, are subtle reminders that caring cannot be truly taught in school, they simply manifest as the natural, almost evolutionary tendencies of women and men in nursing. Recently, a student of mine spent a good hour braiding the hair of her patient who was diagnosed of stage 4 ovarian cancer – two days earlier. The patient had bilateral above knee amputation and will probably never set foot in a hair salon, but the student brought a semblance of normalcy to a life thrown off balance. Outside the room, I could hear beauty parlor reflective conversation between the student nurse and the patient. Suddenly, cancer seems insignificant. When the patient examined her neatly arranged corn rows in front of the mirror, we all saw life, not imminent death. I often recall this story to myself to remind me that the very essence of nursing is human bonds. As a faculty, I partner with my students not simply to teach them learn the ropes but to strengthen nursing’s umbilical connection with life – till the end.

This Thanksgiving…

Think and thank those who continue to move us in positive ways, including the patients who enrich our nursing practice simply because their lives have crossed with ours – by accident or incident.

Note:  The above essay was chosen one of the 12 winners of Inspired Nurses contest through Lippincott Solutions. The essay will be featured in the 2016 Lippincott Publisher calendar.


Are we over-treating fever?



Nurse Practitioner, ICU – Memorial Sloan Kettering Cancer Center in NYC

“You took away her fever. You raised her spirit.” Those words echoed to the tune of soft pleasant music in the new Tylenol commercial. The uplifting, alleviating effect of antipyretics can be attested by many who have suffered from a fever at one point in their life. I still remember in simulation labs, we’re quizzed on the temperature considered to be febrile and our expected immediate follow-up answer of “I’ll administer some Tylenol”. Treating fevers has been drilled into our core medical knowledge. But in actuality, our ability to mount a fever stem from an evolutionary need to survive from an infection and to take it away may not be beneficial.

Our body’s ability to generate heat actually produces a hostile environment for bacterial growth. In vitro studies have shown that pathogen growth is stunted at a core temperature above 37 degrees Celsius. (1) In clinical studies, the patients who are able to generate a febrile response have been associated with lower risk of mortality. (2)(3) Of course, fever has its downsides, including increasing metabolic demand, oxygen demand and in children, potential febrile seizures. So what are we to do? Do we treat the fever or do we not treat the fever? And what do we do about fever in the ICU population? To help us answer the question, the Acetaminophen for Fever in Critically Ill Patients with Suspected Infection study (HEAT trial) has just been published by New England Journal of Medicine. In the study, researchers randomized 700 ICU patients with fever (body temperature>38 degrees Celsius) to either receiving IV Tylenol or placebo every 6 hours until ICU discharge, resolution of fever, cessation of antibiotics, or death. The primary outcome was ICU-free days from randomization to day 28 on follow-up.delete

The result of this study showed that early administration of Tylenol to treat fever due to probably infection had no effect on the number of ICU-free days. (4)This study adds on to the increasing number of negative trials showing that less intervention or more conservative management strategies are acceptable and does not cause harm. Given that ICU patients are already at risk for organ dysfunction in the setting of polypharmacy and their critical illness, I hesitate to further burden their system with Tylenol. Therefore, in patients with suspected infection, antibiotic is the ultimate treatment and antipyretics should only be an afterthought.


  1. Prescott, Lansing M, John P. Harley, Donald A. Klein, Gloria Delisle, and Lewis Tomalty. Microbiology. Boston, Mass: WCB/McGraw-Hill, 1999. Print
  2. Weinstein MP, Iannini PB, Stratton CW, Eickhoff TC. Spontaneous bacterial peritonitis. A review of 28 cases with emphasis on improved survival and factors influencing prognosis. Am J Med. 1978 Apr;64(4):592-8.
  3. Ahkee S, Srinath L, Ramirez J. Community-acquired pneumonia in the elderly: association of mortality with lack of fever and leukocytosis. South Med J. 1997 Mar;90(3):296-8.
  4. Young et al. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. N Engl J Med. 2015 Oct 5. [Epub ahead of print]

Understanding Antibiotic Resistance and How to Prevent It

By: Fidel Lim, DNP, CCRN

Faculty- NYU College of Nursing

More that eighty years ago Alexander Fleming identified Penicillin. After returning from vacation, he found that a mold inhibited bacterial growth around a staphylococcus culture dish. It wasn’t until D-Day in 1944 when the drug fully made its public health debut, when enough of it became available to allow unlimited treatment of allied service men suffering from infections.

A World War II ad reads: “Penicillin kills gonorrhea in four hours. See your doctor today.” Well, a lot has happened since the medical establishment prematurely declared victory over infectious diseases with the discovery antibiotics (Sulfa was the first antibiotic used in 1938). Today’s headlines are much more likely about fears of new epidemics like the Ebola, Middle East Respiratory Syndrome (MERS) and Clostridium infection the growing menace of antibiotic resistance.

Antibiotic resistance is not exactly a new phenomenon. In the 1940s and 50s Streptomycin and INH (Isoniazid) already showed some resistance to the TB bacilli (Porter, 1997). According to the 1998 report of the Institute of Medicine’s forum on Emerging Infections, strains of Staph Aureus resistant to Penicillin were isolated as early as 1945. The chairman of the forum testified that resistance inevitably occurs as bacteria adapt to the presence of antibiotic in their environment.

Today we have MRSA, VRE, VISA, VRSA and MDRTB or XD RTB. If you know what these letters stand for, then chances are you have taken cared of a patient with a resistant infection. And for sure you have already been to at least one conference telling us how astronomically expensive it is to treat resistant infections, not to mention the high rate of mortality.

How do Bacteria Become Resistant?

How bacteria develop resistance against antibiotics is simply a manifestation of the Darwinian notions of the struggle for existence. Bacteria evolve in order to survive. The CDC informs us that bacteria may develop the ability to neutralize or evade the effect of the antibiotic. Exposure to antibiotics therefore provides selective pressure, which makes the surviving bacteria more likely to be resistant.

In addition, bacteria that were at one time susceptible to an antibiotic can acquire resistance through mutation of their genetic material or by acquiring pieces of DNA that code for the resistance properties from other bacteria. The DNA that codes for resistance can be grouped in a single, easily transferable package. This means that bacteria can become resistant to many antimicrobial agents because of the transfer of one piece of DNA. Some bacteria develop the ability to neutralize the antibiotic before it can do harm, others can rapidly pump the antibiotic out, and still others can change the antibiotic attack site so it cannot affect the function of the bacteria (for the full article, log on to

In March 1994, Newsweek magazine published “The End of Antibiotics.” The article warned the public that by means of some clever mechanism, bacteria creates resistance by dismembering the drug, by changing the bacterial cell wall so that antibiotics can’t get in or by pumping out the antibiotics out of the bacteria.

Human hosts are not exactly the helpless victims in the creation of resistance. We live in the age of pills – patients often demand antibiotics from physicians and Nurse Practitioners and too often they are accommodated. An interview with a British doctor in the 1980s revealed what might be a common practice at the time, not only in Britain but elsewhere. It informed that prescribing pills was a way of avoiding a more time-consuming analysis and treatment. Writing a prescription (antibiotics) pleases the patient and relieves the physician of his or her high case volume. Repeated and improper uses of antibiotics are primary the causes of the increase in drug-resistant bacteria.

However, no matter how grim the predictions may be, the situation is not hopeless. A Wall Street Journal article “Curbing Antibiotic Use in War on ‘Superbugs’” (September 3, 2008- reported by Laura Landro)  informed us that hospitals are turning to a new breed of antibiotic SWAT team to win the war against resistant organism. The effort known as antimicrobial stewardship programs will team top pharmacist, infectious disease specialists and microbiologist. This group will monitor the hospital’s use of antibiotics and restrict prescription of certain drugs (for example: Vancomycin) when they become resistant. These new efforts is partially the result of the federal Medicare program plans not to reimburse preventable hospital acquired infections, many of which are cause by resistant organisms.

