American Journal of Critical Care - ajcc.aacnjournals.orgajcc.aacnjournals.org/content/26/2/local/complete-issue.pdfObesity Paradox in Heart Failure and ... MSN, ACNS-BC, CCRN, MARY

Patient Perceptions on Family PresenceDuring CPR

Nurses’ Caring Behaviors Maternal Stress and Anxiety in the PCICU

Nurses’ Postcode Coping After Unsuccessful CPR

New Ways to Explore Nursing Care and Intracranial Pressure

Obesity Paradox in Heart Failure and Diabetes

Review of CORTRAK Adverse Events

Lung Misplacements With Feeding Tube– Placement Device

March 2017 • Volume 26, Number 2

American Journal ofCritical Care

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Evidence-based interdisciplinary knowledge for high acuity and critical care


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Editors in Chief

CINDY L. MUNRO, RN, PhD, ANP

Associate Dean for Research and Innovation, University of South Florida College of Nursing, Tampa, Florida

RICHARD H. SAVEL, MD

Professor of Clinical Medicine, Albert Einstein College of Medicine, New York, New York

Founding Coeditors

CHRISTOPHER W. BRYAN-BROWN, MD, and KATHLEEN DRACUP, RN, DNSc

Editorial Board

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Rochester, New York

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St Louis, Missouri

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Annapolis, Maryland

JUDY L. BEZANSON, RN, DSN

Dallas, Texas

STIJN I. BLOT, RN, PhD

Ghent, Belgium

ELIZABETH J. BRIDGES, RN, PhD, CCNS, CCRN

Seattle, Washington

SUZANNE M. BURNS, RN, MSN

Charlottesville, Virginia

MARIANNE CHULAY, RN, DNSc

Southern Pines, North Carolina

MARTHA A. Q. CURLEY, RN, PhD

Boston, Massachusetts

RHONDA D’AGOSTINO, ACNP-BC

New York, New York

LYNN DOERING, RN, DNSc Los Angeles, California

BARBARA DREW, RN, PhD San Francisco, California

LEWIS A. EISEN, MD

Bronx, New York

DOUG ELLIOTT, RN, PhD

Sydney, New South Wales, Australia

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RAY RAPER, MD


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www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 93

SARAH A. DELGADO, RN, MSN, ACNP-BC

American Association of Critical-Care NursesAliso Viejo, California


Evidence-based interdisciplinary knowledge

for high acuity and critical care

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AMERICAN JOURNAL OF CRITICAL CARE® (Print ISSN 1062-3264, Online ISSN 1937-710X) is published bi monthly (January, March, May, July, September, Nov ember) by the American Association of Critical-Care Nurses (AACN), 101 Columbia, Aliso Viejo, CA 92656. Periodicals postage paid at Laguna Beach, CA, and additional mailing offi ce(s). Postmaster: Send address changes to the AMER ICAN JOURNAL OF CRITICAL CARE, Subscription Service Depart ment, 101 Columbia, Aliso Viejo, CA 92656.

Coming in May …Lee and colleagues assess a 2-step approach

to screen for depressive symptoms in patients

with heart failure to predict mortality.

On the Cover

“The Passionate Wine Maker”

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48'' x 24''

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To view other works by

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Families in Critical Care

Pediatric Critical Care

102 Abstracts of articles available exclusively online at www.ajcconline.org

e11 Administering Polyethylene Glycol Electrolyte Solution Via a Nasogastric Tube: Pulmonary ComplicationsNorma A. Metheny and Kathleen L. Meert

103 Perceptions of Adult Hospitalized Patients on Family Presence DuringCardiopulmonary ResuscitationCarolyn Bradley, Michelle Keithline, Meghan Petrocelli, Mary Scanlon, and

Janet Parkosewich

111 Show Your Stuff and Watch Your Tone: Nurses’ Caring BehaviorsRuth A. Weyant, Lory Clukey, Melanie Roberts, and Ann Henderson

118 Maternal Stress and Anxiety in the Pediatric Cardiac Intensive Care UnitAmy Jo Lisanti, Lois Ryan Allen, Lynn Kelly, and Barbara Medoff-Cooper

94 AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 www.ajcconline.org

March 2017, Volume 26, No. 2


128 Stress and Coping of Critical Care Nurses After Unsuccessful Cardiopulmonary ResuscitationDawn E. McMeekin, Ronald L. Hickman, Sara L. Douglas, and Carol G. Kelley

136 A Novel Approach to Explore How Nursing Care Affects Intracranial PressureDaiWai M. Olson, Camille Parcon, Aljean Santos, Guilla Santos, Ryan Delabar, and

Sonja E. Stutzman

140 Obesity Paradox: Comparison of Heart Failure Patients With and Without Comorbid DiabetesKyoung Suk Lee, Debra K. Moser, Terry A. Lennie, Michele M. Pelter, Thomas Nesbitt,

Jeffrey A. Southard, and Kathleen Dracup

149CORTRAK-Assisted Feeding Tube Insertion: A Comprehensive Review of Adverse Events in the MAUDE DatabaseAnnette M. Bourgault, Lillian Aguirre, and Joseph Ibrahim

157 Update on Effectiveness of an Electromagnetic Feeding Tube–Placement Device in Detecting Respiratory Placements Norma A. Metheny and Kathleen L. Meert

Healthy Work Environments

Brief Report

Cardiovascular Critical Care

Nutrition in Critical Care

97 Editorial Servant Leadership:

The Primacy of Service

Richard H. Savel and

Cindy L. Munro and

100 Clinical Pearls Rhonda Board

126 Evidence-Based Review and Discussion Points

Ronald L. Hickman

162 Commentary Electromagnetic Tube-Placement

Device: The Replacement for the

Radiographic Gold Standard?

Julia Park, Sylvia Krzeminski, Joshua Tan,

Meghana Bandlamuri, and Richard W. Carlson

164 Clinical Evidence Review Preventing Venous Thromboembolism:

The Role of Nursing With Intermittent

Pneumatic Compression

Nancy Dunn and Rebecca Ramos

169 ECG Puzzler Similar ECG Features in

2 Different Diagnoses

Michele M. Pelter, Teri M. Kozik,

Salah S. Al-Zaiti, and Mary G. Carey

172 Education Directory

Visit AJCC’s Web site, www.ajcconline.org, to submit a manuscript or for author guidelines, full text of selected articles, OnlineNOW articles, digital edition access, eLetters, links to AACN’s online continuing education tests, and more.

An Official Publication of the American Association of Critical-Care Nurses


SERVANT LEADERSHIP: THE PRIMACY OF SERVICE By Richard H. Savel, MD, and Cindy L. Munro, RN, PhD, ANP

Editorial

One of the greatest challenges facing anyone

working in critical care is leadership. No

matter who we are, we are at times put into

circumstances that require us to flex our “leadership

muscle.” Some of you might think leadership issues

don’t directly impact you. However, we believe that

leadership skills can help all of us regardless of role.

Whether one is a charge nurse for the day, a nurse

manager in an intensive care unit (ICU), or a bed-

side nurse involved in a code situation, having lead-

ership skills is always valuable. In this editorial we’ll

focus on a particular style of leadership that we feel

is particularly worthwhile: servant leadership.

BackgroundWhat do we mean by servant leadership? To

understand the concept, perhaps it’s best to divide

the construct into premodern and modern. Premod-

ern concepts of servant leadership stretch all the way

back to ancient Chinese writings and early Christian-

ity, during which time it was believed that “to be a

leader, one must be a servant first.”1-3 The modern

concept of servant leadership, which is more ger-

mane to this discussion, was developed by Robert K.

Greenleaf in 1970.4,5 Greenleaf spent his career work-

ing at AT&T as their head of management research.

With respect to servant leadership, Greenleaf wrote:

The servant-leader is servant first.... It begins

with the natural feeling that one wants to serve,

to serve first. Then conscious choice brings one

to aspire to lead. That person is sharply different

from one who is leader first, perhaps because of

the need to assuage an unusual power drive or to

acquire material possessions.... The leader-first

and the servant-first are 2 extreme types. Between

them there are shadings and blends that are

part of the infinite variety of human nature.

The difference manifests itself in the care taken

by the servant-first to make sure that other peo-

ple’s highest priority needs are being served. The

best test, and difficult to administer, is: Do those

served grow as persons? Do they, while being

served, become healthier, wiser, freer, more

autonomous, more likely themselves to become

servants? And, what is the effect on the least priv-

ileged in society? Will they benefit or at least not

be further deprived?1-3

One of the key differences between standard

autocratic leadership and servant leadership is that

the latter is a bottom-up approach, whereas the for-

mer is more top-down. Of course, the classic style of

leadership is that someone high up in a business

structure makes the decisions and the people below

simply follow them. In a servant leadership struc-

ture, this approach is inverted, with the primary job

of the leaders being to foster, nurture, and nourish

the associates in an organization so they can be the ©2017 American Association of Critical-Care Nursesdoi:https://doi.org/10.4037/ajcc2017356


best they can be. Not only are the voices of the asso-

ciates heard, but their ideas are communicated,

disseminated, and implemented much more eas-

ily to those in positions of leadership.

Whom Do We Serve?“Whom do we serve?” Perhaps this is the most

important question we can ask when thinking

about servant leadership in the critical care setting.

First and foremost, we are all here to serve the

patient. Serving patients is our primary focus and

the idea behind patient-centered care. Although

such a thing may seem obvious, it cannot be over-

emphasized, and it is equally important to ask

why. That is, why do we serve? In clinical practice

perhaps the “why” is obvious and straightforward.

We come to work each day to be part of a team that

provides the highest possible level of care to each

and every patient we encounter.

Nevertheless, we may not be able to practice to

our full potential on any given day. Perhaps we are

having personal problems. Perhaps the unit is

understaffed. Perhaps there is some piece of equip-

ment missing. We have all been through these

kinds of situations. This is where a servant leader-

ship approach might be valuable. For servant leaders,

the focus would be that we must serve the patient,

and that as members of the team we are here to

serve one another. Working together, we all win.

Putting Others FirstLet’s use the example of a lead intensivist or

medical director of an ICU. As a servant leader, this

person serves many groups. Serving the patients is

the first priority, of course. Whereas it should go

without saying, doing what is best for the patient is

the primary focus for every member of the organiza-

tion. Next, the medical director is a servant to his or

her fellow physicians in the group. The focus here

is to foster and nurture the junior physicians to

make sure they are progressing properly in their

career. It is about figuring out what is best for each

member of the team and how to ensure that each

person feels that her or his job is meaningful.

The medical director might serve several other

groups: bedside nurses, the nurse administrator of

the unit or units he or she helps supervise, the

senior nursing leadership of the hospital, and so on.

The medical director also serves the physicians who

admit patients to their unit, the chairs of the vari-

ous departments, and the senior administrators for

the entire organization. This kind of approach can

be applied to any member of the interprofessional

team. One begins at the beginning with serving the

patient, then branches out to determine which other

groups must be served as well.

Finding Strengths and WeaknessesOne important characteristic of servant leaders

is their ability to work closely with colleagues to

find their strengths and weaknesses. Such work is

important because one usually can find positions

within an organization where the areas of strengths

are emphasized and the areas of weakness are

deemphasized. For example, a nurse may be

assigned to a particular ICU where he or she is

required to work closely with surgeons, and might

not like it, whereas the same nurse might thrive in

a more medical environment. Perhaps a nurse is

starting to show signs of interest in a particular sub-

specialty area, or is begining to demonstrate interest

in administrative or teaching areas.

As servant leaders, we are always engaging with

members of our team to ensure they are working in

positions that are the best possible fit for their

global strengths and weaknesses. Taking a little extra

time to make these efforts can lead to greater

employee retention, greater productivity, and a

more positive work experience overall—with a bet-

ter patient experience as the ultimate outcome.

Practicing HumilityHumility can be defined as neither overesti-

mating one’s merits nor overvaluing oneself. From a

servant leadership perspective, humility is consistent

with a healthy ego and is not a sign of weakness. The

issue here is to reconcile a leadership position with

the concept of not necessarily knowing, under-

standing, or having all the answers. Again, a true

servant leader is determined to remain modest,

calm, and focused on giving credit to others. In

About the AuthorsRichard H. Savel is coeditor in chief of the American Journal of Critical Care. He is director, Adult Critical Care Services, at Maimonides Medical Center and a professor of clinical medicine at the Albert Einstein College of Med-icine, both in New York City. Cindy L. Munro is coeditor in chief of the American Journal of Critical Care. She is asso-ciate dean for research and innovation at the University of South Florida, College of Nursing, Tampa, Florida.

First and foremost, we are all here to serve the patient.


other words, a great servant leader creates an envi-

ronment where the people in the organization want

to “give it their all,” and by extension the organiza-

tion does well.

Challenges to ImplementationWe would be remiss if we did not mention

some of the challenges to implementation of a ser-

vant leadership culture in an organization. First of

all, most medical centers and medical schools are

still organized into department silos, each with its

own leaders. Leaders of those departments must

take the initiative to focus on servant leadership.

Second, some may be uncomfortable with the ser-

vant leadership model, preferring the more tradi-

tional autocratic style. Regardless, we feel that

servant leadership specifically and explicitly fits well

with the overall goals of critical care nursing and

medicine: never take your eye off the ball; that is,

the patient comes first. Many obstacles to servant

leadership must be overcome so our teams can be

the best they can be.

ConclusionsAs we reflect more deeply about this approach

to leadership, perhaps we realize that it is more

than just a leadership style, but a philosophy of life.

