Interprofessional team interactions about complex care in the ICU: pilot development of an observational rating tool

Abstract Background The awakening and breathing coordination, delirium, and early mobility (ABCDE) bundle is a multicomponent complex intervention that improves outcomes for critically ill adults yet is inconsistently implemented. Effective interprofessional team function (how the team interacts) is key to ABCDE delivery but little is known about how to measure team interactions. The purpose of our study was to examine the reliability of an observational rating tool to assess team interactions about ABCDE in one ICU. Results We pilot tested and evaluated reliability of an observational rating tool to assess team interactions about ABCDE. Two independent raters used this tool in one medical ICU over 4 weeks during morning rounds. We examined which ABCDE components were addressed, which team members initiated interactions, and which participated in interactions about ABCDE. We evaluated inter-rater reliability using Cohen’s kappa statistic and data from interprofessional team interactions for 23 patients. We demonstrated moderate to substantial reliability for whether breathing, coordination, delirium or early mobility were addressed (k = 0.48–0.78) and slight to fair reliability for which team members initiated interactions about ABCDE (0.18–0.40). Reliability was low for whether Awakening was addressed (k = −0.07) and for which team members initiated interactions about awakening (k = 0.05). Conclusions Our study provides pilot evidence of reliability of an observational rating tool to assess interprofessional team interactions about ABCDE. Future work should further test and modify this tool to gain an understanding of how to use team interactions to improve ABCDE delivery.http://deepblue.lib.umich.edu/bitstream/2027.42/134632/1/13104_2016_Article_2213.pd

Student-led Special Interest Groups as a Model for Inclusion of Specialty Hand Content in OTD Curriculum

This article presents a student-led special interest group within a doctorate of occupational therapy (OTD) program as a model to supplement the core curriculum for inclusion of specialty content related to hand therapy. Consisting of advanced educational modules, research article review and discussion, as well as related service projects, the group provides ancillary benefits as well as networking opportunities for student participants. An initial program evaluation demonstrates efficacy as students reported a positive impact on various areas of professional and clinical skills to support specialization in hand therapy upon graduation. The student-driven nature of this experiential learning approach provides more robust content without taxing often limited financial and faculty resources of occupational therapy programs. This model may be generalizable to other areas of occupational therapy practice to provide specialty content for various student interest areas at the academic level, encouraging specialization for new graduates to continue to provide advanced care to diverse populations

Reliability and Validity of the Face, Legs, Activity, Cry, Consolability Behavioral Tool in Assessing Acute Pain in Critically Ill Patients

Background Few investigators have evaluated pain assessment tools in the critical care setting.Objective To evaluate the reliability and validity of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale in assessing pain in critically ill adults and children unable to self-report pain.Methods Three nurses simultaneously, but independently, observed and scored pain behaviors twice in 29 critically ill adults and 8 children: before administration of an analgesic or during a painful procedure, and 15 to 30 minutes after the administration or procedure. Two nurses used the FLACC scale, the third used either the Checklist of Nonverbal Pain Indicators (for adults) or the COMFORT scale (for children).Results For 73 observations, FLACC scores correlated highly with the other 2 scores (ρ = 0.963 and 0.849, respectively), supporting criterion validity. Significant decreases in FLACC scores after analgesia (or at rest) supported construct validity of the tool (mean, 5.27; SD, 2.3 vs mean, 0.52; SD, 1.1; P &amp;lt; .001). Exact agreement and κ statistics, as well as intraclass correlation coefficients (0.67–0.95), support excellent interrater reliability of the tool. Internal consistency was excellent; the Cronbach α was 0.882 when all items were included.Conclusions Although similar in content to other behavioral pain scales, the FLACC can be used across populations of patients and settings, and the scores are comparable to those of the commonly used 0-to-10 number rating scale.</jats:p

After critical care: Challenges in the transition to inpatient rehabilitation.