Nurses’ Role in Preventing Antibiotic Resistance

As a Staff Nurse:

  • Be vigilant with how your unit utilizes antibiotics – ask your local ID team
  • Actively participate in “Pharmacy Committee” meetings and learn what your hospital is doing to address antibiotic resistance
  • Always give antibiotics on time and avoiding skipping a dose
  • Check your patient’s Culture and Sensitivity reports and act as a patient advocate by informing the M.D. if the bacteria are sensitive to a narrow-spectrum antibiotic (preferred than a broad-spectrum antibiotic)
  • Always observe Standard and Contact precautions when caring for patients with resistant organism infections
  • Participate in unit-based surveillance studies to look at trends of resistant infection
  • Read evidence-based and best practice recommendation by logging on to:

What the General Public Can Do to Prevent Antibiotic Resistance

The CDC recommends:

  • Talk with your healthcare provider about antibiotic resistance:
    • Ask whether an antibiotic is likely to be beneficial for your illness
    • Ask what else you can do to feel better sooner
  • Do not take an antibiotic for a viral infection like a cold or the flu.
  • Do not save some of your antibiotic for the next time you get sick. Discard any leftover medication once you have completed your prescribed course of treatment.
  • Take an antibiotic exactly as the healthcare provider tells you. Do not skip doses. Complete the prescribed course of treatment even if you are feeling better. If treatment stops too soon, some bacteria may survive and re-infect.
  • Do not take antibiotics prescribed for someone else. The antibiotic may not be appropriate for your illness. Taking the wrong medicine may delay correct treatment and allow bacteria to multiply.
  • If your healthcare provider determines that you do not have a bacterial infection, ask about ways to help relieve your symptoms. Do not pressure your provider to prescribe an antibiotic.

The pharmaceutical revolution that started in the 1950s has no doubt saved millions of lives, but is has also brought in new unimaginable problems. In his best selling book “The Greatest Benefit to Mankind: A Medical History of Humanity, Roy Porter tells us “the euphoria of the age of Penicillin has turned to anxiety…medicine will have to redefine its limits even as it extends its capacity”. Antibiotic resistance may be inevitable, but we must take a cue from the bacteria itself: we have to evolve in the way we treat and prevent infections if we are to survive.


Global consensus conference on infection control issues related to antimicrobial resistance: final recommendations. American Journal of Infection control. 1999;27(6):503-13.

Porter R. The Greatest Benefit to Mankind: A medical history of humanity. New York: W.W. Norton and Company:1997.

Begley S. The end of antibiotics. Newsweek. 1994; March 28:49-52.

Landro L. Curbing antibiotic use in war on ‘superbugs’. Wall Street Journal. September 3, 2008.

Barry J. The great influenza. New York:Viking:2004.

CDC. Get smart: know when antibiotics work. Available at: Accessed on September 15, 2008.

Going Banana Over Potassium

By Fidelindo Lim, DNP, CCRN

Clinical Assistant Professor

New York University College of Nursing

Among the many electrolytes, potassium takes celebrity status. It commands attention from most clinicians and it is perhaps the most prescribed electrolyte replacement after sodium chloride, followed by magnesium and phosphorous. In Cardiac Units, it is one of the staple drugs, the clinical twin of digoxin. Name brand orange juice products, bottled water and milk are now advertised as “potassium-rich” to lure not only the cardiac-compromised consumers but the general public. Potassium – it does the body good!

The Health Benefits of Potassium

When patients ask why we are giving them potassium, our standard reply is “it’s good for your heart.” But there is more to that. According to the National Council on Potassium in Clinical Practice (Cohn, Kowey, Whelton, & Prisant, 2000) there is evidence to support that high potassium diets may reduce the risk of stroke. As every nurse already know, sodium and potassium have an inverse relationship. Diets high in sodium will not only lead to hypertension, but it will also promote urinary excretion of potassium and therefore loose its health benefits. So, potassium can reduce stroke by lowering sodium levels and consequently maintaining normal blood pressure.

Studies also show that reduction in blood pressure after potassium supplementation is three times higher in African-Americans than in White Americans. This is not new. Caralis et al. (1984), suggests that when potassium level is below 3.5 mmol/L, potassium supplementation is essential even in asymptomatic patients with mild to moderate hypertension.

For patients with history of arrhythmia and myocardial infraction (MI), the threshold for potassium replacement is higher, at 4.0 mmol/L. The association between higher mortality from MI and ventricular fibrillation patients with potassium levels less than 3.9 mmol/L  (normal range: 3.5 to 5.0  mmol/L  has been known for some time (Duke, 1978). This knowledge becomes more important than ever based on the findings that currently, less than 2% of Americans consume the recommended minimum daily requirement for potassium, due primarily to inadequate plant food intake (, n.d.).

Another important consideration is for patient’s taking digitalis. The effect of digitalis is enhanced in the presence of hypokalemia. Maintaining a normal potassium level is important in preventing digoxin toxicity and minimizing the potential adverse reactions of digitalis.

Pass the dried figs please…

          Potassium should come from food sources. Fruits and vegetables are excellent sources of potassium. Its bicarbonate precursors, favorably affect acid-base metabolism, which may reduce risk of kidney stones and bone loss (, 2008). Potassium-rich fruits and vegetables include leafy green vegetables, fruit from vines, and root vegetables. The recommended daily intake for potassium is as follows (, 2008):

Age Group Recommended Daily Intake
Children 1 to 3 years of age 3,000 mg/day
Children 4 to 8 years of age 3,800 mg/day
Children 9 to 13 years of age 4,500 mg/day.
Adolescents and Adults 4,700 mg/day.

When teaching patients about dietary sources of potassium, most nurses stop short at bananas, although it contains average amounts of potassium compared with other food sources. One medium banana has approximately 422 mg of potassium; whereas one baked sweet potato has 694 mg (131 calories) (, 2008). The New England Journal of Medicine published the following categories of excellent sources of dietary potassium:

Highest Content (>1000 mg [25 mmol] per gram)

Dried figs


Very High Content (>500 mg [12.5 mmol] per gram)

Dried Fruits (dates, prunes)



Bran cereals

Wheat Germ

Lima beans

High Content (>250 mg [6.2 mmol] per gram)

Vegetables: Spinach, tomatoes, broccoli, winter squash, beets, carrots, cauliflower,

Fruits: bananas, cantaloupe, kiwi, oranges, mangos

Meats: ground beef, steak, pork, veal, lamb

Eight ounces of orange juice supplies approximately 450 mg of potassium. A glass of milk and a can of regular V-8 juice are also rich in potassium but unfortunately also loaded with sodium or sugar. The drawback of some of the potassium-rich food is cost and potential for weight gain (sweet potatoes with molasses, anyone?). In other words, for cardiovascular health, don’t limit yourself with bananas. Some people are even allergic to it or simply dislike its taste. For a list of excellent food sources of potassium check out the US Department of Agriculture Dietary Guidelines:

Potassium Replacement

In institutional settings, compliance with potassium therapy can be a challenge. Tablets are better tolerated than the liquid form for patients who can swallow. Compliance is also enhanced by the dosing schedule. The less frequent the patient takes the pill, the better the compliance. So, instead of giving 20 mEq BID, ask the doctor to order it as 40 mEq once a day as clinical condition allows. In patients taking diuretics, dietary consumption of potassium rich food is not enough and must be coupled with potassium supplement – an important teaching moment for patients and caregivers.

Making Potassium Easier to Swallow

Mixing potassium liquid with juice or ice makes it easier to swallow. To prevent the occlusion of feeding tubes (very annoying), give the liquid form instead of crushing the pills. Lastly, it is important to note that magnesium is an essential co-factor for potassium uptake and maintenance of intracellular potassium level. Therefore, potassium supplement works best when the magnesium level is within normal range (1.5 – 2.5 mEq/L). The clinically thinking nurse would be inclined to check the magnesium level when receiving orders to replace potassium.


Evidence from large, longitudinal studies, using worldwide sampling indicates that high-quality diets rich in potassium might achieve greater health benefits, including blood-pressure reduction (by extension a reduction in stroke and other cardiovascular events), than aggressive sodium reduction alone (Opari, 2014). Nurses are at the forefront of patient education. Discharge instructions and public health education using the teach-back method may help improve health literacy among high-risk populations.

African-Americans commonly have a relatively low intake of potassium and a high prevalence of elevated blood pressure and salt sensitivity, this population subgroup may especially benefit from an increased dietary intake of potassium (, 2008).


Cohn, J., Kowey. P., Whelton, P., & Prisant, L. M. (2000). New guidelines for potassium replacement in clinical practice. Archive of Internal Medicine, 160(16), 2429-2436.