Servant leadership permits us to demonstrate lead-

ership without requiring the spotlight. It is a leader-

ship style in which the emphasis is on leading while

being unassuming: an opportunity to lead and let

others take the credit. Servant leadership stresses the

importance of aspirations for the organization

rather than ambitions for a particular person:

humility, collaboration, and a meaningful work

experience lead to positive results. What is exciting

about servant leadership is that it allows people

who may not have a classic leadership personality

(eg, outgoing, take-charge, seeking the spotlight) to

step forward and say, “I would like to help here.” It

allows all of us to see that there is a style of leader-

ship whereby leaders are there to support the orga-

nization and support us.

There is much to read about servant leadership,

and so we have included additional references.6-13

With this editorial we hope to have stimulated some

thought and encouraged further dialogue on the

topic of servant leadership. We wish for readers to

consider the merits of this philosophy in themselves

and in the leadership structure of their organiza-

tions. This deceptively simple but powerful approach

to leadership can lead both to excellent results for

our organizations and to profound meaning in the

lives of those it touches.

The statements and opinions contained in this editorial are solely those of the coeditors in chief.

FINANCIAL DISCLOSURESNone reported.

eLettersNow that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click “Submit a response” in either the full-text or PDF view of the article.

REFERENCES1. Wilson RT. Servant leadership. Physician Exec. 1998;24

(5):6-12.2. Schwartz RW, Tumblin TF. The power of servant leadership

to transform health care organizations for the 21st-century economy. Arch Surg. 2002;137(12):1419-1427.

3. Anderson RJ. Building hospital-physician relationships through servant leadership. Front Health Serv Manage. 2003;20(2):43-47.

4. Greenleaf RK. The Servant as Leader. Westfield, IN: The Greenleaf Center for Servant Leadership; 1970.

5. Greenleaf RK. The Power of Servant Leadership. San Fran-cisco, CA: Berrett-Koehler Publishers, Inc; 1998.

6. Autry JA. The Servant Leader: How to Build a Creative Team, Develop Great Morale, and Improve Bottom-Line Performance. New York, NY: Crown Business; 2004.

7. Howatson-Jones IL. The servant leader. Nurs Manag (Har-row). 2004;11(3):20-24.

8. Hunter JC. The World's Most Powerful Leadership Princi-ple: How to Become a Servant Leader. New York, NY: Crown Publishing Group; 2004.

9. Sipe JW, Frick DM. Seven Pillars of Servant Leadership: Practicing the Wisdom of Leading by Serving. Mahway, NJ: Paulist Press; 2009.

10. Jenkins M, Stewart AC. The importance of a servant leader orientation. Health Care Manage Rev. 2010;35(1):46-54.

11. Waterman H. Principles of “servant leadership” and how they can enhance practice. Nurs Manag (Harrow). 2011;17 (9):24-26.

12. Boden TW. The first shall be last: the essence of servant- leadership. J Med Pract Manage. 2014;29(6):378-379.

13. Trastek VF, Hamilton NW, Niles EE. Leadership models in health care —a case for servant leadership. Mayo Clin Proc. 2014;89(3):374-381.

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

A true servant leader is determined to remain modest, calm, and focused on giving credit to others.


Clinical Pearls Rhonda Board, RN, PhD, CCRN, Section Editor

Clinical Pearls is designed to help implement evidence-based care at the bedside by summarizing some of the most clinically useful material from select articles in each issue. Readers are encouraged to photocopy this ready-to-post page and share it with colleagues. Please be advised, however, that any substantive change in patient care protocols should be carefully reviewed and approved by the policy-setting authorities at your institution.

Putting Evidence-Based

Care in Your Hands

Nurses’ Stress Following Unsuccessful CPR

Approximately 40%-84% of all resuscitation

attempts in the intensive care unit result in death within 24 hours. However, little known about the effects of postcode stress on nurses who have expe-rienced unsuccessful patient cardiopulmonary resuscitation (CPR). McMeekin and col-leagues surveyed 432 nurses who participated in CPR within the previous year where the outcome was death, to identify their stress, coping, and posttraumatic stress symptom severity. They found the following: • Ineffective coping behaviors had a significant effect on posttrau-matic stress symptom severity. • Female participants experienced significantly higher postcode stress than male participants. • Nurses who had debriefing support had significantly lower postcode stress than those without the support. The authors suggest an understanding of postcode stress and stress symptoms can help identify resources to improve the health of critical care nurses, assist those most at risk, and possibly reduce premature departure from the profession.

See Article, pp 128-135

Patients’ Views on Family Presence During CPR

Many professional organizations have endorsed family presence (FP) during cardiopulmonary resuscitation (CPR),

and many nurses favor this practice. However, family members have mixed opinions and there is limited information from patients. Bradley and colleagues interviewed adult patients to explore their perceptions of FP during CPR. They found at least half of the patients considered it import-ant and felt they should be the decision makers about who is present. Younger age and nonwhite race were significantly associated with the desire for FP during CPR. Patients have preferences about FP, and reasons why they do or do not want FP include the following: • Benefits for both patient and family, such as not dying alone and helping families cope with end-of-life • Assurance that the health care team was performing CPR correctly and doing everything possible to revive them • Concern FP would distract the health care team • Worry for the family members who wit-ness CPR The authors recommend that hospitals establish a FP during CPR policy that considers the patient’s preference.


©2017 American Association of Critical-Care Nurses, doi:https://doi.org/10.4037/ajcc2017316

Maternal Stress and Anxiety in the Cardiac Pediatric Intensive Care Unit

Having a child in the pediatric intensive care unit (PICU) causes parental stress and anxiety. However, little work has been done exploring the stress of parents with an infant

undergoing neonatal open-heart surgery. Lisanti and colleagues studied the sources of stress for mothers of infants admitted to a cardiac PICU within 1 month of birth. They found the following: • The highest stressor was infant’s appearance and behavior. • The second highest stressor was parental role alteration. • Mothers with more than 1 child had higher anxiety. • Mothers’ anxiety was higher when examined less than 1 week after surgery compared to after 1week. Critical care nurses can play a key role in alleviating mater-nal stress by: • Supporting the parental role by allowing mothers to feed, hold, and change their infants. • Educating the mothers on infant behavioral signs of pain and how to respond to them. • Screening mothers for high anxiety and helping them to acquire coping skills.


Feeding Tube –Insertion Devices

The CORTRAK tube–insertion device uses an electromag-netic signal to trace tube placement on a portable moni-tor. Although users are trained, misplacement of feeding

tubes can still occur. Bourgault and colleagues reviewed adverse events related to this device use over the past 10 years. They found 54 adverse events reported with 98% being feeding tube placement in the lung, and the resulting primary complications were pneumothorax and pneumonitis. Furthermore, in 89% of the reports the tube tracing was omitted or the user failed to recognize the misplacement. The authors note that tube misplacement is not unique to CORTRAK use. Their recommendations for practice with this device include: • Removal of feeding tube if lung placement is suspected • Confirmation by a second “superuser” • Using real-time insertion tracings and not graphic stills • Development of institutional processes for documenta-tion and performance improvement. Use an alternate validated confirmatory method when there is uncertainty about feeding tube placement.



Background Patients sometimes require insertion of a nasogastric tube for the administration of a large volume of a polyethylene glycol electrolyte solution. If the tube is malpositioned, the risk for direct instillation of the solution into the lung increases. The risk for aspiration also increases if the infusion rate exceeds gastrointestinal tolerance.Purpose To review published cases of patients’ experiencing adverse pulmonary events after administration of polyethylene glycol electrolyte solution via a nasogastric tube and to offer suggestions to prevent these outcomes. Methods A search of the literature from 1993 through 2014 was performed by using the PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Scopus databases.Results In the 12 case reports located, none of the patients had radiographs to verify tube location before infusion of polyethylene glycol electrolyte solution. After symptoms developed in 3 children (ages 8-11 years), radiographs showed their tubes incorrectly positioned in the bronchus, lung, or esophagus; ports of a fourth child’s tube were in the orophar-ynx. The remaining 8 patients (ages 5-86 years) never had radiographs to determine tube placement. Pulmonary com-plications from the infusions of polyethylene glycol electrolyte solution contributed to the death of 5 of the patients.Conclusion Relatively simple maneuvers to reduce the likelihood of adverse pulmonary events following the admin-istration of large volumes of polyethylene glycol electrolyte solution via a nasogastric tube are well worth the cost and effort to protect patients from potential serious injury. (American Journal of Critical Care. 2017; 26:e11-e17)

©2017 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ajcc2017522

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ADMINISTERING POLYETHYLENE GLYCOL ELECTROLYTE SOLUTION VIA A NASOGASTRIC TUBE: PULMONARY COMPLICATIONSBy Norma A. Metheny, RN, PhD, and Kathleen L. Meert, MD

The American Journal of Critical Care offers an exclusively online publication process that disseminates cutting-edge research on high acuity and critical care in the most timely and effi cient manner possible. The abstracts below represent full-text articles available exclusively on the American Journal of Critical Care Web site, www.ajcconline.org. These OnlineNOW articles are fully peer reviewed, edited, formatted, and citable. Reprints of the full-text articles are available by calling (800) 899-1712 or (949) 362-2050 (ext 532) or by e-mailing [email protected].

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©2017 American Association of Critical-Care Nursesdoi:https://doi.org/10.4037/ajcc2017550

F amilies in Critical Care

Background Family presence during cardiopulmonary resuscitation in acute care is not widespread. Patients are not likely to be asked about their wishes for family presence or if they wish to be the decision makers about who should be present. Objective To explore the perceptions of patients on general medical units and to find factors independently associated with family presence during cardiopulmonary resuscitation.Methods A cross-sectional study of 117 randomly selected adult patients was conducted at an academic medical center. Participants were interviewed via a sur-vey to obtain information on demographics, knowledge of cardiopulmonary resuscitation, sources of information on resuscitation, and preferences for family presence. Results About half of the participants agreed or strongly agreed that family presence during cardiopulmonary resuscitation was important (52.1%), that the participant should be the decision maker about who should be present (50.4%), and that the patient should give con-sent ahead of time (47.0%). Participants indicated that they would want an adult sibling, parents, or others (20.5%); spouse (14.5%); adult child (8.5%); close friend (5.1%); or companion (4.3%) present during cardiopul-monary resuscitation. Younger participants (20-45 years old) were 6.28 times more likely than those ≥ 66 years old (P = .01) and nonwhite participants were 2.7 times more likely than white participants (P = .049) to want family presence.Conclusion Patients have strong preferences about family presence during cardiopulmonary resuscitation, and they should have the opportunity to make the decision about having family present. (American Journal of Critical Care. 2017; 26:103-110)

PERCEPTIONS OF ADULT HOSPITALIZED PATIENTS ON FAMILY PRESENCE DURING CARDIOPULMONARY RESUSCITATIONBy Carolyn Bradley, RN, MSN, CCRN, Michelle Keithline, RN, MSN, CCRN, Meghan Petrocelli, RN, BSN, CCRN, Mary Scanlon, RN, BSN, and Janet Parkosewich, RN, DNSc


Family presence during cardiopulmonary resuscitation (CPR), endorsed by several pro-fessional organizations,1-4 is not universally accepted in acute care. Permitting family presence during CPR is usually at the discretion of health care providers (HCPs). Most staff members are unaware of the existence of family presence policies5 or are incon-sistent in adhering to these policies.6-8

Few studies on family presence

during CPR have been focused on patients’

perspectives.


Studies on family presence have focused on the

perceptions of HCPs and patients’ family members.

Most nurses who participated in these studies were

in favor of family presence during CPR6,9-13 and were

more accepting of family presence than were physi-

cians.10-12,14-16 Nurses thought they needed to antici-

pate family members’ emotional responses to

resuscitation efforts and to tailor their multifaceted

role in supporting patients’ families during this

difficult event.6,13,17,18 Reservations of physicians

stemmed from their concerns that the team would

underperform if patients’ family members were pres-

ent.10,19,20 In addition, HCPs may feel anxious when

patients’ family members are present.10,12,16 Concerns

about family members’ emotional responses to wit-

nessing a loved one’s resuscitation was a common

theme in many studies.10,21,22

Views on family presence during CPR from

the family members’ perspective are mixed. Family

members who endorsed family presence thought

that they needed to witness

the efforts of the HCPs in

order to understand what was

going on10,15 and that being

present was their right.10,15,23

Families who remained with

their loved ones during CPR

found that being there helped

with their grieving process,

aided in closure, and provided

a positive presence and comfort to the patient.15,24

Persons with past experience witnessing CPR were

more likely than those without such an experience

to support family presence.25 Families who did not

support family presence during CPR thought that

the experience might be too distressing.11

Results of studies10,11,26 with patients indicated

that patients who wanted family presence would

feel supported and comforted during this time. Like

patients’ family members, patients thought it was

their right to have family presence during CPR.10,27

In 1 study,28 patients even indicated which family

members they wished to be present. Of note, family

presence during CPR was something that patients

thought HCPs should ask patients about at the time

of admission.11,29

Drawing conclusions on the basis of studies on

family presence during CPR from a patient’s perspec-

tive is difficult because of the variation in research

methods.10,11,23,25,26,28-30 More studies are needed to

adjust for important covariates, which are necessary

to identify predictors of patients’ preference for fam-

ily presence during CPR. Our aims were to explore

the perceptions of patients hospitalized on general

medical units and to determine factors independently

associated with family presence during CPR.

Methods Design, Setting, and Sample

We used a cross-sectional design to answer the

following 5 research questions:

1. How important is it for patients to have fam-

ily present during CPR?