PURPOSE/OBJECTIVE: The aftermath of treatment for critical illness and/or critical injury in the intensive care unit (ICU) often includes persisting cognitive and emotional morbidities as well as severe physical deconditioning (a constellation termed post-intensive care syndrome, or PICS), but most patients do not receive psychological services before they enter the inpatient rehabilitation facility (IRF). Although a burgeoning literature guides the efforts of critical care providers to reduce risk factors for PICS - for example, reducing the use of sedatives and enacting early mobilization, there is need for a corresponding awareness among IRF psychologists and other providers that the post-ICU patient often arrives in a state of significantly reduced capacity, with persisting cognitive impairments and acute psychological distress. Many are at risk for long-term complications of posttraumatic stress disorder, general anxiety and/or clinical depression, and assuredly all have experienced a profound life disruption. This paper offers a multilevel perspective on the adaptation of post-ICU patients during inpatient rehabilitation, with discussion of the psychologist\u27s role in education and intervention. RESEARCH METHOD/DESIGN: Clinical review paper. RESULTS: NA. CONCLUSIONS: To optimize response to rehabilitation, it is important to understand the behavior of post-ICU patients within a full biopsychosocial context including debility, cognitive and emotional impairment, disruption of role identities, and environmental factors. The psychologist can provide education about predictable barriers to participation for the post-ICU patient, and guide individual, family and team interventions to ameliorate those barriers. (PsycINFO Database Recor

592-P: Epidermal Nrf2 Orchestrates Tissue Regeneration through Direction Regulation of Ccl2

Diabetic ulcers are costly chronic wounds and are the leading cause of lower-extremity amputations. Dysfunctional redox balance underlies a key part of diabetic wound repair pathology that results from misregulation of master antioxidant gene regulator Nrf2. While Nrf2 regulation is relevant for wound repair, how Nrf2 onsets a regenerative response is unclear. Using in-depth analyses, we uncover Nrf2 expression in keratinocytes to be vital for physiologic wound repair. In vivo spatio-temporal analysis shows deregulated nuclear translocation of Nrf2 in diabetic wound keratinocytes (WT: 96.97%±3.6%; Db: 22.50%±16.4%; p&amp;lt;.005), which correlates with reduced activation of many antioxidant gene targets (p&amp;lt;.005). To elucidate the role of Nrf2 in the epidermis, we utilized double transgenic mice to conditionally delete Nrf2 in keratinocytes (K14 CreER; Nrf2fl/fl; cKO) in vivo. Importantly, we find loss of epidermal Nrf2 results in a significant wound repair delay that reminisces delays observed in diabetic mice (WT: 16.0±0d; Db: 32±0d; cKO: 33±2d; p&amp;lt;.0005). RNA-seq of cKO wound keratinocytes reveals Nrf2 regulates epidermal release of extrinsic cues that affect non-autologous responses that are critical for regeneration, most notably immune cell guidance (p&amp;lt;.05). The magnitude of this signaling defect is shown through failure of cKO wounds to traffic monocyte/macrophages to the injury site (WT: 130.0±15.0cells/area; cKO 35.0±2.6cells/area; p&amp;lt;.05). This defect results from reduced expression of Ccl2 in cKO wounds, which we find to possess a Nrf2-binding motif that exhibits dynamic Nrf2 binding upon wounding. Induced expression of Nrf2 in primary keratinocytes results in Ccl2 upregulation, and its application is sufficient for restoring physiologic wound regeneration in cKO and diabetic wounds (p&amp;lt;.0001). We provide evidence describing an essential role of Nrf2 in regulating critical wound healing events and provide the basis for continued investigation on its therapeutic value. Disclosure A.P. Villarreal Ponce: None. M. Tiruneh-Worku: None. J. Lee: None. J.A. David: None. C. Guerrero-Juarez: None. K. Dammeyer: None. J. Kuhn: None. J. Kwong: None. D. Ceradini: None. Funding American Diabetes Association/Pathway to Stop Diabetes (1-16-ACE-08 to D.C.) </jats:sec

Keratinocyte-Macrophage Crosstalk by the Nrf2/Ccl2/EGF Signaling Axis Orchestrates Tissue Repair

Unveiling the molecular mechanisms underlying tissue regeneration provides new opportunities to develop treatments for diabetic ulcers and other chronic skin lesions. Here, we show that Ccl2 secretion by epidermal keratinocytes is directly orchestrated by Nrf2, a prominent transcriptional regulator of tissue regeneration that is activated early after cutaneous injury. Through a unique feedback mechanism, we find that Ccl2 from epidermal keratinocytes not only drives chemotaxis of macrophages into the wound but also triggers macrophage expression of EGF, which in turn activates basal epidermal keratinocyte proliferation. Notably, we find dysfunctional activation of Nrf2 in epidermal keratinocytes of diabetic mice after wounding, which partly explains regenerative impairments associated with diabetes. These findings provide mechanistic insight into the critical relationship between keratinocyte and macrophage signaling during tissue repair, providing the basis for continued investigation of the therapeutic value of Nrf2