Caralis, P. V., Matterson, B. J., & Perez-Stable, E. (1984). Potassium and diuretic-induced ventricular arrhythmia in ambulatory hypertensive patients. Mineral Electrolyte Metabolism, 10 (3), 148-154.

Duke, M. (1978). Thiazide-induced hypokalemia: Association with acute myocardial infarction and ventricular fibrillation. JAMA, 239(1), 43-45. (2008). Dietary Guidelines for Americans 2005. Retrieved from

Oparil, S. (2014). Low sodium intake–cardiovascular health benefit or risk? New England Journal of Medicine, 371(7), 677-679. doi: 10.1056/

Stuck Inside a Cloud: Optimizing Sedation To Reduce ICU-Associated Delirium in Geriatric Patients


Lim, Fidelindo A. DNP, RN, CCRN

“Never slept so little

Lost my concentration I could even lose my touch

Talking to myself

Crying out loud

Only I can hear me

I’m stuck inside a cloud…”

-George Harrison


Elderly population account for over 50% of all intensive care admissions and during their stay, up to 87% of them suffer from delirium. There is a large body of evidence demonstrating increased mortality and worse cognitive function for elderly patients who become delirious during their intensive care unit stay. While the cause of delirium is multi-factorial, inappropriate and outdated sedation methods are preventable causes. We review the current best evidences and provide what we believe are the best sedation strategies that are in line with the Society of Critical Care Medicine’s Pain, Agitation and Delirium (PAD) best practice guideline to reduce the incidence of ICU-associated delirium.


The critically ill elderly patients (age 65 and older) account for 42-52% of all intensive care unit (ICU) admissions in the United States and they have to fight an uphill battle while they’re there. (1) Along with the initial insults that brought them to the ICU, they are vulnerable to various iatrogenic complications. One injury that significantly contributes to negative patient outcome is ICU-associated delirium. (2) It is estimated to affect up to 80% of all ventilated patients and this number increases to 87% for older ICU patients, which amounts to billions of dollars every year in health care costs in addition to the immeasurable burden on the patient, their family and care providers. (1)(3) Even though delirium among hospitalized older adults is highly prevalent, the exact mechanism remains still elusive despite increasing research. (3) Delirium is characterized as an acute fluctuation of mental status and cognitive function. (3)(4) Patients who are delirious can be hyperactive with features similar to those who are acutely psychotic (e.g., agitation, hallucination, delusion, and combative behavior) or hypoactive with presentations that mimic depressive mood disorder (e.g., flat-affect, inattention, disorganized thoughts and depression). (4) Often times overlooked or mistaken as simple agitation, depression or downplayed as simply confusion resulting from advanced age, it’s increasingly evident that delirium is a major contributor to increased ICU length of stay, increased likelihood of transfer to skilled nursing facility and post-traumatic stress disorder (PTSD) after discharge. (5-7)(10) Notably, among the elderly critically ill population, the duration of a patient’s delirium is positively associated with increased mortality. (8) Similarly, patients who suffered ICU-associated delirium have been noted to suffer from enduring cognitive impairment long after their ICU discharge. (6) Those who remained delirious for extended periods of time exhibited more severe level of cognitive dysfunction. (6) Despite evidence suggesting ICU-associated delirium is crucial to patient outcomes; its incidence is mostly grossly under diagnosed and therefore untreated. (5) If used properly and routinely, validated delirium screening tools such as the Confusion Assessment Method for ICU (CAM-ICU) should be able to assist clinicians to accurately identify and treat delirium. (4)

The development of ICU-associated delirium is multifactorial. For the ICU patients, endotracheal intubation, its resultant pain and discomfort and the choices of sedations providers use to maintain ventilator synchrony remain significant risk factors. (9) Pain is a major contributor to delirium and it is often overlooked by bedside nurses as well as providers. (3)(5) Patients who were later discharged from ICU often recollect the painful procedures that they endured while hospitalized and how they contributed to their distress. (3)(7) In an emergent setting, patients are being induced and then paralyzed for intubation without adequate analgesia and sedation after intubation. (11)(12) Upon arrival in the ICU, it is traditionally thought to be more beneficial to keep mechanically ventilated patients in a state of deep sedation partly so that patients won’t have recollection of their unpleasant experience. (7)(12) In order to achieve this, patients are maintained in deep sedation using sedatives such as benzodiazepines, leading to a state of unresponsiveness, except to painful stimuli. (7)(12) There is now a growing body of evidence showing that this strategy of using benzodiazepines as the primary sedation to keep patients deeply sedated while inadequately treating their pain, under dosing on analgesia, is a flawed paradigm and that leads increases time of intubation, ICU and overall hospital length of stay and mortality. (3)(7)(12)(13) To manage behavioral symptoms of delirium, anti-psychotics such as haloperidol are used although it has never been shown to decrease the duration of delirium. (14) Similar pharmacological agents (eg.,olanzapine, and quetiapine) given concomitantly with haloperidol did not shorten the duration of delirium. (14) The current evidence emphasizes optimization of analgesia and sedation along with strategies to reduce deep sedation in order to prevent ICU-associated delirium. (3)(7)(10)(12) This article will discuss the optimal sedation strategies to reduce the incidence of delirium, highlights key practice guidelines from the Pain, Agitation, Delirium (PAD) Care Bundle and explore the role of critical care nurses in its implementation.

Review of Sedation Strategies

Hypnotics or Opioids?

Benzodiazepines such as midazolam and lorazepam are the main agents used in the ICU to maintain sedation. (3)(12)(13) It acts on the BZ receptors and thus accentuates the effect of Gamma-Amino Butyric Acid(GABA) that provides a neuro-inhibitory affect that leads to sedation. (3) They also provide anxiolytic and amnesiac effects that make them favorable agents for sedation. (3) Adverse reactions include respiratory and hemodynamic depressions. (3) When used as intravenous boluses, midazolam has a short onset and short half-life (elimination half-life is between 1.5 to 2.5 hours) while lorazapam is more potent, therefore emergence from short-term sedation takes longer. (3) As a continuous infusion, the short half-life of midazolam no longer applies due to its penetration of peripheral tissues, and active metabolites. (7) In addition, the elderly are commonly more sensitive to the sedative effect of benzodiazepines due to worse hepatic function and renal insufficiency. (3) All of which contributes to delayed emergence from benzodiazepines. When comparing patients who were sedated using benzodiazepines with those maintained on non-benzodiazepines, patients who were on non-benzodiazepines had shorter duration of mechanical ventilation and ICU length of stay. (13)

Propofol is an anesthetic agent that inhibits GABA receptors thus producing its sedative effect. (2)(3)(12) Its short acting onset and half-life make it a popular agent for induction and maintenance of sedation, especially in those patients who require constant neurological assessment. (2)(3) Adverse reactions include respiratory and hemodynamic depression. (2)(3) A rare adverse reaction is propofol infusion syndrome (PRIS) which is associated with prolonged infusion time at high infusion rate. (15) Compared with benzodiazepines, propofol has not been associated with longer ICU length of stay and prolonged mechanical ventilation. (2)(3)(7)(12-13)

Dexmedetomidine (Precedex) is a selective alpha-2 agonist that produces sedation and analgesic effects. (2-3) The advantage to its use is unique in that it does not cause respiratory depression and can be used in non-intubated patients. (3) The main adverse reactions are bradycardia and hemodynamic instability that are more prevalent when bolus doses are given. (3) There is some evidence that dexmedetomidine can reduce the incidence of delirium. (2-3)(7)

Fentanyl and morphine infusions are the main mu-receptor stimulating opioids used as analgesic for ventilated patients. (2)(3) Fentanyl’s advantage is that it provides a degree of anxiolytic properties and less likely to cause hypotension. (3)(16-17) As an intravenous bolus, it also has a relatively short onset and elimination half-life (elimination half-life 2 hours). (3) However, this property is altered by impaired hepatic function and its active metabolites. (3)(16-17) The use of morphine as an infusion for sedated and ventilated patient is less recommended due to higher potential to cause delirium. (16) In addition, its vasodilatory effect makes its use less favorable in critically ill patients who are already hemodynamically unstable. (16)(18) Remifentanil is another agent used in the ICU and its favorable aspects include less active metabolites and short onset and half-life (elimination half-life 3-10 minutes).(16)(18) However, remifentanil has been associated with immunosuppression; therefore its usage in patients who are already immunosuppressed or are at risk for it should be judicious. (7)(16)(18)

Due to the high incidence of unrecognized and under-treated pain in the critically ill population, the resultant contribution to delirium and the hypnotics sparing effect of opioids, there is a movement to use analgesic as the primary sedation for mechanically ventilated patients. (5)(16-17) Several studies that have examined the feasibility, safety and efficacy of this “analgosedation” strategy have found positive results in reduction of ventilator time, incidences of delirium, hospital length of stay and long-term mortality. (6-18)

Sedation Vacation or Targeted Light Sedation?