2. Which family members would the patients

want to be present during CPR?

3. Do patients wish to be the decision maker

about family presence?

4. Do patients think it is important for them to

give consent for family presence?

5. What factors are associated with patients’

preferences for family presence during CPR?

Family presence was defined as having someone who

is biologically or legally related to the participant, a

companion, or a close friend remain with the patient

during CPR. CPR was operationalized as performing

chest compressions to regain pulse or circulation

and/or performing rescue breathing to regain venti-

lation, breathing, or lung function.

The study was conducted on 6 inpatient medi-

cine units at Yale New Haven Hospital, New Haven,

Connecticut, a 1541-bed academic medical center.

About the AuthorsCarolyn Bradley is a service line educator, Michelle Keithline, Meghan Petrocelli, and Mary Scanlon are clini-cal nurses, and Janet Parkosewich is the nurse researcher, Yale New Haven Hospital, New Haven, Connecticut.

Corresponding author: Carolyn Bradley, Yale New Haven Hospital, 4-527A East Pavilion, 20 York St, New Haven, CT 06510 (e-mail: [email protected]).


Data on patients’demographics, CPR knowledge and sources of information, and preferences for family presence during CPR were collected.

Potential study participants were randomly selected

from a list of patients with full code status (n = 910).

Of these patients, 46% (n = 418) met eligibility cri-

teria, which included being able to read and speak

English. Patients were excluded if they were under-

going treatment for cancer or related complica-

tions, had impaired decision-making capacity, or

had received narcotics or sedatives within the previ-

ous 2 hours. At time of recruitment, 58% of the

participants were unavailable (eg, off unit, discharged,

or asleep), 14% (n = 57) declined, and 28% (n = 118)

were enrolled in the study and completed the inter-

view. The study was approved by the institutional

review board.

ProceduresAfter a participant provided written consent, a

15-minute private interview was conducted at the

participant’s bedside by 1 of 6 investigators, who were

not direct care providers, by using a survey designed

specifically for this study. Face validity and content

validity of the survey were determined by a panel

of 6 advanced practice nurses. The survey was pilot

tested by a small group of laypersons. The initial

survey items were focused on CPR knowledge. Par-

ticipants were asked to define CPR in their own

words, and their responses were documented verba-

tim by the interviewer on the survey form. Responses

were read back to the participants to validate data

accuracy. For participants unable to define CPR cor-

rectly, we reviewed the definition and asked them

to repeat this information to verify their under-

standing. We determined participants’ sources of

CPR information by asking them if they had seen

or heard about CPR from the media or through

discussions with HCPs or family members.

The survey contained 3 statements on family

presence during CPR. Participants were asked to

rate their level of agreement for each item by using

a 5-point Likert scale. The 3 statements were as fol-

lows: Should you need CPR, it is important for you

to (1) have a family member present, (2) be the

one to decide if this person should be present, and

(3) give verbal or written permission ahead of time

to have a family member present. Finally, we asked

participants to explain why family presence during

CPR was or was not important to them. Responses

were documented verbatim and were repeated to

the participant to verify accuracy.

Statistical AnalysisThe number of participants (n = 118) in the ran-

dom sample was based on an a priori power analysis

(effect size 0.15; = .05; 80% power; 10 predictor

variables) for logistic regression. One participant

withdrew from the study; therefore, 117 participants

were included in the data analysis. Data were ana-

lyzed by using SPSS, version 22, software (IBM SPSS).

Measures of central tendency (mean, standard devi-

ation, range) for interval and ratio variables and fre-

quencies and percentages for nominal variables were

used to describe the sample and responses to the first

4 research questions.

To determine factors associated with the partici-

pants’ preferences for family presence during CPR,

we recoded the outcome variable as a dichotomous

variable by combining the agree and strongly agree

responses as a yes response and strongly disagree,

disagree, and uncertain responses as a no response.

To determine candidate

variables for the logistic

regression, we used 2 anal-

ysis and independent t tests

(age) to examine associa-

tions between demographic

factors, CPR knowledge,

sources of CPR informa-

tion, and the importance of

family presence during CPR.

We used inductive con-

tent analysis to gain further

insight into participants’

perceptions of family presence during CPR. Each

investigator independently interpreted and coded

every participant’s response to the open-ended

questions written verbatim during the interviews to

ensure accuracy and trustworthiness. Once this step

was completed, we met as a group to discuss the

codes and reach consensus about emerging themes.31

Results Demographic Factors

The majority of the 117 participants were female

(56.4%), were white (60.7%), and had at least some

college education (54.6%). The mean age was 54.2

years (SD, 15.9) (Table 1).

CPR Knowledge and Sources of Information Participants were knowledgeable about CPR.

Most (95.7%) were able to define CPR correctly.

Of note, 46.2% of the participants reported that

they were CPR certified at some point.

Five questions were asked to explore the partici-

pants’ sources of CPR information. Almost every

participant had seen CPR being performed on tele-

vision or other media (98.3%). Most participants


(52%) had not discussed with family members the

participants’ wishes to have CPR performed should

the need arise. However, upon admission to the hos-

pital, only 30.8% of the sample recalled talking with

HCPs about CPR wishes. Of these participants, just

a small percentage (24%) remembered the person

they had spoken with, namely, the physician (12%),

staff nurse (11%), or advanced practice nurse (1%).

Research Questions 1 to 4 Family presence during CPR was an important

topic for the study participants. Approximately

one-half of the participants agreed or strongly agreed

that family presence during CPR was important

(52.1%), that they wished to make the decision

about who should be present (50.4%), and that

giving verbal or written consent ahead of time to

have a family member present was important

(47.0%; Table 2). These participants identified a

preference for the person they wanted to be present

by indicating a spouse (14.5%), adult child (8.5%),

close friend (5.1%), or companion (4.3%). The

highest percentage of participants (21%) selected

the other category and wrote in their preference to

have a sister, brother, mother, father, girlfriend,

fiancé, or person with power of attorney present

should they need CPR. In particular, 1 participant

specified “anyone but my son.”

Research Question 5The variables demographics, CPR knowledge,

and sources of CPR information were examined to

determine the factors associated with the importance

of having family presence during CPR (Table 3). Of

the demographic factors, age, race or ethnicity, and

education had a statistically significant unadjusted

association with the importance of family presence

during CPR. Participants with a mean age of 50 years

agreed with the importance of family presence during

CPR, whereas patients with a mean age of 58.7 years

disagreed with this statement (P = .003). To further

examine the association between age and family

presence during CPR, we created 2 dummy variables:

ages 20 to 45 years as the younger age variable and

ages 46 to 65 years as the middle age variable. Ages

66 years and older was used as the reference variable.

Most participants in the younger age group (72.2%)

agreed with the importance of family presence

during CPR, compared with middle-aged (47.3%)

and older (34.6%) participants (P = .008). In addi-

tion, nonwhites (68.9%) were more likely than

whites (42.3%) to agree with this statement (P = .005),

Characteristics

Table 1Demographic characteristics of the sample (n = 117)

Age, y 20-45 46-65 66

Sex Female Male

Marital status Married or with a domestic partner Single Divorced Separated

Race or ethnicitya

White Black Hispanic Asian Mixed

Educationa Eighth grade Some high school High school Some college College graduate Graduate school

a Some data are missing.

(30.8)(47.0)(22.2)

(56.4)(43.6)

(41.0)(37.6)(18.8)(2.6)

(60.7)(23.1)(9.4)(1.7)(4.3)

(2.6)(4.3)(36.8)(28.2)(17.9)(8.5)

365526

6651

484422 3

712711 2 5

3 543332110

No. (%)

Question:Should you need CPR….

Table 2Participants’ preferences regarding family presence during cardiopulmonary resuscitation (n = 117)

It is important for you to have a family member present.

It is important for you to be the one to decide if this person should be present.

It is important for you to give verbal or written consent (permission) ahead of time to have a family member present.

31 (26.5)

39 (33.3)

33 (28.2)

30 (25.6)

20 (17.1)

22 (18.8)

14 (12.0)

23 (19.7)

21 (17.9)

18 (15.4)

16 (13.7)

11 (9.4)

24 (20.5)

19 (16.2)

30 (25.6)

Strongly agreeAgreeUncertain

No. (%) of patients

DisagreeStronglydisagree


and participants with less than a college education

(64.7%) were more likely than were participants

with some college education or higher (42.2%) to

agree (P = .02).

We found no association between the CPR

knowledge of participants and their perception of

the importance of family presence during CPR. Simi-

larly, participants’ sources of information, including

being CPR certified, watching CPR on television or

other media or being performed (live) on someone,

and discussing CPR with HCPs or a family member

were not associated with this perception.

After demographic factors, CPR knowledge, and

sources of CPR information were adjusted for, age

and race or ethnicity were independently associated

with the perceived importance of family presence

during CPR. Participants 20 to 45 years old were more

than 6 times more likely to agree with wanting to

have family presence during CPR than were partici-

pants 66 years and older (95% CI, 1.466-26.868;

P = .01; Table 4). Participants who report their race

as nonwhite were about 2.7 times more likely than

whites to agree with the importance of family pres-

ence during CPR (95% CI, 1.002-7.316; P = .049).

Participants with less than a college education were

more likely than participants with a college educa-

tion to agree with the importance of family presence

during CPR (95% CI, 0.988-7.001; P = .05).

Qualitative Analysis The overarching theme of the qualitative analy-

sis was patient- and family-centered care (see Figure).

Within this overarching theme, 6 subthemes emerged

that described why family presence was or was not

important to participants. The 3 subthemes related

to the importance of family presence are elaborated

in the following material.

Beneficial to Patient and Patient’s Family. Benefits

for the patient included not being alone or dying

alone and receiving comfort and a helpful presence

from a family member. For example, participants

commented, “If it’s your last breath, it should be

with someone you love,” and “I believe that encour-

agement from family can make me stronger—it

would help.”

Participants expressed the importance of having

their family witness all that was being done for them

during the resuscitation: “I would want my loved

one to see the efforts involved in my resuscitation,”

and “I wouldn’t want her to wonder what else could

have been done to save my life.”

On the basis of the close and supportive relation-

ship that patients have with their family members,

Variable

No. (%) of participants

Table 3Unadjusted factors associated with the preference of participants to have family present during cardiopulmonary resuscitation (CPR)

Age, y 20-45 46-65 66

Sex Male Female

Marital status Not married Married

Ethnicity All other ethnicities White

Education < College education College education

CPR definition Incorrect definition Correct definition

CPR certification Not certified Certified

Seen CPR being performed on someone No Yes

Seen CPR being performed on television/media No Yes

Talked with health care providers about wishes No Yes

Talked with family about wishes No Yes

Age, mean (SD), y

.008

.33

.70

.005

.02

.58

.09

.35

.95

.93

.98

.003

10 (27.8)29 (52.7)17 (65.4)

27 (52.9)29 (43.9)

32 (46.4)24 (50.0)

14 (31.1)41 (57.7)

18 (35.3)37 (57.8)

3 (60.0)53 (47.3)

34 (54.8)21 (38.9)

33 (44.6)23 (53.5)

1 (50.0)55 (47.8)

39 (48.1)17 (47.2)

29 (47.5)26 (47.3)

58.7 (15.7)

26 (72.2)26 (47.3) 9 (34.6)

24 (47.1)37 (56.1)

37 (53.6)24 (50.0)

31 (68.9)30 (42.3)

33 (64.7)27 (42.2)

2 (40.0)59 (52.7)

28 (45.2)33 (61.1)

41 (55.4)20 (46.5)

1 (50.0)60 (52.2)

42 (51.9)19 (52.8)

32 (52.5) 29 (52.7)

50 (15.0)

PYesNo

Variable

Table 4Adjusted associations with the preference of having family member present during cardiopulmonary resuscitation

Age (20-45 y)

Race (nonwhite)

< College education

1.466-26.868

1.002-7.316

0.988-7.001

6.280

2.708

2.630

.01

.049

.05

95% CIOdds ratioP


participants thought the family members would

want to be present: “Family wouldn’t agree with

being asked to leave, especially my mother.”

Another positive effect of witnessing CPR

expressed by participants was related to helping

their family cope with the end of life: “I think it

would help my partner suffer less if he can see

everyone working to bring me back.”

Lack of Confi dence in HCPs. Participants who

wanted family presence thought that HCPs would

perform better and do more to save them with a

family member present: “If they are in the room,

they will help to urge the health care team to work

harder to revive me. Better work would be done if

family is watching over them.”

Lack of Trust in HCPs. Participants had a desire for

their family members to witness that CPR was being

properly performed. Participants were also concerned

about abuse or the lack of proper care: “If some-

thing went wrong, the family could witness it,” and

“Protection to make sure I am not being abused.”

Similarly, 3 subthemes conceptualized why partic-

ipants indicated that family presence is not important.

Worries About Family Member. The idea of family

presence during CPR raised numerous concerns for

participants. They worried that the experience would

be traumatic, upsetting, scary, or stressful for their

loved ones: “Too traumatic for them, especially if it

didn’t work,” and “There’s not much they can do.

Why put them through that?”

Some participants did not want their family

members to have false hope about the participant’s

recovery from the event, whereas others did not want

this event to be the last memory of them: “As a

health care provider, I have performed CPR . . . it

gives families a glimmer of hope that their loved

one will be saved. Then, when we have to stop,

they ask ‘Why?’” Another participant commented,

“Wouldn’t want my family to remember last thoughts

of me as being coded.”

Maintenance of Patient-Focused Care. Participants

were concerned that a family member’s presence

during CPR would distract the health care team

from saving the patient’s life: “Focus should be on

emergency work and not family member.”

Some participants were fearful about delays in

care if they indicated that they wanted a family mem-

ber present should they need CPR. They thought

that they would have to wait until family members

were contacted for CPR to be performed: “In case

no one was around I wouldn’t want to miss the care.”

Family Presence Unnecessary. Some participants

revealed that during resuscitation they would not

be aware of their surroundings, others did not have

a caring relationship with their family, and, ulti-

mately, family presence would not affect the out-

come of CPR. Comments included the following:

“I don’t think I would be aware of who was there

if I was in that condition.” “I don’t think it is import-

ant; my family does not care.” “Either way it would

not matter if a family member was present or not; it

would be the same outcome.”

Discussion This study was the fi rst of its kind with a ran-

dom sample of inpatients with a face-to-face private

interview in which multivariate analysis was used

to determine factors independently associated with

patients’ wishes to have family presence during CPR.

Similar to the fi ndings of other studies,10,25,28-30 our

results indicated that some patients wished to have

family members present during CPR. Our results

were comparable to those of other investigations25,28

in which younger age had a statistically signifi cant

association with a desire for family presence. In an

unadjusted analysis, Benjamin et al28 found a trend

for the association between nonwhite race and fam-

ily presence. However, in our study, after important

covariates were adjusted for, younger age and non-

white race were independently associated with this

preference. Therefore, these demographic variables

may be important predictors of patients’ wishes to

have families present.

Our results concur with those of other investi-

gators11,29 who found that patients want to be asked

about family presence during CPR and want the

patients’ preferences taken into consideration. The

participants in our study were specifi c about the

person they wanted with them should they require

CPR. HCPs cannot assume which family member a

patient would want to be present during CPR. Unlike

other researchers, we specifi cally asked our partici-

pants about the importance of obtaining consent

Figure Themes for the importance of family presence to patients during cardiopulmonary resuscitation.

Patient- and family-centered care

Family presence is important to

the patient

Family presence is not important to the patient

• Benefi cial to patient and patient’s family• Lack of confi dence in health care providers• Lack of trust in health care providers

• Worries about family member• Maintenance of patient-focused care• Family presence unnecessary


for family presence and discovered that many do

agree with the formality of consent.

Like others,10,11,26 we found that patients who

favored family presence during CPR thought they

would feel supported and comforted. However, we

identified 2 novel reasons for family presence that

were related to patients’ lack of confidence and trust

in HCPs. In our participants’ minds, having family

observe resuscitation efforts would motivate the

team to work harder and ensure that care was being

provided properly.

In our study and in other investigations, com-

mon reasons for not wanting family presence during

CPR included patients’ concern for their loved one’s

reaction11,28 and a desire to keep HCPs focused on

resuscitation efforts without family distractions.28

Some patients in our study thought that family pres-

ence was unnecessary because it would not make a

difference to them or the outcome of CPR. Another

new concern that emerged in our study was fear of

delaying CPR; some patients thought that HCPs

would not start CPR until a patient’s family mem-

bers had arrived. This misperception should be clari-

fied during discussions on code status and family

presence, highlighting the importance of having

these discussions at the time of hospital admission.

In summary, approximately one-half of the par-

ticipants in our study agreed that family presence

during CPR is important. Patients have a variety of

reasons that affect their decisions for family involve-

ment during this critical event. Knowing the view of

a patient and the patient’s family members on fam-

ily presence during CPR is an essential component

to promoting patient- and family-centered care.

Limitations Generalizability of our findings to other popu-

lations of patients is limited because the sample was

drawn solely from medical units and did not include

patients who were unable to speak and read English.

Obtaining the views of patients admitted to specialty

settings would be beneficial. Larger diverse samples

would enhance the power to detect differences

among factors associated with patients’ preferences

for family presence during CPR.

Conclusions Keeping families together during a crisis is

important in the provision of patient- and family-

centered care. Patients have strong preferences about

family presence during CPR. Patients should have

the opportunity to make their decision about family

presence during CPR during the discussion on code

status at the time of admission to the hospital.

Our results were used to create a policy on family

presence during CPR in our hospital with the spe-

cific aim of providing patient- and family-centered

care. Other acute care hospitals can replicate this

process to develop or revise a policy on family pres-

ence during CPR, which may include determining the

patient’s preference.

ACKNOWLEDGMENTSWe extend our appreciation to Wei Teng, PhD, and Nelson Leach, RN, BSN, CCRN, for their contributions to the study.

FINANCIAL DISCLOSURESThis research was supported by a grant from Sigma Theta Tau International Honor Society of Nursing, Delta Mu Chapter.


SEE ALSO For more about family presence during resuscitation, visit the Critical Care Nurse website, www.ccnonline .org, and read the article by Pasek and Licata, “Parent Advocacy Group for Events of Resuscitation” (June 2016).

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3. Fulbrook P, Latour J, Albarran J, et al. The presence of fam-ily members during cardiopulmonary resuscitation: Euro-pean Federation of Critical Care Nursing Associations, European Society of Paediatric and Neonatal Intensive Care and European Society of Cardiology Council on Car-diovascular Nursing and Allied Professions joint position statement. Eur J Cardiovasc Nurs. 2007;6(4):255-288.

4. Morrison LJ, Kierzek G, Diekema DS, et al. Part 3: ethics: 2010 American Heart Association guidelines for cardiopul-monary resuscitation and emergency cardiovascular care. Circulation. 2010;122(8)(suppl 3):S665-S675.

5. Zavotsky KE, McCoy J, Bell G, et al. Resuscitation team perceptions of family presence during CPR. Adv Emerg Nurs J. 2014;36(4):325-334.

6. Lowry E. “It’s just what we do”: a qualitative study of emer-gency nurses working with well-established family presence protocol. J Emerg Nurs. 2012;38(4):329-334.

7. Pankop R, Chang K, Thorlton J, Spitzer T. Implemented family presence protocols: an integrative review. J Nurs Care Qual. 2013;28(3):281-288.

8. Porter J, Cooper SJ, Sellick K. Attitudes, implementation and practice of family presence during resuscitation (FPDR): a quantitative literature review. Int Emerg Nurs. 2013;21(1): 26-34.

9. Carroll DL. The effect of intensive care unit environments on nurse perceptions of family presence during resuscita-tion and invasive procedures. Dimens Crit Care Nurs. 2013; 33(1):34-39.

10. Duran CR, Oman KS, Abel JJ, Koziel VM, Szymanski D. Atti-tudes toward and beliefs about family presence: a survey of healthcare providers, patients’ families, and patients. Am J Crit Care. 2007;16(3):270-279.

11. Grice AS, Picton P, Deakin CD. Study examining attitudes of staff, patients and relatives to witnessed resuscitation in adult intensive care units. Br J Anaesth. 2003;91(6):820-824.

12. Howlett MS, Alexander GA, Tsuchiya B. Health care provid-ers’ attitudes regarding family presence during resuscitation of adults: an integrated review of the literature. Clin Nurse Spec. 2010;24(3):161-174.

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14. Colbert JA, Adler JM. Clinical decisions. Family presence during cardiopulmonary resuscitation—polling results. N Engl J Med. 2013;368(26):e38.

15. Meyers TA, Eichorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000;100(2):32-42.

16. Mian P, Warchal S, Whitney S, Fitzmaurice J, Tancredi D. Impact of a multifaceted intervention on nurses’ and phy-sicians’ attitudes and behaviors toward family presence during resuscitation. Crit Care Nurse. 2007;27(1):52-61.

17. McClement SE, Fallis WM, Pereira A. Family presence during resuscitation: Canadian critical care nurses’ perspectives. J Nurs Scholarsh. 2009;41(3):233-240.

18. Walker WM. Emergency care staff experiences of lay presence during adult cardiopulmonary resuscitation: a phenomeno-logical study. Emerg Med J. 2014;31(6):453-458.

19. Basol R, Ohman K, Simones J, Skillings K. Using research to determine support for a policy on family presence during resuscitation. Dimens Crit Care Nurs. 2009;28(5):237-247.

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21. Ong ME, Chung WL, Mei JS. Comparing attitudes of the public and medical staff towards witnessed resuscitation in an Asian population. Resuscitation. 2007;73(1):103-108.

22. Tudor K, Berger J, Polivka BJ, Chlebowy R, Thomas B. Nurses’ perceptions of family presence during resuscitation.

Am J Crit Care. 2014;23(6): e88-e96.23. Mazer MA, Cox LA, Capon JA. The public’s attitude and per-

ception concerning witnessed cardiopulmonary resuscita-tion. Crit Care Med. 2006;34(12):2925-2928.

24. Holzhauser K, Finucane J, De Vries SM. Family presence during resuscitation: a randomised controlled trial of the impact of family presence. Australas Emerg Nurs J. 2006; 8(4):139-147.

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F amilies in Critical Care

Background Although it is perceived as essential, docu-mentation of caring behaviors executed by nurses is rarely done. To facilitate what is important to patients and their family members, we need to understand what behaviors are perceived as caring or not caring. Objective To explore perceptions of nurses’ caring behav-iors among intubated patients and their family members.Methods A phenomenological study of 14 patients who were intubated, restrained, sedated, and received pain medication in an acute cardiovascular intensive care unit. The 14 patients and 8 of their family members were interviewed about their perceptions of this experience. A semistructured interview guide was used. Data were analyzed by using an inductive method consistent with qualitative research. Results Themes that emerged most often were providing information, providing reassurance, demonstrating profi-ciency, and being present. Other behaviors identified as caring behaviors were nurses giving guidance and using a soothing tone of voice. Behavior that was contrary to the perception of caring appeared as isolated incidents. These included negative attitude, interrupting sleep, not receiving information, and poor pain management.Conclusion When patients and family members are asked directly about their experience, valuable insight is gained into what they perceive as caring and what con-tributes to recovery as perceived by those in crisis and in high-intensity medical settings. Capturing these data is elemental to designing high-quality, safe environments that facilitate healing. (American Journal of Critical Care. 2017; 26:111-117)

SHOW YOUR STUFF AND WATCH YOUR TONE: NURSES’ CARING BEHAVIORSBy Ruth A. Weyant, RN, MSN, CCRN-CMC, Lory Clukey, RN, PhD, PsyD, CNS, Melanie Roberts, MS, APRN, CCRN, CCNS, and Ann Henderson, PhD, APRN, CNS

1.0 HourC EThis article has been designated for CE contact

hour(s). See more CE information at the end of

this article.


The original purpose of this study was to explore the perceptions of patients and their family members about the experience of restraint use during intubation.1 Patients and their families were also queried about what was helpful or not helpful during their time in critical care. Little has been published about the perceptions of patients undergoing mechanical ventilation and their families who spend time in

the intensive care unit. This article explores these perceptions related to nurses’ caring behaviors.

Nurses’ caring behaviors are

rarely documented.


Intubation is indicative of a physiological alter-

ation requiring mechanical ventilation. This problem

places the patient and the patient’s family in a crisis.

It is at these traumatic times that nursing care becomes

critical to families in need.

There has been some concern in the nursing pro-

fession that with the demands of a high-technology

environment, some aspects of caring may be subju-

gated to the workload demands of attending to high-

acuity patients and their families. Wilkin and Slevin2

asserted that with the proliferation of technology,

nurses in intensive care units may have difficulty

focusing on the human aspect of caring, because of

the competing demand of moni-

toring the data generated from the

technology, time constraints, and

the need to attend to protocols and

standardized algorithms. Examin-

ing the perceptions of the people

we are caring for is important. How

do family members of intubated and restrained

patients in a cardiac intensive care unit perceive

the care received from nurses? What do they iden-

tify as caring or not caring behaviors? These are

questions we asked of patients and family mem-

bers on an acute cardiac intensive care unit.

Nurses see caring as being at the heart of what

they do. Documentation of caring is rarely done,

however. Brenner et al3 reported that their data

indicated that the act of documenting caring behav-

iors increased awareness of what those behaviors

are. Those authors asserted that documentation of

nurses’ caring behaviors needs improvement.3 We

need to understand what behaviors patients and their

family members perceive as caring or not caring to

help nurses learn how to document these behaviors,

because caring is such an essential part of our practice.

Methods In a phenomenological study, 14 patients who

had been intubated, restrained, sedated, and had

received pain medication in a cardiovascular inten-

sive care unit were interviewed about their percep-

tions of this experience. Eight family members from

this group of 14 patients also were interviewed. These

patients were physically restrained with wrist restraints,

had light to moderate doses of sedation medication,

and had pain medication available. Family members

were asked a series of 5 open-ended questions about

their experience of having a loved one intubated and

restrained (Table 1).

This study was approved by the institutional

review board of the Medical Center of the Rockies,

where the study was conducted, with corresponding

agreement by the University of Northern Colorado,

with which 1 of the authors has an affiliation. A sem-

istructured interview guide was used. Once written

informed consent was obtained, interviews were

conducted after the patient left the intensive care

unit and before the patient was discharged from

the hospital. All interviews were tape recorded by

the primary investigator (R.A.W.). A co-investigator

(L.C.) was present for the first 2 interviews to assist

in developing nonbiased interviewing techniques.

All interviews were transcribed; any personal identi-

fying information was removed and code letters were

used to protect confidentiality. Data were collected

until saturation of common themes was reached.

Data were analyzed by using NVivo 9 qualitative

research software (QSR International).