Sedation vacation, also known as spontaneous awake trials is a strategy where heavily sedated patients are woken up daily by reducing the dosage of their sedative to the point where they’re spontaneously awake or are visibly uncomfortable. The sedation will then be restarted but at a reduced dose. (3)(19-20) Many thought this strategy would contribute to pain, agitation and PTSD in these mechanically ventilated patients. (5) However, data on this strategy showed the exact opposite effect. (7)(12)(19-20) Patients who underwent daily sedation vacation had less symptoms of PTSD upon discharge and less cognitive dysfunction. (3)(7)(19-20) In addition to more favorable neurological function, those who underwent daily sedation vacation also had fewer days mechanically ventilated, decreased length of stay and decreased long-term mortality.(19-20) A drawback of this strategy is that it resulted in increased incidences of agitation and self-extubation, however, re-intubation rate and mortality were unchanged. (19-20)

Another sedation strategy challenges the tradition of deep sedation strategy by maintaining patients on targeted light sedation at all times without the mandatory sedation vacation. (7)(19-20) Using validated sedation scales such as Richmond Agitation and Sedation Scale (RASS), patients receive either intermittent sedative boluses or only low sedative infusions to achieve a sedation level of RASS 0 to -2 (0 being awake and alert, -2 being arousable by voice). (19-22) Similar to studies on sedation vacation, the targeted light sedation strategy also achieved favorable outcomes such as less time on ventilator, less delirium and shorter length of stay. (19-20)

Interestingly, combining these two strategies does not provide a synergistic effect on delirium. 20(19) In the Sedation Lightening and Evaluation of A Protocol (SLEAP) trial, combining daily sedation vacation and targeted light sedation strategy showed no difference in time on ventilator or length of stay when compared to the control group that used only one sedation strategy. (20) Patients who were managed on the combined strategy paradoxically received more sedation due to high incidences of agitation and pain while at the same time; nurses reported increased workload and reported more ventilator issues. (20) Neither of these strategies can be used universally without discretion. (3)(19-20) For example, patients who are under neuromuscular blockade are not candidates for sedation vacations or light sedation. (3)(19-20) Patients who are withdrawing from alcohol are similarly unsuitable for the aforementioned sedation strategies. (3)(19-20)

Highlights of PAD Guidelines and Nursing Implications

The role of critical care nurse in managing mechanically ventilated patient is crucial and cannot be understated. Frequent bedside monitoring of patient’s pain, agitation and delirium levels and titrating intervention accordingly is key to the success of any sedation protocol. (3)(5)(23) It is imperative that critical care nurses across all levels become early adopters or “champions” of the PAD care bundle. Below are the highlights of the latest guidelines on managing PAD in the critical care setting espoused by the Society of Critical Care Medicine (SCCM) and the American College of Critical Care Medicine (ACCM). (3)

Pain Guidelines

Universally considered as the fifth vital sign, pain is routinely assessed and evaluated by critical care nurses. Implementation of the pain aspect of the PAD care bundle must acknowledge well-known barriers of pain management such as knowledge deficits, misconceptions about assessment, lack of experience, resistance to the use of validated tools, limited competences or assessment skills, poor communication, and not accepting patients’ descriptions of pain as the gold standard. (24) There is historical evidence that patients’ experiences of pain and distress do not fully agree with nurses’ and assistant nurses’ assessments and the staff may underestimate pain among intensive care elderly patients. (25) The PAD care bundle includes the following key points (26):

  • Performing routine pain assessments every 2-3 hours and more frequently as needed in all ICU patients, regardless of whether patients can self-report their pain or not.
  • Self-reporting is considered the “gold standard” in pain assessment.
  • Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable pain assessment tools for use in ICU patients.
  • Patients are considered to be in significant pain if they self-report their pain intensity of 4 or greater (0–10 Numeric Rating Scale [NRS]) or have either a BPS score of 6 or greater (BPS range = 3–12) or a CPOT score of 3 or greater (CPOT range = 3–8) if they cannot self-report.
  • Treat pain promptly, within 30 minutes of recognizing significant pain levels.
  • First optimize pain management and sedate patients only if needed.

A holistic and comprehensive pain assessment that incorporates an algorithm is essential, particularly among the hospitalized older adults. (26-27) Renal and hepatic functions must be taken into considerations as well as patient and family preferences within the overall context of quality and safety.

Agitation and Sedation Guidelines

A profusion of sedation scales have been studied and used in critical care. Both the Richmond Agitation-Sedation Scale (RASS) and the Sedation-Agitation Scale (SAS) are considered the most valid and reliable subjective scales for use in critically ill adult patients. (28) It is incumbent upon critical care nurses be able to use these tools, along with other relevant tools such as the CAM-ICU with high reliability. (4)(21-23) The PAD care bundle includes the following key points (26):

  • Assessment and documentation of sedation/agitation must be performed in all ICU patients, using either the RASS or SAS sedation scale, at least four times per nursing shift (e.g., every 2–3 hours), and more frequently as needed.
  • Medication orders for sedation must have specified parameters in order to prevent oversedation.
  • The choice of sedative agent to use in critically ill patients must be informed by the following factors: a) the specific indications for sedation and the sedative goals for each patient; b) the compatibility between the clinical pharmacology of a sedative, its side effect profile, and the relative contraindications for its use in a critically ill patient; and c) the overall costs (not limited to pharmacy costs) associated with using a particular sedative.

With a set of sedation protocol in place, its functional implementation depends in various factors such as the critical care nurse’s judgment and acceptance of the protocol. (7) Therefore when the institution establishes a sedation protocol, it’s important to educate and gain the acceptance of the nursing staff and take into consideration the additional workload in order to plan staffing accordingly. (7)(20)(23) Sedation strategies that relies heavily on hypnotics are a practice that is engrained in many experienced clinicians; therefore introducing alternative strategies such as analgosedation might meet resistance at first. (7)(16)(20)(23) Understanding the implications of particular sedation strategies and their implications on patient outcomes is essential in translating protocols into practice.

Delirium Guidelines

ICU-associated with delirium is a major independent contributor to mortality and other negative outcomes such as prolonged duration of mechanical ventilation, prolonged hospitalization, post-discharge institutionalization, and increased health care cost, and long-term cognitive dysfunction among others. (2-3)(10)(12) The PAD care bundle includes the following key points (26):

  • Identify and treat reversible causes of delirium in critically ill patients.
  • Treatment should include both non-pharmacologic and pharmacologic strategies, with an emphasis on implementing non-pharmacologic interventions first.
  • Pharmacologic treatment of delirium should include: a) adequate analgesia; b) discontinuation of benzodiazepines (except in patients with suspected ethanol or benzodiazepine withdrawal); c) resumption of patients’ psychiatric medications, if indicated; d) treatment of drug withdrawal syndromes, if suspected; and e) antipsychotics, if clinically indicated.

The emphasis on non-pharmacologic strategies in the prevention and treatment of delirium rest largely within the nursing domain. The American Association of Critical Care Nurses (AACN) endorses the use of CAM-ICU or the Intensive Care Delirium Screening Checklist (ICDSC) as assessment tools. (29) Collaborative interventions such as early mobility with physical and occupational therapy have been shown to reduce ICU length of stay, reduced prevalence of delirium and lower sedative use. (30) Compliance to activity orders (e.g., out-of-bed as tolerated) requires coordinated nursing care and support from management stakeholders to maintain staffing mix that meets national benchmarks. Nurses can use motivational interactions to encourage patients to comply with exercise and activity regimen to ensure compliance.

Another nursing-sensitive aspect of delirium prevention is optimizing rest and sleep among critically ill patients. Various strategies such having patients use earplugs, clustering nursing activities, enforcing dedicated quiet times during the day and night, reduced lighting or dimming hallway lighting, and minimizing volume of staff voices have all been shown to improve sleep and reduce delirium among patients. (26)

Translation to Practice

Implementation of best practice evidence remains a challenge in health care. The current Pain, Agitation, and Delirium (PAD) Care Bundle brings special attention to the process and approach to PAD management rather than specific recommendations for using certain medications in different clinical situations. (2) For this reason, a collaborative and interdisciplinary management that is patient-centered is called for. Given the available evidence, it is recommended to implement sedation strategy that prioritizes opioid usage for pain management with judicial usage of hypnotics if not outright avoided. (3) The optimal strategy should begin at the moment of intubation. Once a patient is intubated, continuous infusion of fentanyl or remifentanyl should be initiated at an adequate rate with intermittent boluses given until the patient reports no pain or shows no sign of pain. (11) If the patient remains agitated and is refractory to verbal reassurance and opioid boluses, non-benzodiazepine hypnotics such as propofol can be given as intravenous boluses. If the decision to start continuous hypnotic infusion is made, preference should be given to drugs such as propofol and dexmedetomidine, both of which are less associated with delirium than benzodiazepines. (3)(7)(12-13) Further agitations can be managed by antipsychotics such as haloperidol. (14) Either daily sedation vacations or targeted light sedation strategy can be used but not in conjunction. (20)


Older adults in critical care settings remain vulnerable to delirium and more likely to have poorer outcomes. (8) Pain, agitation, and delirium are closely interwoven pathophysiologic phenomena and each one invariably impacts the outcomes of the other. Inadequate or inappropriate choices of sedation contribute to the development of delirium and poorer outcomes. (12) Benzodiazepines have been found to be associated with higher incidence of delirium, prolonged mechanical ventilation days and longer ICU days. (13) Inadequate treatment of pain also contributes to delirium and should be adequately addressed. (9) Sedation vacation and targeted light sedation are proven strategies that decrease delirium, PTSD and other long-term negative outcomes. (2-3)(12)(19-20)

It is important for clinicians to be aware of the various factors that contribute to the development of ICU delirium, optimize sedation strategies for mechanically ventilated patients to improve overall patient outcomes. The ICU PAD care bundle does not propose a specific drug treatment strategy for all ICU patients, but maintains that treatment goals focus on patients’ pain management as a priority and to use appropriate pharmacological agents that are not associated with inducing delirium to sedate patients when necessary. (26) It is essential that critical care nurses become full partners in the implementation and evaluation of the PAD care guidelines paying close attention to patterns unique to older adults.


1)Pisani MA. Considerations in caring for the critically ill older patient. J Intensive Care Med. 2009 Mar-Apr;24(2):83-95. doi: 10.1177/0885066608329942. Epub 2008 Dec 28.

2) Patel SB, Kress JP. Sedation and analgesia in the mechanically ventilated patient. Am J RespirCrit Care Med. 2012 Mar 1;185(5):486-97. doi: 10.1164/rccm.201102-0273CI. Epub 2011 Oct 20.

3) Barr J, Fraser GL, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306. doi: 10.1097/CCM.0b013e3182783b72.

4) Ely EW, Margolin R, Francis J, et al: Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001; 29:1370–1379

5) Spronk PE, Riekerk B, et al. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med. 2009 Jul;35(7):1276-80. doi: 10.1007/s00134-009-1466-8. Epub 2009 Apr 7.

6) Pandharipande PP, Girard TD, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013 Oct 3;369(14):1306-16. doi: 10.1056/NEJMoa1301372.

7) Peitz GJ, Balas MC, et al. Top 10 myths regarding sedation and delirium in the ICU. Crit Care Med. 2013 Sep;41(9 Suppl 1):S46-56. doi: 10.1097/CCM.0b013e3182a168f5.

8) Pisani MA, Kong SY, et al. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J RespirCrit Care Med. 2009 Dec 1;180(11):1092-7. doi: 10.1164/rccm.200904-0537OC. Epub 2009 Sep 10.

9) Zaal IJ, Devlin JW, et al. A Systematic Review of Risk Factors for Delirium in the ICU.Crit Care Med. 2014 Sep 23.

10) Ely EW, Shintani A, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004 Apr 14;291(14):1753-62.

11) Shehabi Y, Bellomo R, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J RespirCrit Care Med. 2012 Oct 15;186(8):724-31. doi: 10.1164/rccm.201203-0522OC. Epub 2012 Aug 2.

12) Devlin JW, Fraser GL, et al. Pharmacological management of sedation and delirium in mechanically ventilated ICU patients: remaining evidence gaps and controversies. SeminRespirCrit Care Med. 2013 Apr;34(2):201-15. doi: 10.1055/s-0033-1342983. Epub 2013 May 28.

13) Fraser GL, Devlin JW, et al. Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit Care Med. 2013 Sep;41(9 Suppl 1):S30-8. doi: 10.1097/CCM.0b013e3182a16898.

14) Page VJ, Ely EW, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Respir Med. 2013 Sep;1(7):515-23. doi: 10.1016/S2213-2600(13)70166-8. Epub 2013 Aug 21.

15) Chen L, Lim FA. Propofol infusion syndrome: A rare but lethal complication. Nursing. 2014 Dec;44(12):11-3. doi: 10.1097/01.NURSE.0000456376.94907.11.

16) Devabhakthuni S, Armahizer MJ, et al. Analgosedation: a paradigm shift in intensive care unit sedation practice. Ann Pharmacother. 2012 Apr;46(4):530-40. doi: 10.1345/aph.1Q525. Epub 2012 Apr 10.

17) Strøm T, Martinussen T, et al. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010 Feb 6;375(9713):475-80. doi: 10.1016/S0140-6736(09)62072-9. Epub 2010 Jan 29.

18) Dahaba AA, Grabner T, et al. Remifentanil versus morphine analgesia and sedation for mechanically ventilated critically ill patients: a randomized double blind study. Anesthesiology. 2004 Sep;101(3):640-6.

19) Hughes CG, Girard TD, et al. Daily sedation interruption versus targeted light sedation strategies in ICU patients. Crit Care Med. 2013 Sep;41(9 Suppl 1):S39-45. doi: 10.1097/CCM.0b013e3182a168c5.

20) Mehta S, Burry L, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012 Nov 21;308(19):1985-92.

21) Sessler CN, Gosnell M, Grap MJ, Brophy GT, O’Neal PV, Keane KA et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J RespirCrit Care Med 2002;166:1338-1344.

22) Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S et al. Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS).JAMA 2003; 289:2983-2991.

23) Balas MC, Burke WJ, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med. 2013 Sep;41(9 Suppl 1):S116-27. doi: 10.1097/CCM.0b013e3182a17064.

24) Ista E, van Dijk M, van Achterberg T.Do implementation strategies increase adherence to pain assessment in hospitals? A systematic review.Int J Nurs Stud. 2013 Apr;50(4):552-68. doi: 10.1016/j.ijnurstu.2012.11.003. Epub 2012 Dec 11.

25) Hall-Lord M.L., Larsson G., and Steen B.Pain and distress among elderly intensive care patients: comparison of patients’ experiences and nurses’ assessments. Heart Lung 1998; 27: pp. 123-132

26) Barr J, Pandharipande PP.The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 Pain, Agitation, and Delirium Guidelines in an integrated and interdisciplinary fashion.Crit Care Med. 2013 Sep;41(9 Suppl 1):S99-115. doi: 10.1097/CCM.0b013e3182a16ff0.

27) Harmon JR, Higgins I, Summons P, Bellchambers H.Efficacy of the use of evidence-based algorithmic guidelines in the acute care setting for pain assessment and management in older people: a critical review of the literature.Int J Older People Nurs. 2012 Jun;7(2):127-40. doi: 10.1111/j.1748-3743.2010.00261.x. Epub 2010 Dec 28.

28) Robinson BR, Berube M, Barr J, et al.Psychometric analysis of subjective sedation scales in critically ill adults.Crit Care Med. 2013 Sep;41(9 Suppl 1):S16-29. doi: 10.1097/CCM.0b013e3182a16879.