Results Caring behaviors of the nurses were identified

and each is discussed in more detail in this article.

The themes that emerged most frequently were

About the AuthorsRuth A. Weyant is a staff registered nurse in the cardiac intensive care unit, Medical Center of the Rockies, Love-land, Colorado. Lory Clukey is an associate professor, University of Northern Colorado, Greeley, Colorado. Melanie Roberts is a critical care clinical nurse specialist, Medical Center of the Rockies. Ann Henderson is an edu-cation nurse specialist, Medical Center of the Rockies.

Corresponding author: Ruth A. Weyant, RN, MSN, CCRN-CMC, Medical Center of the Rockies, 2500 Rocky Mountain Ave, Loveland, CO 80538 (e-mail: [email protected]).


providing information, providing reassurance, demon-

strating proficiency, and being present (Table 2). Other

behaviors identified as caring behaviors were nurses

giving guidance and using a soothing tone of voice.

Behavior that was contrary to the perception of car-

ing appeared as isolated incidents. They included

negative attitude, interrupting sleep, not providing

information, and poor pain management. Although

we thought that saturation was reached for the posi-

tive behaviors identified, comments on behaviors

perceived as not caring were infrequent and satura-

tion was not likely in this domain. Participants were

asked specifically about what behaviors they per-

ceived as not helpful, but few unhelpful behaviors

were identified.

Providing InformationFamilies often have little time to prepare for

cardiac surgery. Despite this, families interviewed

for this study reported receiving education about

restraints and other information they perceived as

being relevant. For example, 1 family member said,

“They told us before surgery that he would have to

be restrained so he couldn’t pull the tubes out.”

Explaining the rationale for the nursing care being

provided was perceived as a comfort. One patient

said the nurse “being there and telling me what they

were gonna do and why they were gonna do it” was

a comfort. Another patient said, “From what I hear,

they informed my family on the hour lots of times,

like every 15-20 minutes, about what was going on.”

Providing direct information was helpful. Patients

and family members appreciated explanations and

even repetition of information. One patient said,

“That explanation, I mean, I’m sure I heard it several

times . . . just to know . . . sometimes you don’t hear

things the first time.”

These results are consistent with results of a

study conducted by Von Essen and Sjoden,4 in which

patients identified nursing behaviors related to actions

that treated their physical illness as demonstration

of caring. Using a Caring Assessment Report Evalua-

tion Q-sort questionnaire, the researchers found that

subscales relating to the following nurse behaviors

were the most highly rated by patients: monitors

and follows through, anticipates, and explains and

facilitates. Knowledge-based behaviors such as inter-

preting what was happening and providing explana-

tions were identified by family members of trauma

patients as being helpful and indicating caring by

nurses.5 In addition to providing information, nurses

also provided emotional support through reassurance,

which is also based in nursing knowledge.

Providing ReassuranceAn important aspect of nursing care according to

patients and their family members was the reassur-

ance that nurses provided. During this high-intensity

situation, the expertise of the nurses was demonstrated

when they could inform clients about what was

happening and what was being done. The nurses’

ability to provide reassurance allowed clients to

relax and trust in the skilled care being provided.

Questions for the patient

Questions for the family member

Table 1Semistructured interview questions

1. In the intensive care unit (ICU), we restrain patients who are on the ventilator with soft wrist restraints. What was it like for you being restrained in the ICU?

2. What do you remember being said to you while you were on the ventilator? Who was talking with you?

3. How do you remember feeling and what did you think? Tell me more about that.

4. What seemed to help you or provide comfort while you were restrained and on the ventilator?

5. What did not help you while you were restrained and on the ventilator?

1. In the intensive care unit (ICU), we restrain patients who are on the ventilator with soft wrist restraints. What was it like for you to see your family member restrained in the ICU? What do you remember about the restraints?

2. What do you remember being said to you while your family member was on the ventilator? Who was talking with you?

3. How do you remember feeling and what did you think? Tell me more about that.

4. What seemed to help you or provide comfort while your family member was restrained and on the ventilator?

5. What did not help you while your family member was restrained and on the ventilator?

Table 2Nurses’ caring behaviors in critical care for intubated patients and family members

Providing information

Providing reassurance

Demonstrating proficiency

Being present

Giving guidance, voice tone

Giving direct information and explaining what was being done and why

Offering encouragement that things were going as expected, explanations about what was happening, and reassurance that things were under control

Providing care with confidence

Being physically present and responding to calls in a timely manner

Providing information about what to do and expect; using a soothing and pleasant tone of voice

Behavior Definition


Patients and families are keen

observers of nurses’ clinical

proficiency.

One patient said, “I knew she was on my side.

I knew she wasn’t trying to do me any harm.” When

asked what specifically helped the patient feel the

nurse was on his side, this patient replied, “Well,

just that calming, kindly reassurance and the expla-

nation that when I could control my breathing the

ventilator tube could come out.”

Talking to patients and letting them know what

was going on was perceived as helpful not just to

the patient but to the family member

as well. One patient’s family member

said, “The thing that helped me the

most was, he was just laying there

unconscious basically. I didn’t sup-

pose he could hear or respond or any-

thing, but when they were up there

at the bedside, they would talk to

him and say ‘we’re going to move you

up’ . . . to me that was neat that he

was responding and everything’s okay.” Another

patient indicated that he appreciated “just reassur-

ance from the staff.” When asked how he might

feel if he did not have this reassurance from the

staff, this patient noted, “Oh, you would have been

much more worried then you are. You would be

totally bewildered and lost.”

Wilkin and Slevin2 identified similar nursing

behaviors deemed as caring. They noted that comfort-

ing patients consisted of providing information, lis-

tening, and giving reassurance. Wiman and Wikblad6

identified being present, open, and able to provide

reassurance as notable when nurses demonstrated

caring behaviors in the emergency department.

Demonstrating ProficiencyAs nurses, we expect clinical competency from

ourselves. Although not often acknowledged overtly,

patients and families are keen observers of our clini-

cal proficiency. The skill and adeptness of nursing

practice that are demonstrated can influence the

patients’ and families’ perception of nursing care. One

family member noted, “There were times when his

oxygen wasn’t where it needed to be and they were

really hustling and working hard to get things right.”

The things that nurses do can be perceived as

very significant to our clients, especially when those

actions demonstrate caring and provide comfort.

These common nursing interventions can influence

patients’ and family members’ perceptions of the

care they receive and most likely influence patient/

family satisfaction. For example, a patient said,

“They were excellent at making sure I was comfort-

able and very, very good at moving me and making

sure they moved me in a way that didn’t hurt. They

were right there always . . . I remember someone being

there the whole time.” Another patient said, “If I

even thought I had a pain, they were right there with

pain pills or whatever.” A family member said, “In

general, that night, it was just focused and I felt very

comfortable and even when I laid down, I felt like

he would be in good hands.” Having confidence in

nursing expertise allowed family members to relax

and get some much-needed rest.

Being PresentPatients and families described how nurses were

present for them. The concept of presence goes beyond

just the physical availability of the nurse and seems

to encompass an overall demeanor and attitude.

A patient’s family member said, “Every time they left

the room, they said ‘if you need anything call us,’

and they were always right there within a few min-

utes.” A patient commented, “They [nurses] acted

like they cared.” Timeliness and attention appear to

contribute to the perception that the nurse was pres-

ent for patients and family members. “I never had to

wait for anybody. I don’t think I asked for anything

I didn’t get. They were really helpful,” said a patient.

Nurses’ presence was perceived as being a com-

fort. “It was comforting that I could have the people

[nurses] there for me,” said another patient. The con-

cepts of presence and caring have been noted to be

synonymous.7 For nurses to be able to demonstrate

caring, they must be able to be open, be willing to

expose themselves to difficult situations and experi-

ences, and have professional maturity that allows

them to become personally involved with patients

and patients’ families.

Giving Guidance, Voice ToneA few participants noted qualities that reflect

caring behaviors of nurses that are often not noted

as having particular valence. These qualities, however,

may be very important in the overall perception of

care received.

Providing guidance is an intervention nurses per-

form daily. We not only answer questions but help

instruct on what a patient or family member needs to

do to restore health. One participant informed us,

“When they talked to me and told me what to do,

I would calm down and do what I needed to do.”

In giving guidance, nurses are using their exper-

tise and demonstrating competence. Knowing the

patient and being attentive allows the nurse to truly

be present and attend to the needs of the patient.

One patient said, “I just remember somebody’s

voice kept telling me to breathe . . . I don’t know

who it was.”


Patients’ family members need to be informed about what nurses are doing and why.

Another aspect of behavior perceived as caring

was tone of voice. Although we are not always aware

of the tone we are using, it appears to be important.

“Whoever the nurse was had a very pleasant voice,

a very calming effect, and she was in control. I knew

she was working for me. I think that was comforting,”

said another patient. The patient who recalled some-

one telling them to breathe said of the nurse’s voice,

“It was very soothing. It was a woman’s voice. A very

soothing woman’s voice.”

The importance of voice tone has been noted in

other studies.5 Even when patients are not fully cog-

nizant or able to respond, our presence and the tone

of voice we are using matter.

Contrary BehaviorsAlthough most comments about nursing care

were positive, a negative encounter for patients or

family members can often mar their perception of

care received. Behaviors that were deemed unhelpful

were related to the following: attitude, lack of optimal

pain control, interrupting sleep, and not providing

enough information. Behaviors that were contrary

were determined by the researchers asking specifi-

cally what was helpful and what was not helpful in

relation to nursing behaviors. Detailed exploration

and saturation on this select topic were not pursued

and were not the focus of this study, but the percep-

tion offered by a less-than-satisfied patient and his

wife is informative and so is presented here.

In this 1 instance, the patient requested a back

massage and felt that the nurse’s attitude was lacking.

The patient reported that after he requested a back

massage the nurse replied, “No, we aren’t masseuses,

we’re nurses.” This angered the patient and became

a focus of the patient’s perception of care received.

He went on to note that he did not feel his pain was

controlled optimally and noted that poor pain con-

trol leads to exhaustion: “The thing is, you spend so

much of your energy fighting that pain that you are

just wore out.”

The negative perception was sustained by this

patient’s wife, who noted interruption of sleep as a

problem: “He wanted to sleep and they kept waking

him up, so he got mad.”

She also indicated that she may not have had

as much information or understood explanations

given. She said, “Not knowing what to expect creates

more fear.”

Although information from 1 dyad does not pro-

vide a rigorous foundation of data, it is important to

note what patients and family members may find

aggravating. We often report the positive aspects of

nursing care, but we can also learn a good deal from

hearing what has not gone well for our patients and

family members. Reminders of what does not work

can help make us more aware and encourage us to

pay attention to our caregiving behaviors.

Discussion Patients and family members who were in a high-

acuity, intensive health crisis were able to identify

which nursing behaviors were helpful to them. These

behaviors can be developed in staff and nursing stu-

dents. Patients’ satisfaction scores improve with for-

mal education on explicit behaviors that promote

connection with patients and their families.8,9 These

behaviors are perceived as caring behaviors. In high-

technology areas where there is concern that nurses’

caring behaviors may be lost behind the technology,

there is a need for recognizing and reinforcing such

behaviors and for finding ways to provide quantifiable

measures and document these essential behaviors.2

Providing InformationPatients’ families are very aware of what we as

nurses are doing with and to their loved one. One

comment was “I think the nurses explaining what

was happening when everything was being done

was comforting or why he was responding the way

he was . . . Talking us through it was important.”

Family-centered care puts the needs of the whole

family as the focus of intervention. In a literature

review of caring for family members, Rutledge et al10

recognized family-centered care as essential for

healing of the patient and meeting the needs of the

family in a highly stressful and uncer-

tain environment. Family members

need to be informed about what we

are doing and why. Patients and

families noted that this was very

important and reassuring to them.

In a critical care environment,

there is an abundance of technology

and nurses are very busy attending

to various tasks. Family members are

observing all the busyness while experiencing fear,

uncertainty, and a high level of stress.11,12 When nurses

explain to families exactly what is going on, what is

being done, the status of the patient, and why things

are happening, family members feel reassured.

Providing ReassuranceReassurance is a cross-cultural need.13 In a criti-

cal care situation, it may be one of the most comfort-

ing aspects for patients and their families, helping to

mitigate the stress, chaos, uncertainty, and, some-

times, the painful experience. Although nurses


To be present, nurses need to

develop skills in active listening.

provide expert skilled care, it is often the words we

say and the reassuring tone of voice used that patients

and their families remember. One patient commented

on “just that calming, kindly reassurance and the

explanation that when I could control my breathing

and I could relax.” One patient was reassured by

the nurse “being there and telling me what they

were gonna do and why they were gonna do it . . .

They would tell you it was gonna hurt.”

Demonstrating ProficiencyA common factor across several studies14-17 is the

expectation that nurses know what to do. Critical care

nurses are highly knowledgeable and proficient in

providing care in acute situations. The

ability to manage a physiological crisis

requires quick action and competence.

Patients and their families are keen

observers of nurses’ actions. “There

were times when his oxygen wasn’t

where it needed to be and they were

really hustling and working hard to

get things right. They kept saying that it probably

wasn’t a problem, but you knew it was a concern.

It was just neat to see them work that hard and get

the job done,” commented one family member.

Being PresentBeing present with patients and their families

requires nurses to have a well-developed skill in active

listening. Patients or family members will often tell

the nurse what they need or want if we ask and solicit

that information from them directly. Doing this takes

awareness and willingness to put the patient and

family members at the center of care, not just assum-

ing that we know what is needed.14

Voice ToneAsking patients and families about their experi-

ence of nursing care is essential to continue to build

a body of evidence that informs and educates nurses.

They help us recognize what it is that we do that is

important to them. Something like using a soothing

voice tone may seem inconsequential when working

in a high-technology environment, but it may be one

of the most meaningful interventions for patients

and their families.

LimitationsThis study was conducted at 1 facility and in 1

kind of critical care setting. Thus the transferability

of the results is limited, because the philosophy and

policies for this institution may be unique and not

generalizable to other institutions. This facility already

promotes family-centered care, which may account for

the strong positive characteristics attributed to the

nurses by family members. Future research is recom-

mended at various institutions in critical care settings.

Expansion on the findings of this study are needed

to further build a body of knowledge related to caring

behaviors in intensive care units.

Conclusion More research that explores the patient and

family perspective in the critical care environment is

needed. As we move toward more patient-centered

models of care, patients and their families can guide

us in providing optimal and relevant nursing care.

We are at a time in health care when the qual-

ity of care and the safety of patients are paramount.

Although nurses are spending much time doing

documentation, little information reflects the essence

of nurses’ caring behaviors. Even when patients com-

plete satisfaction inventories, much of the caring

that nurses do goes unacknowledged. To capture

the many behaviors that nurses engage in that con-

tribute to the healing and safety of patients, we need

to design our assessment tools to reflect what patients

and their family members identify as caring behaviors.

Data from studies such as this contribute to under-

standing what is perceived by our patients and fami-

lies as caring and contribute to recovery as perceived

by those in crisis and high-intensity medical settings.

Capturing these data is elemental to designing high-

quality, safe environments that facilitate healing.

ACKNOWLEDGMENTSThis study was conducted at Medical Center of the Rockies in Loveland, Colorado, and was a collaborative effort with the University of Northern Colorado School of Nursing. We thank Nancy Reno, RN, BSN, for transcribing our interviews.



SEE ALSO For more about patient satisfaction challenges, visit the Critical Care Nurse website, www.ccnonline.org, and read the article by Glowacki, “Effective Pain Management and Improvements in Patients’ Outcomes and Satisfac-tion” (June 2015).


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10. Rutledge DN, Donaldson NE, Pravikoff DS. Caring for families of patients in acute or chronic health care settings: part 1, principles. Online J Clin Innovations. 2000;3(2):1-26.

11. Rutledge DN, Donaldson NE, Pravikoff DS. Caring for fami-lies of patients in acute or chronic health care settings: part 2, interventions. Online J Clin Innovations. 2000;3(3):1-52.

12. Browning G, Warren NA. Unmet needs of family members in the medical intensive care waiting room. Crit Care Nurs Q. 2006;29(1):86-95.

13. Khalaila R. Meeting the needs of patients’ families in inten-sive care units. Nurs Standard. 2014;28(43):37-44.

14. Bijttebier P, Vanoost S, Delve D, Ferdinande P, Frans E. Needs of relatives of critical care patients: perceptions of relatives, physicians and nurses. Intensive Care Med. 2001; 27(1):160-165.

15. Freitas KS, Kimura M, Ferreira KA. Family members’ needs at intensive care units: comparative analysis between public and private hospital. Rev Lat Am Enfermaqem. 2007; 15(1): 84-92.

16. Kinrade T, Jackson A, Tomnay JE. The psychosocial needs of families during critical illness: comparison of nurses’ and family members’ perspectives. Aust J Adv Nurs. 2010; 27(1):82-88.

17. Hinkle JL, Fitzpatrick, E. Needs of American relatives of intensive care patients: perceptions of relatives, physicians and nurses. Intensive Crit Care Nurs. 2011;27(4):218-225.


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Pediatric Critical Care


Background Mothers whose infants are born with com-plex congenital heart disease (CCHD) experience stress during their infant’s hospitalization in a pediatric cardiac intensive care unit (PCICU).Objectives This study addressed 2 research questions: (1) What are the parental stressors for mothers whose infants with CCHD are in the PCICU? And (2) What are the relationships of trait anxiety and 3 parental stress-ors to the parental stress response of state anxiety in mothers whose infants with CCHD are in the PCICU?Methods This descriptive correlational study included 62 biological mothers of infants admitted to a PCICU within 1 month of birth who had undergone cardiac sur-gery for CCHD. Maternal and infant demographics and responses to the Parental Stressor Scale: Infant Hospi-talization and the State-Trait Anxiety Inventory were collected at 3 major PCICUs across the United States.Results Mothers’ scores revealed that infant appear-ance and behavior was the greatest stressor, followed by parental role alteration, then sights and sounds. The combination of trait anxiety and parental role alteration explained 26% of the variance in maternal state anxiety. Mothers with other children at home had significantly higher state anxiety than did mothers with only the hospitalized infant.Conclusions Results from this study revealed factors that contribute to the stress of mothers whose infants are born with CCHD and are hospitalized in a PCICU. Nurses are in a critical position to provide education and influence care to reduce maternal stressors in the PCICU, enhance mothers’ parental role, and mitigate maternal state anxiety. (American Journal of Critical Care. 2017; 26:118-125)

MATERNAL STRESS AND ANXIETY IN THE PEDIATRIC CARDIAC INTENSIVE CARE UNITBy Amy Jo Lisanti, RN, PhD, CCNS, CCRN-K, Lois Ryan Allen, RN, PhD,

Lynn Kelly, RN, PhD, and Barbara Medoff-Cooper, RN, PhD



this article.

E RBEvidence-Based Review on pp 126-127


Congenital heart disease (CHD) is the most common birth defect, with a rate of 8 per 1000 live births.1 When infants are born with complex congenital heart dis-ease (CCHD), they require surgery during the early weeks of life with inpatient care provided in a pediatric cardiac intensive care unit (PCICU). Parents experi-ence stress as a result of their infants’ diagnosis and hospitalization.2-4 The paren-

tal stress associated with this very serious and acute period surrounding open heart surgery is often overwhelming.

Parental stress in neonatal intensive care units

(NICUs) and pediatric intensive care units (PICUs)

has been well described throughout the past 3

decades. Past research on parental stress has been

largely focused on parents of premature infants or on

older children in the PICU, but little work has been

done to explore the stress of parents who have new-

borns undergoing cardiac surgery soon after birth.5-7

These studies provide a foundation for understand-

ing parental stress in the PCICU, but are insufficient

to describe the unique experience for parents of

infants undergoing neonatal open heart surgery.

With the improvements in survival after neonatal

cardiac surgery, the needs of these medically fragile

infants have become more complex. The cardiac

diagnoses of many of these infants are made in utero

at approximately 20 weeks’ gestation. Therefore, par-

ents begin to experience stress even before the infant

is born and admitted to a PCICU.2 In addition, the

postoperative recovery is often a nonlinear process,

requiring multidisciplinary care to manage comorbid

conditions and complications, including prolonged

intubation, chylothorax, bleeding, infection, cardiac

arrest, seizures, failure to thrive, and feeding difficul-

ties.8,9 Because infants often experience some of these

complications, parental stress is further exacerbated.

Moreover, parents of children with CHD report

higher amounts of stress than parents of healthy

children or parents of children with other diseases.10-12

The source of stress appears to emanate from

the infant, parent, and environment. Depending

on the severity of CCHD, infants may need to be

immediately separated from their parents at birth

for resuscitation and intervention in the PCICU.13

The physical separation of parent and child can

cause significant stress for parents.14-16 In the PCICU,

infants may appear blue or in respiratory distress.

They often require various technologies, tubes,

medications, and wires for care and monitoring.17,18

The appearance and behavior of the infant creates

stress for parents in addition

to the sights and sounds of

the critical care environment.

Parents are unable to provide

for their infants’ basic needs,

such as clothing, feeding, and

comforting, altering their

sense of parental role with the

infant.19 Mothers experience

greater stress and anxiety than

fathers do when their infant/

child is in the critical care

environment.20-22 This stress is often accompanied by

a myriad of postpartum issues, such as physical dis-

comfort, fatigue, hormonal changes, and the chal-

lenge of initiating lactation through mechanical

breast pumping. Therefore, when examining stress,

mothers and fathers must be examined separately.

The number of stressors faced by parents influ-

ences their stress response.23 Anxiety is the predomi-

nant manifestation of stress at the bedside and is

the most referred to in published reports as a stress

response.24-28 Two types of anxiety exist: trait anxiety

and state anxiety.29 Trait anxiety is an individual’s

tendency to perceive a stressful situation as threaten-

ing and respond with elevated levels of state anxiety.

State anxiety is the amount of anxiety experienced

at a specific moment in time. This study focused on

state anxiety as a stress response of mothers in the

PCICU during the first few weeks after the infant’s

surgery for CCHD.

About the AuthorsAmy Jo Lisanti is a postdoctoral fellow at the University of Pennsylvania School of Nursing, and a clinical nurse specialist/nurse researcher at Children’s Hospital of Phil-adelphia, Philadelphia, Pennsylvania. Lois Ryan Allen and Lynn Kelly are professors emeritus of nursing, Wid-ener University School of Nursing, Chester, Pennsylvania. Barbara Medoff-Cooper is a professor, University of Pennsylvania School of Nursing, and a nurse scientist at Children’s Hospital of Philadelphia.

Corresponding author: Amy Jo Lisanti, RN, PhD, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 (e-mail: lisanti @email.chop.edu).

Little research has explored the stress of parents who have newborns undergoing cardiac surgery soon after birth.



Purposes of the Study The primary purpose of this study was to explore

the stressors and stress response of mothers whose

infants with CCHD were being cared for in the PCICU.

This study addressed 2 research questions: (1) What

are the parental stressors for mothers whose infants

with CCHD are in the PCICU? and (2) What are the

relationships of trait anxiety and 3 parental stressors

to the parental stress response of state anxiety in

mothers whose infants with CCHD are in the PCICU?

Theoretical Framework This study used the PCICU Parental Stress Model,

which was based on a synthesis of the literature,

revisions from prior stress theories developed by

Miles and colleagues,30-32 and adjustments to fit

research in the PCICU environ-

ment (see Figure). The PCICU

Parental Stress Model posits that

stress is an overarching concept

encompassing a stress stimulus, or

stressor, that elicits a reaction, or

stress response. The model

describes parental stress in the

critical care setting as emanating

from personal factors, such as trait

anxiety, and 3 categories of parental stressors: infant,

parent, and environment. These sources of stress

combine to contribute to parental stress response.

Methods This study used a descriptive correlational design

to identify the relationships among parental stressors

and stress response.

SettingData collection occurred at 3 major PCICUs at

children’s hospitals across the United States, 2 in

the northeast mid-Atlantic region and 1 in the west.

Approval was obtained from the institutional review

board at each hospital.

SampleMothers who were at least 18 years of age, English

speaking, with full-term infants who had undergone

cardiac surgery for CCHD were approached for par-

ticipation in this study. Mothers were excluded if

their infants had other genetic or congenital abnor-

malities diagnosed or if the infant was undergoing

end-of-life care. Informed consent was obtained

from each study participant before data collection.

Research InstrumentsStudy participants completed the Parental

Stressor Scale: Infant Hospitalization (PSS:IH) and

the State-Trait Anxiety Inventory (STAI). The PSS:IH

is designed to measure parents’ perception of stress-

ors related to the hospitalization of an infant being

cared for in any type of hospital unit.33 PSS:IH has 3

subscales: infant appearance and behavior, parental

role alteration, and sights and sounds. The PSS:IH

has established validity and reliability.33 Mothers

rated each item on a scale from 1 to 5. A total mean

score was computed for each mother. The internal

consistency reliability (Cronbach ) was 0.91. Reli-

ability for each subscale was as follows: 0.83 for

infant appearance and behavior, 0.81 for parental

role alteration, and 0.81 for sights and sounds.

The STAI is a well-established research instru-

ment that has been used by researchers for more

than 30 years. The STAI has two 20-item subscales:

one for state anxiety and one for trait anxiety.29 The

state anxiety scale measures how persons feel at this

current moment. The trait anxiety scale measures a

person’s tendency toward anxiety by asking people

how they generally feel. Mothers rated each item on

Figure The Pediatric Cardiac Intensive Care Unit (PCICU) Parental Stress Model, with application to this study italicized. Abbreviations: ICU, intensive care unit; PSS:IH, Parental Stressor Scale: Infant Hospitalization; STAI, State-Trait Anxiety Inventory.

Parental stress response

State anxiety (state anxiety

subscale of STAI)

Personal factors• Trait anxiety (trait anxiety subscale of STAI)• Timing of diagnosis

Infant• Appearance and

behavior (PSS:IH subscale)• Severity of illness

Parent • Parental role

alteration (PSS:IH subscale) • Life circumstances • Unmet needs

• Worry or uncertainty about outcome

Environment • ICU sights and sounds

(PSS:IH subscale) • ICU staff

• Unexpected admission

Total

This study identified the relationships among parental

stressors and stress response.


a scale from 1 to 4. A total score was computed for

each mother participating in the study. The internal

consistency reliability (Cronbach ) was 0.95 for the

state anxiety scale and 0.91 for the trait anxiety scale.