29) AACN Practice Alert (2011). Retrieved from

30) Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: A quality improvement project. Arch Phys Med Rehabil. 2010;91:536–542

Room with a View: Clutter Included?

by Fidelindo Lim, DNP, CCRN & Vince Tran, BSN, RN


Your “new” room is now ready. Hospital room, that is. The architects are finally catching up with designing and re-designing hospital rooms that could match the suites of the local Marriott, with a built-in perk of making the patient feel better. In August this year, a front-page article in the New York Times (this must be important) extolled the growing trend of curating hospital rooms, this time with the nurses’ input and the patient’s well being in mind. Of course, this is not a revolutionary concept and the author wondered why it has not been the standard all these years.

The Times reported that in the new room, there was a 30 percent reduction in patient’s request for pain medication, patients in the new rooms rated the food and nursing care higher compared with patients in the old rooms, although the meals and care were not different (Kimmelman, 2014). And, oh yes, patient satisfaction scores are improved in the new space that’s lauded as “simple, airy and visually arresting”.


So this nurse walks into a patients room

Imagine this. You walk into a patient’s room that’s larger than an average Manhattan studio apartment.  It has floor to ceiling windows with a water view, subdued lighting, artwork, an oversized sofa and a 40-inch flat screen TV (on with no one watching, of course). You scan the room as good nurses do and what “arrested” your field of vision? On the bedside table are empty nebulizer “bullets”, half-empty saline flushes and some unused ones, medication wrappers, empty intravenous medication bags, an insulin syringe cap and a cup with what looks like serousanguinous fluid. You realized the patient is not able to turn her head to see the water view, but smacked in front of her is trash – the detritus of patient care. You sigh. With that, you detected a smell of an unidentified effluvia of bodily discharges you suspected emanated from the miasmatic trash bin. Suddenly you feel tired and it’s only the first hour of your shift.


Nurses often lament the lack of workspace and the outright bad design of some hospital rooms that have outlived customer-service demands.  We are now seeing modern patient care spaces that are meant to reinvigorate the patient and staff but the flow of healing energy is blocked or soaked up by clutter and trash – notable for throwing the room’s Feng Shui off balance. Sound design can only go so far in fostering a healing environment around the bedside. People who enter (hospital staff) the room and the clutter they leave behind influence the overall “architecture” and ambience of the space.

Preventable side effects of health care 

Bedside clutter is the collateral effect of modern-day patient care. In spite of technological advances in health care (or maybe because of it) the tide of trash-clutter washing ashore at the patient’s bedside shows no signs of retreating. No wonder the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey asks patients to rate how often their room and bathroom were kept clean during their hospital stay (HCAHPS, n. d.). National data suggest that there is plenty of room for improvement. Nationwide, cleanliness ranks an average of only 73% compared with 85% on quality of discharge teaching (HCAHPS, 2014).  Could it be that what patient’s consider an unclean room or bathroom simply meant cluttered and disorganized surroundings that may not necessarily be unclean?


We don’t need a randomized control trial study to inform us that clutter around work environments is a threat to patient safety. They can cause accidents, compromise body mechanics or simply make work more inefficient. The effect of clutter at the bedside and the nurse’s role in mitigating it is best illustrated by the observations of Florence Nightingale (1860):


I once told a very good nursethat the way in which her patients room was kept was quite enough to account for his sleeplessness; and she answered quite good-humouredly she was not at all surprised at it as if the state of the room were, like the state of the weather, entirely out of her power. Now in what sense this woman to be called a nurse?(p. 45).


A nurse might demure in doing a bit of housekeeping, invoking that it is “not my job.” However, in the greater scheme of culture of safety, keeping the bedside clutter-free is everyone’s concern, including the patient and their visitors.


Perceptual Awareness: Look, listen and de-clutter

Keeping the bedside tidy and uncluttered need not be a Sisyphean ordeal. We can simply tag it along hourly rounding visits to the bedside (hourly rounding is another one of those “new” initiative we should have been doing all along). If the golden rule of patient safety is first “Do no harm”, we propose that the best way to keep the bedside clean is first dont make a mess. Here are some suggestions, based on the guiding principles of refuse, remove and refresh the three “Rs”, on how to maintain a healing environment at the bedside and beyond:


Refuse (to clutter)

To keep the bedside and other work areas free from clutter, be aware of the materials required for each task. Nurses often share an affinity to being efficient, highlighted by the common practice of gathering saline flushes, sterile caps for infusion lines, tape, and a plethora of items commonly used in a normal day-to-day shift. While this practice is highly time-saving, being conscientious about the use and disposal of materials will help minimize potential clutter. Whenever choosing a practice that makes caring for patients more convenient to a nurse, refuse to allow such practices from infringing on the patient’s often-limited personal space. A nursing mantra could be “I refuse to horde supplies at the bedside.”



And although preventing the accumulation of medical supplies may minimize potential clutter, this suggestion cannot ensure the cleanliness of a patient’s room. Due to common interactions between a patient and his or her environment, other personnel including healthcare workers, visitors, and at times the patient, may unintentionally leave clutter at the bedside. This is where hourly rounding is necessary, a time when a nurse can assess a patient’s environment and remove impediments of therapy. While hourly rounding is traditionally meant to ensure physiologic needs are met, the extra step of removing clutter in a patient’s room can provide wondrous effects on patient outcomes.



After a patient’s bedside has been decluttered, a patient may still benefit from  refreshing the room. Bear in mind that patient’s lengthy stay in a hospital may often be the culprit of a patient’s irritability. Simply recall a time when you had felt uncomfortable staying in a hotel or in a friend’s guest room for an extended period of time. While the area may be pristine, a hospital room can never emulate the comfort of being in one’s own home.  A nurse may help refresh a patient’s room through using aromatherapy, rearranging some furniture to the patient’s preference, or even remaking a patient’s bed. While these tasks may seem of little importance, these gestures are often what patients remember, especially for those whose length of stay exceeds a few days.


Keeping a patient’s room clean and orderly is one of many ways that nurses exemplify the promise to not only treat diseases, but to also treat patients. There are obvious benefits from keeping a patient’s bedside free from tangled IV lines, but let us not forget the psychological benefits of feeling at ease in one’s temporary home away from home.


Nightingale reminds us that “the well (hospital staff) have a curious habit of forgetting that what is to them but a trifling inconvenience, to be patiently put upwith, is to the sick a source of suffering, delaying recovery, if not actually hastening death (Nightingale, 1860, p. 52). Let us keep the bedside clean and clutter free – it does the patient good.


Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). (n. d.). HCAHPS Survey. Retrieved from

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). (2014). Summary of HCAHPS survey results October 2012 to September 2013 Discharges. Retrieved from

Kimmelman, M. (2014). In Redesigned Room, Hospital Patients May Feel Better Already. New York Times, August 21, 2014.

Nightingale, F. (1860). Notes on nursing: What it is and what it is not. London: Harrison and Sons.

A Study in Scarlet Restrictive Red Blood Cell Transfusion Strategy

by Leon Chen, MSc, AGACNP-BC, CCRN, CPEN

Anemia due to various etiologies occurs in critically ill patients requiring blood transfusion. Traditional transfusion goals guide our transfusion to achieve a hemoglobin goal of at least 10 g/dL. However, it is becoming increasingly evident that a restrictive transfusion goal of 7 g/dL may improve survival outcome, reduce infection, and reduce health care expenditure. Moreover, this strategy has been proven to be effective in a variety of patient population, including those who are critically ill, septic patients, those with a history of cardiac disease, those with gastrointestinal blood, or those who suffered traumatic injury. This article reviews some of the evidence supporting the restrictive transfusion strategy.

…therefore it seems right, as the operation now stands, to confine transfusion to the first class of cases only, namely those in which there seems to be no hope for the patient unless blood can be thrown in the veins.

Although descriptions of blood transfusion experiments date back to the 1600s, the first successful human-to-human blood transfusion is credited to Dr. James Blundell, a British obstetrician. He used blood transfusion to treat several patients with post-partum hemorrhage and was able to resuscitate them in 1818. Through his work, it was established that blood transfusions must be conducted between subjects of the same species, it be transferred through a syringe, and that a small amount of air injected into the vein is tolerated but large amounts would be lethal. In modern critical care medicine, blood transfusion is a common practice used to treat anemia due to various etiologies. Anemia of critical illness is a multifactorial phenomenon that is extremely prevalent. The cause of this condition is a combination of bone marrow suppression due to infection/inflammation, frequent phlebotomies, inadequate nutrition, neocytosis, and hemodilution. However, it is becoming increasingly evident that supraphysiological transfusion goals increase hospital-acquired infection, increase mortality, and increase health care expenditures.

Critically ill patients

The perceived benefit of blood transfusion is built on the concept of maximizing oxygen delivery by increasing oxygen-carrying capacity with red blood cell infusion. The benefit of blood transfusion on mortality was demonstrated in several studies that showed that anemia is an independent risk factor in cardiac surgery and critically ill patients. In 1999, the TRICC (Transfusion Requirements in Critical Care) trial published in the New England Journal of Medicine changed practice and demonstrated that for critcally ill patients in the intensive care unit (ICU), a restrictive transfusion goal of 7 g/dL of hemoglobin is not inferior to the traditional goal of 10 g/dL, with beneficial trend toward the restrictive goal. The TRICC trial did not, however, establish a clear beneficial threshold for patients with cardiac disease. Therefore, many cardiologists still recommend a transfusion goal of 10 g/dL for patients with cardiac disease.

Cardiac patients

The majority of available randomized controlled trials that have evaluated transfusion strategies in adult ICU patients with cardiac disease have found that restrictive transfusion approach is noninferior to a liberal transfusion strategy. Most of these studies used a restrictive goal of 7 or 8 g/dL as their transfusion threshold and have found it to be safe. In addition, there are other retrospective studies that associate blood transfusions and higher hemoglobin (>11 g/dL) goals with increased mortality and ischemic events in adult cardiac patients. Numerous factors explain why blood transfusion does not lead to beneficial effects in patients. In observational studies of Jehovah’s Witness patients and African children in resource-scarce areas, anemia based on 5 g/dL of hemoglobin is noted to be well tolerated. Blood transfusions lead to an increase in viscosity and thus an increase in systemic vascular resistance. Oxygen delivery does not increase after blood transfusion despite a theoretical increase in oxygen-carrying capacity. This is potentially due to the altered oxygen-carrying capacity in transfused red cells while in storage, termed “storage lesion.” In addition, blood transfusion has immunomodulating effects that lead to decreased immune system in patients already vulnerable to infection. This effect has been associated with increased ICU stays and mortality. Finally, other complications suchas TRALI (transfusion-related acute long injury), volume overload, and infections are all considerations when the decision to transfusion is made.

Septic patients

In the landmark Early Goal Directed Therapy for Sepsis and Severe Sepsis Trial, patients who had hemoglobin levels of less than 10 g/dL were transfused. The rationale behind this was to maximize oxygen delivery for these septic patients who have theoretical oxygen deficit. As mentioned previously, this theoretical benefit is impaired in practice due to the storage lesion. Later, large randomized controlled trials have firmly established that restrictive strategy with a hemoglobin threshold of 7 g/dL is the definitive treatment option for septic patients.

Patients with upper gastrointestinal bleeding

In a fascinating study, Villaneuva and colleagues, at a single center in Spain, randomized patients with hematemesis or melena to a restictive strategy group with a hemoglobin threshold of 7 g/dL versus a liberal strategy group with a hemoglobin threshold of 9 g/dL. THe outcome showed that the group with restrictive strategy is that with less transfusion, splenic pressure is lower, therefore leading to a less propensity of bleeding.

Trauma patients

In the trauma world, damage control resuscitation has become the standard of care. This resuscitation strategy emphasizes on stopping the hemorrhage, correcting acidosis, hypothermia, and coagulopathy to improve outcome. A key part of damage control resuscitation is permissive hypotension by restricting crystalloid infusion and also using a restrictive transfusion strategy. Restricting transfusion has been shown to decrease bleeding by decreasing splenic pressure and breaking existing clots.

Clinical implication

The latest trend in medicine seems to point toward a restrictive approach in the management of various conditions. Transfusion studies in critical illness, sepsis with gastrointestinal bleed, and even trauma all seem to suggest that restrictive transfusion protocols are not only safe but also beneficial. Unless the patient is having active acute coronary syndrome or bleed or is hemodynamically unstable, the available evidences suggest that a lower hemoglobin goal of 7 to 8 g/dL should be the transfusion goal. Less is more may emerge to be the best strategy in medicine.

This article and references can be found in Critical Care Nurse Quarterly Volume 38, No. 2, pp 217-219 with permission from Leon Chen.

Eye of the beholder: Grand rounds at the museum

“WHAT DO YOU SEE IN HIS EYES?” asks Dr. Rothenberg.

After a brief pause, someone replies, “He looks sad.” Another states, “He’s kind of emaciated.” After directing us to look just below the left eyelid, Dr. Rothenberg asks, “Do you see a sign of a scar?” Several of us nod. She tells us this scar is a remnant of trachoma, also called Egyptian ophthalmia.

This clinical scrutiny is taking place not at the bedside of a teaching hospital but in the Egyptian gallery of the Metropolitan Museum of Art in New York. Dr. Rothenberg, a retired pathologist and now a museum docent, is our guide. When I’d requested a student group tour called “Health and Illness in Art,” I first was told the museum had no themed tours—but then it created one for us and we’ve been back three times. During the tour, nursing students examine great art while honing their observational skills.


For centuries, art has depicted various states of health and illness. As we examine the Metropolitan’s masterpieces, we reflect not only on the history but also the health of the figures represented. Our guide shows us a Rembrandt painting of a man with syphilis. She instructs us to examine the buboes of Saint Roch depicted in a stained glass from the Middle Ages. We marvel at the dignity portrayed in the Death of Socrates, a painting by Jacques-Louis David. In Renoir’s late works, we see how his debilitating arthritis transformed his work. In front of Fernando Botero’s paintings, we smile shyly at his subjects’ unapologetic obesity. A sarcophagus of a Roman physician engraved with the trappings of his profession reveals that even thousands of years ago, advertising and self-promotion didn’t end at death’s door. We see artworks that confirm our guide’s observation at the beginning of the tour—that nothing truly is original and human nature hasn’t changed much over the millennia.

My personal favorite is the sculpture of Ugolino and his sons by Jean-Baptiste Carpeaux (pictured above). Ugolino was accused of treason and sentenced to die of starvation with his sons, all of them locked in a tower. Here we stand and stare at the prisoners’ nakedness, seeing the despair and terror in the sons’ eyes as they offer themselves as food for their starving father. We see the tension in their muscles and bones, and imagine the cries that might have emerged from their lips. Heavy chains at the sculpture’s base punctuate the subjects’ inescapable destiny—death. The sons’ sacrificial offer makes me think of the enormous self-denial families endure for their sick loved ones. In Ugolino’s contorted pose, I see stress—the consequence of many illnesses—immortalized in marble. The subjects’ imprisonment calls to mind the poor health suffered by many among our incarcerated population. Their sentence of starvation brings to mind diabetes at a cellular level (with cells starving amidst plenty), as well as the mountain of food that goes to waste in hospitals— and elsewhere—every day. The subjects’ nakedness reminds me of the loss of dignity some patients suffer from the carelessness of healthcare workers who fail to ensure their privacy.

Nurses are living witnesses and recorders of life as it occurs in real time, at the bedside and elsewhere. Although few of us take brush to canvas to document our patients’ appearance or the dramas they live out every day, we are masters nonetheless—not in the sense of Rembrandt or Picasso but in the purposeful rendering and application of the healing arts. In some ways, perhaps, we’re in the same league as the great artists.

Last month during clinicals, the patient of one of my students died. On his bed someone had carefully arranged objects of apparent importance to him—stone quartz, a bracelet, a stick with a hollowed gourd attached to it. As we gathered around the bedside, I asked everyone to look carefully and remember where each object was placed, reminding them that after postmortem care, we’d have to put these back where we found them. During this time, our movements were gentle and focused out of reverence for the patient, akin to those of a painter or a sculptor. The room was as quiet as an artist’s studio. Perhaps nurses are artists. Or maybe we’re the subjects of a master creator of a higher order, whose palette is the world.

Our museum visits are akin to walking rounds at the hospital—rounds that enable us not just to see the triumph of artistry over the mundane and the monotonous, but to sharpen our assessment skills.The visits have initiated tiny ripples in the reflecting pool of the observer’s mind. Observation is the requisite for masterful reflection and clinical precision. Yet an irony of nursing education is its reverence for critical thinking at the expense (too often) of observation. Observing art is a sublime exercise in truly looking and feeling—one that can help us become better nurses.