Results Participants included 62 biological mothers

of infants admitted to the PCICU within 1 month

of birth. The sample size was sufficient for a power

of 80% with a moderate effect size. The overall

majority of the mothers were white, non-Hispanic

(n = 47), married, well-educated, with 1 or 2 chil-

dren (Table 1). Almost three-quarters of the moth-

ers (n = 45) received a prenatal diagnosis on their

infants’ CHD. Infants were nearly evenly distributed

between males (n = 29) and females (n = 32) and

univentricular (n = 33) and biventricular (n = 28)

CHD. Infants had a variety of cardiac defects and

surgeries. At birth, infants were full-term with appro-

priate birth weight for gestational age. At the time

of data collection, infants were a mean age of 16.79

days old and had undergone cardiac surgery just more

than 1 week earlier (Table 2).

The parental stressors for mothers were identi-

fied on the PSS:IH. The mean score for the total

PSS:IH was 3.52 (SD, 0.72), with scores ranging

from 1.70 to 4.81. Infant appearance and behavior

had the highest subscale score (mean, 4.03; SD,

0.86). The second highest mean score was for the

parental role alteration subscale (mean, 3.77; SD,

0.81). The sights and sounds subscale had the lowest

mean score (mean, 2.52; SD, 0.85). Rank order by

means for all 22 items on the PSS:IH revealed that

the 5 strongest stressors, with mean scores from 4.05

to 4.56, referred to mothers’ not being able to

parent or comfort their baby or protect their baby

from pain. These items included, in rank order

beginning with the highest: “seeing your child in

pain,” “not being able to protect your baby from

pain and painful procedures,” “when your child

looks afraid, upset, or cries a lot,” “not being able

to comfort or help your baby,” and “being separated

from your baby.” Descriptive statistics for the STAI

revealed that mothers’ state anxiety scores (mean,

44.18; SD, 13.30) were significantly higher (t = 6.74,

df = 61, P < .001) than their trait anxiety scores (mean,

33.79; SD, 8.92).

Stepwise multiple regression was computed to

determine the relationships among the 4 predictor

variables (maternal trait anxiety, parental role

alteration, infant appearance and behavior, and

sights and sounds) and maternal state anxiety.

Although maternal trait anxiety (r = 0.46), parental

role alteration (r = 0.32), and sights and sounds

(r = 0.37) were significantly correlated with state

anxiety (P ≤ .006), only maternal trait anxiety and

parental role alteration entered into the regression

(Table 3). Maternal trait anxiety and parental role

alteration were not significantly related (r = 0.20,

P = .06). Sights and sounds failed to enter the equa-

tion because of multicollinearity.

Variable

Table 1Maternal and infant demographics

Maternal race

Marital status

Level of education

Diagnosis

Surgery

a Percentages may not total 100% because of missing data, multiple diagnoses, or multiple surgeries.

1 (2) 6 (10)48 (77) 7 (11)

14 (23)37 (60)1 (2)5 (8)

4 (6)5 (8)

15 (24)23 (37) 7 (11)1 (2)

19 (31)12 (19)10 (16) 9 (15)

8 (13) 6 (10)4 (6)4 (6)

40 (65)

13 (21) 6 (10) 6 (10)5 (8)3 (5)3 (5)

32 (52)

American Indian/Alaskan NativeBlack/African AmericanWhiteUnknown/other

SingleMarriedDivorcedPartnered

Partial high schoolGraduated high schoolPartial collegeCollege graduateMaster’s degreePhD/doctoral degree

Hypoplastic left heart syndromeTransposition of the great arteries (D-loop)Ventricular septal defectPulmonary stenosis (valvular and

subvalvular)Coarctation of the aortaAtrioventricular canalDouble-outlet right ventricleTetralogy of FallotOther

Norwood procedureAortic arch repairArterial switch operationAtrial septal defect closureCoarctation end to end Tetralogy of Fallot repairOther

No. (%)aCategory

Variable

Table 2Descriptive statistics for selected infant characteristics

Gestational age at birth, weeks

Birth weight, g

Infant’s age at the time of data collection, days

Length of time postoperatively at data collection, days

37-41

2530-4336

4-44

1-46

0.93

409.12

9.37

9.73

38.92

3379.28

16.79

9.11

RangeMean SD


Infant appearance and behavior was

the highest stressor for mothers.

Independent t tests were used to explore differ-

ences between groups based on the class of the

infant’s CCHD (univentricular vs biventricular

physiology), the timing of the diagnosis (prenatal

vs postnatal), the number of children (1 child vs

more than 1 child), and the time of data collection

(< 1 week postoperatively vs ≥ 1 week postoperatively).

No significant differences were found between uni-

ventricular and biventricular groups or between pre-

natal and postnatal timing of diagnosis on any of

the stressor or anxiety measures. State anxiety scores

were significantly higher (t = -2.26, df = 51, P = .03)

for the 24 mothers with more than 1 child (mean,

48.07; SD, 13.33) than for the 28 mothers with only

1 child (mean, 40.21; SD, 11.97). In addition, state

anxiety scores were significantly higher (t = 2.03,

df = 40, P = .049) for mothers whose infants were less

than 1 week postoperative (mean, 47.95; SD, 13.70)

than for mothers whose infants were 1 week or more

postoperative (mean, 40.24; SD, 10.77).

Discussion This study is the first to examine maternal

stressors and stress response in a PCICU. The results

of this study confirm that mothers experience stress

while their infants are hospitalized in a PCICU.

Mothers in this study perceived stressors from

parental role alteration, infant

appearance and behavior, and

sights and sounds of the PCICU.

The highest rated stressor in this

study was infant appearance and

behavior. Using a revised version

of the PSS:IH, the PSS:CH, Franck

and colleagues3 also reported that

child appearance and behavior was the highest rated

stressor for both mothers and fathers across 5 separate

time points throughout the PCICU hospitalization.

Parental role alteration was the second highest

source of stress for mothers in this study. Items

within this subscale reflect the mother’s ability to

safeguard her baby from harm or discomfort as well

as her ability to be close, care for, and hold her baby.

Mothers perceived stress from not being able to per-

form basic parenting tasks for their babies. Mother-

ing of an infant usually centers around clothing,

feeding, diaper changing, and holding. Most, if not

all, of these parenting functions are paused during

the critical care admission, especially during the

immediate postoperative period. Parental role alter-

ation was also reported to be the highest stressor

in other studies using the PSS:NICU.20,24,34 The com-

plexity of care that postoperative infants require is

often reflected by their critical appearance in a PCICU,

which may have influenced why infant appearance

and behavior was the highest rated stressor by mothers

in this study.

The 2 highest rated items in the PSS:IH were

on the infant appearance and behavior subscale

and the parental role alteration subscale. These

items both addressed infant pain from the moth-

er’s perspective: seeing the infant in pain, and

being unable to comfort or prevent pain. Parental

worry about infant pain contributes to parental

stress in the NICU.22,35

The subscale sights and sounds was the lowest

rated stressor in this study, consistent with other

published reports3,33,36; however, sights and sounds

still contributed a moderate amount of perceived

stress for mothers. Every patient in the PCICU is

connected to a cardiopulmonary monitor that

audibly alarms when the patient’s vital signs move

outside set parameters. A mother can observe the

monitor and often becomes very in tune with her

infant’s vital signs. The physical layout of the PCICUs

for most participants in this study was open, with

bay-style rooms that allowed parents to see and

hear the activity at another patient’s bedside. The

results of this study suggest that these aspects of

the PCICU environment create stress for mothers

visiting their infants.

Although infant appearance and behavior was

the highest rated stressor, only trait anxiety and

parental role alteration entered into the multiple

regression to predict state anxiety scores. Research

has documented the link between parental role

alteration and stress response in other ICU set-

tings.22,34 Shaw and colleagues21 reported that paren-

tal role alteration was the most strongly correlated

variable to stress response, as measured by acute

stress disorder, in 40 parents of infants hospitalized

in a NICU. In the classic study by Miles and col-

leagues,32 trait anxiety and parental role alteration

influenced stress response, as measured by state anx-

iety. The mean trait anxiety scores of mothers in our

study fell within the 50th percentile of normative

mean published values for working women aged 19

to 49 years, which is an expected finding as this

study’s sample was a group of healthy young

women.29 In contrast, the mean state anxiety scores

Model

Table 3Stepwise regression predicting maternal state anxiety

1. Trait anxiety

2. Parental role alteration

<.001

.04

1

1

16.03

4.27

0.21

0.05

0.21

0.26

0.46

0.51

PFR R2 R2 df


of mothers in our study were high, around the 83rd

percentile.29 State anxiety scores were significantly

higher than trait anxiety scores in our sample. State

anxiety in 119 mothers of hospitalized NICU infants

was reported with mean scores of 51.53 (SD, 14.96)

by Shields-Poe and Pinelli22 and 51.25 (SD, 14.10)

by Franck and colleagues.35 Although these means

are higher than those of mothers in our study, trait

anxiety scores published by Shields-Poe and Pinelli

(mean, 39.2; SD, 11.02) and Franck et al (mean,

41.61; SD, 11.02) were also higher than the means

reported in our study. State anxiety in pregnant

women who had an infant with a prenatal diagnosis

of CCHD was also high (mean, 44.14; SD, 14.69).

Trait anxiety scores for these pregnant women were

also higher than normative mean published values,

potentially influencing state anxiety scores.4 Although

trait anxiety is a nonmodifiable factor affecting state

anxiety, it can be screened for and identified early so

that psychosocial supports and interventions can be

provided to mediate maternal state anxiety.

The results of this study also showed that moth-

ers with more than 1 child experienced higher stress

response than did mothers with only the hospital-

ized infant. Mothers who have other children may

need additional support to cope with the hospital-

ization as they manage competing responsibilities of

caring for children at home and watching over their

infant in the PCICU. Finally, maternal state anxiety

was significantly higher less than 1 week postoper-

atively when compared with maternal state anxiety

scores obtained 1 week postoperatively or more.

Franck and colleagues3 reported that parental stress

was reduced in the PCICU when measured on post-

operative day 8, in comparison with stress scores

measured preoperatively, on postoperative day 3,

and on postoperative day 5. This study adds to grow-

ing evidence that the first week postoperatively is a

period of extreme stress for mothers. Additional psy-

chosocial supports should be offered to help moth-

ers cope during the immediate postoperative period.

Limitations This study had a relatively homogeneous sam-

ple, which decreases generalizability to the greater

population. Maternal perception of stressors and

stress response was measured at only 1 point in time

after the infant had surgery. Mothers’ perception of

stressors and stress response may change throughout

the infant’s hospitalization. In this study, only one

type of stress response, state anxiety, was measured.

Mothers may experience a variety of stress responses.

The relationships between stressors and multiple

stress responses need to be explored. Finally, this

study relied on self-reported measures to examine

perception of stressors and stress response. Objective

data were not gathered for these variables.

Conclusions and Implications This study was the first to explore the stressors

and stress response of mothers whose infants with

CCHD were being cared for in a PCICU. The results

of this study confirm that these mothers perceive

stressors from their infants’ appearance and behavior,

parental role alteration, and the sights and sounds

of the PCICU. Mothers also experienced a height-

ened stress response of state anxiety. Trait anxiety

and parental role alteration were the best predictors

of state anxiety for mothers in the PCICU. Additional

research is needed to build on this leading study.

Nurses are in a critical position to provide edu-

cation and influence care to reduce maternal percep-

tion of stressors, enhance mothers’ parental role, and

mitigate mothers’ state anxiety. Nurses can support

mothers through this stressful time. Mothers may

also benefit from increased

education on interpreting their

infants’ behavioral cues and

signs of pain as well as how to

respond to those cues in the

setting of the PCICU. Nurses

can facilitate the enhance-

ment of parental role for

mothers as their infant recovers from cardiac surgery

by allowing holding and participation in feeding,

changing, or clothing the infant as appropriate.

Finally, nurses can screen mothers for high trait anx-

iety and identify mothers at risk for heightened

stress response. Interventions can be created to assist

mothers in coping with their anxiety, such as the use

of mindful meditation or cognitive behavioral ther-

apy. The results of this study can guide continuing

education on parental stress and prompt cultural

change within PCICUs to provide additional psy-

chological support to mothers.

ACKNOWLEDGMENTSThe following institutions participated in the study: Widener University School of Nursing, Chester, Penn-sylvania; Children’s Hospital of Philadelphia, Philadel-phia, Pennsylvania; Phoenix Children’s Hospital, Phoenix, Arizona; Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; and the University of Pennsylva-nia School of Nursing, Philadelphia, Pennsylvania. The authors express gratitude to the members of the research teams at each participating site: Barbara Fasick, RN-NIC,

MS, PPCNP-BC, PCNS-BC, Wilma M. Berends, MSN, Michele Osborn, RN, MSN, CCRN, Tess Wright, RN, BSN, CCRN, Desiree Fleck, RN, PhD, and Darcy Brodecki, BS.

Nurses are in a criti-cal position to support mothers through this stressful time.

www.ajcconline.org

FINANCIAL DISCLOSURESThis research study was supported by the national Insti-tutes of Nursing Research (NINR R01 NR002093), The National Institutes of Health/National Center for Advanc-ing Translational Sciences (UL1TR001878), and a grant from the Eta Beta Chapter of Sigma Theta Tau.


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18. Board R, Ryan-Wenger N. Stressors and stress symptoms of mothers with children in the PICU. J Pediatr Nurs. 2003; 18: 195-202.

19. Seideman RY, Watson MA, Corff KE, Odle P, Haase J, Bow-erman JL. Parent stress and coping in NICU and PICU. J Pediatr Nurs. 1997;12:169-177.

20. Dudek-Shriber L. Parent stress in the neonatal intensive care unit and the influence of parent and infant characteristics. Am J Occup Ther. 2004;58:509-520.

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21. Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acute stress disorder among parents of infants in the neonatal intensive care nursery. Psychosomatics. 2006; 47:206-212.