Fidel Lim Photo (2)

Fidelindo Lim, DNP, CCRN

Fidelindo Lim is a clinical faculty at NYU College of Nursing and a per diem nurse educator for NYP Weill Cornell and Hospital for Special Surgery.

This American Nurse Today publication can also be found at

Interdisciplinary Care and Collaboration: Participate or Perish

By: Travis Baird, MS, NP, RN, CCRN

“Individual commitment to a group effort – that is what makes a team work, a company

work, a society work, a civilization work.”

-Vince Lombardi

The increasingly complex healthcare environment encourages active and dynamic

collaboration among healthcare providers. With changes in the delivery of care and the

introduction of the Affordable Care Act, many people will be able to afford insurance;

this in turn will create opportunities for quality of care to be provided to millions of

Americans who were previously uninsured. With reform, healthcare systems will

compete to offer the best patient and family centered services, the most current medical

innovations, and positive outcomes found on evidence-based practice. Reimbursement

from government and insurance payments will rely on positive outcomes, transparency,

and quality of care from healthcare systems. Achieving positive outcomes will depend on

the dynamic, coordinated, and interdisciplinary efforts of its healthcare participants.

Many organizations such as Kaiser Permanente and the Robert Wood Johnson foundation

have been looking at ways to improve the communication and coordination of care

among healthcare professionals, developing successful models of interdisciplinary

collaborations that have gained admiration and support from the Institute of Medicine.

Ideally, all healthcare systems should work in synchrony and provide care that is superb

and patient centered. However, many healthcare professionals and some institutions

continue to operate in virtually separate domains. An atmosphere of isolation and lack of

communication continues, and is affecting efficient delivery of care for patients and their

families. At the North Shore-LIJ -Heart and Vascular institute, the vision of the future

emphasizes teamwork and collaboration in which, interdisciplinary teams work together

to ensure that all our patients receive care that is individualized, coordinated, and tailored

using the most innovative methods to achieve superior patient care results.

Cardiovascular services embody complex and often dynamic sub specialties designed to

improve heart and vascular care and outcomes. The importance of working as a team is

directly correlated to patient satisfaction and overall quality of care. Working together

towards a common goal enhances better outcomes and increases patient and family

satisfaction, and gives the provider, and allied healthcare team members the commitment

and joy of performing at their best with each patient they touch.


How Can Nurses Become Full Partners in Interprofessional Collaboration?

Interprofessional collaboration is now considered one of the core competencies of any

health profession education and practice. At the heart of the efforts to make the delivery

of care collaborative is patient safety and quality of care, taking into consideration the

patient’s preferences and their active participation. Nurses are expected to be full partners

in this endeavor. The competency domains of interprofessional practice includes

values/ethics for interprofessional practice, roles/responsibilities, interprofessional

communication, and teams/teamwork (Interprofessional Education Collaborative [IPEC],

2011). It is beyond the scope of this blog to list all the possible roles that nurses can play

in interprofessional collaboration but here are a few suggestions for bedside nurses:

  •  Be an active participant during interdisciplinary rounds. Don’t just stand there.

Share with the team the nursing perspective or the patient’s preferences during


  • Ask any team members who come to the bedside “what’s the plan for the patient?”

This will promote collaboration and improve communication between various


  •  Participate in unit practice council or shared governance committees dealing with

interprofessional issues. This will allow an active voice from front line staffers in

designing and implementing quality improvement projects directed at improving

interprofessional collaboration.

  • Explore patients’ preferences with regards to their care trajectories and empower

them to be proactive in determining their choices. Refer the patient to the “Ask

Me Three” website (

  •  Stay up-to-date with your current knowledge of best practices and best evidence

depending on your specialty. A knowledgeable nurse is better able to advocate for

evidence-based care.

  • Organize an interprofessional event at your respective unit or have an on-going

professional development event (e.g., monthly) led by various specialties.

  • Attend interprofessional conferences locally or nationally. This is a good

opportunity to learn what others are doing and learn from their experiences.

  • Take on a leadership role in interprofessional committees. This will enhance

professional parity of nurses among he various health professions.

These are just a few examples on how nurses can be a valuable team member and leader

in making interprofessional collaboration a viable framework of care. The IPEC reminds

us that “mutual respect and trust are foundational to effective interprofessional working

relationships for collaborative care delivery across the health professions. At the

same time, collaborative care honors the diversity that is reflected in the individual

expertise each profession brings to care delivery” (IPEC, 2011, p. 18). It is not enough to

say we are working together, we must deliberately work interprofessionally.

Travis Baird

Travis Baird earned his Bachelors of Science in Nursing from

Adelphi University and an MSN in Adult Geriatric Nurse Practitioner from Hunter

College School of Nursing. He is ANCC certified adult geriatric primary care NP and a

CCRN. Currently Travis is a Nurse Practitioner in Cardiology at the Wellness and

Diagnostic center at New York Presbyterian Lower Manhattan hospital.

A Nurse’s Notes on New Year’s ResolutioNs

A Nurse’s Notes on New Year’s ResolutioNs


By Fidelindo Lim, DNP, CCRN

It’s the most promising time of the year. A clean slate ahead and a chance for a fresh start. There is no doubt nurses are making New Year’s resolutions like everybody else. I sometimes wonder how it would be like if I could hear or read the unspoken declarations of all the nurses for the coming year? I bet it will be a cacophony of oaths to do better, reflections on missed opportunities, obstinate desires to excel, and plucks to get things right among others.


As nurses, we are assumed to be good in planning (care plans anyone?). To prove this point, I’d like to propose an approach on how to make evidence-based (don’t we just love this phrase!?) resolutions for nurses. A basic template would be the SMART acronym on how to write goals we learned in Fundamentals of Nursing. High-quality resolve needs to be specific, measureable, attainable (or has an action/verb), realistic, and has a time frame. Yes, they make sense, whether you are naughty or nice. Smartly written resolutions have ring of success around them, a certain formality that begs your attention.


But, here is the disclaimer – I personally don’t prepare New Year’s resolutions (e.g., make a list). This doesn’t mean I don’t think about them. What I find amusing or enlightening is hearing other people’s resolutions. This taught me a lesson – one of the surest ways to unhappiness is to compare oneself to others – so I stopped asking. At year’s end I do a little life review, not the your-whole-life-flashing-at-you variety but a quiet and lazy conversation with myself, to ask the “so, what’s the plan?” types of questions. This exercise exhausts me while horizontal on the sofa! And I was quick to pronounce a nursing diagnosis of “activity intolerance” for the last days of the year.


On my first year as a nurse in the U. S., I used to list the areas of improvement I wanted for myself in relation to my performance at the bedside. The background to this is that I was told I was not meeting expectations (I was not told which ones) while on orientation and was running the risk of getting terminated or fired, after merely four weeks on the job! Written on a yellow pad paper, I affixed this list on the fridge door. Periodically, I’d pick up this list to draw a line across the ones I have already met and add new ones to the list. Looking back, I realize that I was making New Year’s resolutions, asynchronous to the passing of the year. On a weekly basis I was refining my skills by resolving to improve each time I encountered a deficiency. I regret now I did not keep that list as it would be revelatory to see what changed and what stayed the same in my practice. Since I am no longer a bedside nurse, I would like to imagine my top ten resolutions if I were a staff nurse at a hospital in 2014. Here they are (in random order):


  1. Arrive 30 minutes early for work
  2. Perform hourly rounding hourly
  3. Tie the back and neck straps of the isolation gown every time
  4. No matter what the rush, I won’t forget to flush those saline locks and CVLs
  5. Turn patients every two hours and not just document the task
  6. De-clutter the bedside before leaving the patient’s room
  7. Be nice to the nurse educators when they come around to give in-service
  8. Know where the location of the fire extinguisher even if JC is not around
  9. Answer the call bell promptly – in 3 minutes or less
  10. Always do hand hygiene before, in-between and after patient care


SMART aren’t they? Will I be able to keep them? Let’s save that question for the next life review. The essence of resolutions is the promise to do good work. Nurses’ need not wait for the end of the year to examine their resolve. The handoff during change-of-shift is our twice daily opportunity to make these covenants lived realities for our patients, for ourselves.

Happy New Year Nurses! And keep saving lives!

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Fidelindo Lim, DNP, CCRN

Fidelindo Lim is a clinical faculty at NYU College of Nursing and a per diem nurse educator for NYP Weill Cornell and Hospital for Special Surgery.