22. Shields-Poe D, Pinelli J. Variables associated with parental stress in neonatal intensive care units. Neonatal Netw. 1997; 16(1):29-37.

23. Lazarus RS. Stress and Emotion: A New Synthesis. New York, NY: Springer; 1999.

24. Franck LS, Cox S, Allen A, Winter I. Measuring neonatal inten-sive care unit-related parental stress. J Adv Nurs. 2005; 49: 608-615.

25. Huckabay LMD, Tilem-Kessler D. Patterns of parental stress in PICU emergency admission. Dimens Crit Care Nurs. 1999; 18(2):36-42.

26. Melnyk BM, Alpert-Gillis L, Feinstein NF, et al. Creating opportunities for parent empowerment: program effects on the mental health/coping outcomes of critically ill young children and their mothers. Pediatrics. 2004;113:e597-e607.

27. Preyde M, Ardal F. Effectiveness of a parent “buddy” pro-gram for mothers of very preterm infants in a neonatal intensive care unit. CMAJ. 2003;168:969-973.

28. Turan T, Basbakkal Z, Özbek S. Effect of nursing interven-tions on stressors of parents of premature infants in neona-tal intensive care unit. J Clin Nurs. 2008;17:2856-2866.

29. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. State-Trait Anxiety Inventory for Adults: Manual, Instrument, and Scoring Guide. Palo Alto, CA: Consulting Psychologists Press; 1983. Retrieved from http://www.mindgarden.com.

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1. Identify the specific stressors that contribute to the experience of stress for mothers of neonates hospitalized

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2. Describe the relationship of maternal stressors and trait anxiety with the maternal stress response of state

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3. Discuss methods to reduce the perception of stressors and maternal stress response.

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30. Holditch-Davis D, Miles MS. Mothers’ stories about their experiences in the neonatal intensive care unit. Neonatal Netw. 2000;19(3):13-21.

31. Miles MS, Carter MC. Assessing parental stress in intensive care units. Am J Matern Child Nurs. 1983;8:354-359.

32. Miles MS, Carter MC, Hennessey J, Eberly TW, Riddle I. Testing a theoretical model: correlates of parental stress responses in the pediatric intensive care unit. Matern Child Nurs J. 1989;18:207-219.

33. Miles MS, Brunssen SH. Psychometric properties of the parental stressor scale: infant hospitalization. Adv Neonatal Care. 2003;3:189-196.

34. Busse M, Stromgren K, Thorngate L, Thomas K. Parents’ responses to stress in the neonatal intensive care unit. Crit Care Nurse. 2013;33(4):52-60.

35. Franck LS, Cox S, Allen A, Winter I. Parental concern and distress about infant pain. Arch Dis Child Fetal Neonatal Ed. 2004;89:F71-F75.

36. Wereszczak J, Miles MS, Holditch-Davis D. Maternal recall of the neonatal intensive care unit. Neonatal Netw. 1997; 16(4): 33-40.


©2017American Association of Critical-Care Nurses, doi:https://doi.org/10.4037/ajcc2017698

Evidence-Based Review and Discussion PointsBy Ronald L. Hickman, RN, PhD, ACNP-BC

Evidence-Based Review (EBR) is the journal club feature in the American Journal of Critical Care. In a journal club, attend ees review and critique published research articles: an important first step toward integrating evidence-based practice into patient care. General and specific questions such as those outlined in the “Discussion Points” box aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications of the article for clinical practice. When critically appraising this issue’s EBR article, found on pp 118-125, consider the questions and discussion points outlined in the “Discussion Points” box.

Congenital heart disease is a commonly

occurring birth defect that has significant

impact on newborns and their families.

Often a newborn’s diagnosis of congenital heart

disease is made in utero. Consequently, newborns

with this diagnosis often require complex care

that includes cardiac surgery and prolonged stays

in a neonatal or pediatric intensive care unit.

Yet, the impact of congenital heart disease not

only affects the newborn but extends to the

entire family system.

Parents of newborns and infants with congenital

heart disease experience antepartum and postpar-

tum stress. There is foundational research that

establishes an association between paren-

tal stress among mothers and fathers of

premature infants and older children in

a pediatric intensive care unit. However,

there has been minimal investigation

into the unique experiences of parents

of newborns with congenital heart dis-

ease who underwent cardiac surgery.

To address a gap in the literature,

the authors conducted a descriptive study

to identify the parental stressors and

establish the relationships among trait

anxiety, parental stressors, and state

anxiety in mothers of newborns with

congenital heart disease. Sixty-two moth-

ers of newborns who underwent cardiac

surgery for congenital heart disease were

recruited from 3 pediatric intensive care

units across 3 hospitals. Within a month

of the newborn’s birth, participants were

administered the Parental Stressor Scale:

Infant Hospitalization (PSS: IH) and

the State-Trait Anxiety Inventory (STAI)

to assess parental stressors, as well as

trait and state anxiety.

The authors identified 3 sources of

parental stress and established influential

associations between trait anxiety and

parental role alteration on the intensity

of state anxiety among mothers of new-

borns with congenital heart disease.

Among participants, newborn appear-

ance and behavior was considered to be

most distressing. Parental role alteration,

the mothers’ perception of not being

Investigator Spotlight

This feature briefly describes the personal journey and background story of the EBR article’s investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.

Amy Jo Lisanti, RN, PhD, CCNS, CCRN-K, is a Ruth L.

Kirschstein National Research Service Award, Research

on Vulnerable Women, Children, and Families postdoctoral

fellow at the University of Pennsylvania School of Nursing

and a nurse scientist at Children’s Hospital of Philadelphia

in Pennsylvania. She has more than 15

years of experience as a cardiac pediatric

nurse and clinical nurse specialist. As a

clinician and scientist, Lisanti is passion-

ate about generating new knowledge

that can impact practice and improve

the care of pediatric cardiac patients and

their families.

Lisanti says mentorship was a vital

component for the success of her study.

“I cannot underscore enough the importance of having a

mentor to guide you through the entire process of research.”

Specifically, she appreciates the guidance from her coau-

thors, “Dr Barbara Medoff-Cooper and Dr Lois Ryan Allen

helped craft my research questions, design the study, and

supported me through the entire research process. I am also

grateful to my dissertation committee and readers for their

expert consultation.”

She acknowledges that her story would not be complete

without mentioning the importance of a strong support sys-

tem. “Don’t believe that life has to come to a halt in order to

conduct your first research study. I had to make sacrifices and

certainly no one can do everything, but often we can accom-

plish much more than we think possible—especially with a

strong support system and mentorship,” she says.

Amy Jo Lisanti


About the AuthorRonald L. Hickman is an associate professor, Case Western Reserve University, and an acute care nurse practitioner at University Hospitals Case Medical Center, Cleveland, Ohio.

Discussion Points

A. Description of the Study

Why do the authors focus on mothers of

newborns with congenital heart disease?

What is the purpose of the study?

B. Literature Evaluation

What is the difference between trait and

state anxiety?

How do the authors justify the need to

conduct the study?

C. Sample

Who was eligible to participate in this study?

Who was excluded from this study and why?

D. Methods and Design

Why do you suspect the authors used 3

pediatric intensive care units across 3 hospi-

tals? How could this influence their results?

Describe how data were collected for this

study.

E. Results

What were the major findings of this project?

How can you use the findings of this project

to positively impact the quality of nursing care

at your hospital?

able to safeguard or provide care for their newborns,

was the second highest source of parental stress and

the third source of parental stress was associated

with the sights and sounds of the pediatric intensive

care unit. Additionally, the authors report that trait

anxiety and parental role alteration scores predicted

the intensity of anxiety among mothers of children

with congenital heart disease. Based on their results,

the authors recommend that critical care nurses exam-

ine practices to reduce maternal stressors and mitigate

maternal state anxiety.

Information From the AuthorsAmy Jo Lisanti, RN, PhD, CCNS, CCRN-K, lead

author on this study provides additional informa-

tion about the research. She says that the study

grew out of her interactions with parents of infants

with congenital heart disease, which revealed the

parents’ concerns about engagement in care and the

unique stress of parents of newborns undergoing

cardiac surgery.

According to Lisanti, this study was not her

initial remedy to address the needs of parents of

infants with congenital heart disease. “As a new

clinical nurse specialist, 1 of the initiatives I led was

interdisciplinary developmental rounds” she says.

She adds, “My intention was that the rounds would

help provide point-of-care education to staff and

families, create individualized developmental plans

of care for infant patients, and drive the culture

forward in the unit. What I did not expect was that

the rounds also created a forum for parents to share

their stories of their infant’s diagnosis with congeni-

tal heart disease, their infant’s birth, and the subse-

quent hospital experience.”

Influenced by the unintended consequences of

the developmental care rounds, Lisanti identified the

need to investigate the unique experiences of parents

of newborns with congenital heart disease. She points

out that parents discussed their stress and looked

forward to rounds. “This sparked an interest for me

to understand the unique stress that these parents

experience while their newborn undergoes cardiac

surgery,” she adds.

Implications for PracticeLisanti encourages the readers of the American

Journal of Critical Care to implement practices that

enhance the parental role and reduce symptoms of

stress and anxiety in mothers of newborns with con-

genital heart disease. “Nurses should be aware of the

stressors and stress response experienced by mothers

of newborns with congenital heart disease” she says.

According to Lisanti, this study expands nursing

knowledge on the need to educate mothers on their

parental role while in the pediatric intensive care unit.

The author hopes that the findings of her study

will promote higher quality care for newborns and

their mothers. Committed to further developing a

parental stress model for the pediatric intensive care

unit, Lisanti looks forward to future studies examin-

ing the linkages among parental stress, anxiety, and

postdischarge stress response. “My goal is to design

and test interventions to reduce stress for parents of

infants with congenital heart disease,” she says.




Healthy Work Environments

Background Participation by a critical care nurse in an unsuccessful resuscitation can create a unique height-ened level of psychological stress referred to as postcode stress, activation of coping behaviors, and symptoms of posttraumatic stress disorder (PTSD).Objectives To explore the relationships among postcode stress, coping behaviors, and PTSD symptom severity in critical care nurses after experiencing unsuccessful cardiopulmonary resuscitations and to see whether institutional support attenuates these repeated psycho-logical traumas.Methods A national sample of 490 critical care nurses was recruited from the American Association of Critical-Care Nurses’ eNewsline and social media. Participants completed the Post-Code Stress Scale, the Brief COPE (abbreviated), and the Impact of Event Scale–Revised, which were administered through an online survey.Results Postcode stress and PTSD symptom severity were weakly associated (r = 0.20, P = .01). No significant associations between coping behaviors and postcode stress were found. Four coping behaviors (denial, self-distraction, self-blame, and behavioral disengagement) were significant predictors of PTSD symptom severity. Severity of postcode stress and PTSD symptoms varied with the availability of institutional support. Conclusions Critical care nurses show moderate levels of postcode stress and PTSD symptoms when asked to recall an unsuccessful resuscitation and the coping behav-iors used. Identifying the critical care nurses most at risk for PTSD will inform the development of interventional research to promote critical care nurses’ psychological well-being and reduce their attrition from the profession. (American Journal of Critical Care. 2017; 26:128-135)

STRESS AND COPING OF

CRITICAL CARE NURSES

AFTER UNSUCCESSFUL CARDIOPULMONARY RESUSCITATIONBy Dawn E. McMeekin, RN, DNP, CNE, Ronald L. Hickman, Jr, RN, PhD,

ACNP-BC, Sara L. Douglas, RN, PhD, and Carol G. Kelley, RN, PhD, AGNP-BC



this article.


Each year, thousands of critical care nurses in the United States and worldwide per-form cardiopulmonary resuscitation.1-4 It is estimated that between 40% and 84% of all resuscitation attempts within critical care units result in immediate or imminent death of the patient within 24 hours.1-3,5,6 Because critical care nurses have frequent and cumulative exposures to unsuccessful cardiopulmonary resuscitations, psycho-

logical trauma often ensues.7 The literature in this area is nascent. Despite a growing workforce demand for registered nurses in critical care, turnover and vacancy rates are high.7,8 Investigation of the cumulative psychological injuries associated with unsuccessful cardiopulmonary resus-citation is warranted and may offer new insights on strategies to attenuate the psychological morbidity associated with providing life-sustaining care and highlight a need for psychologi-cal support processes that may aid in the retention of critical care nurses in the workforce.

The influence of postcode stress and coping

behaviors on the psychological health of critical

care nurses is unclear. However, it is hypothesized

that critical care nurses who are exposed to the psy-

chological trauma of cardiopulmonary resuscita-

tion efforts that fail to prolong the patient’s life will

perceive heightened states of postcode stress, coping

behaviors, and lower states of psychological health.

Therefore the aims of this article are to examine the

relationships among postcode stress, coping behav-

iors, and the severity of symptoms of posttraumatic

stress disorder (PTSD), to evaluate the influential

demographic characteristics associated with post-

code stress and PTSD symptom severity, and to

describe the association between access to institu-

tional psychological support (availability of post-

code debriefing) and magnitude of postcode stress

and PTSD symptom severity in a national sample

of critical care nurses.

Background Critical care nurses are prone to observe or take

part in life-sustaining procedures (eg, cardiopulmonary

resuscitation) that can alter their ability to manage

negative emotion effectively and can precipitate

significant decrements in their psychological health.

Repeated participation in unsuccessful resuscitation

attempts creates a unique form of psychological

stress known as postcode stress, which has significant

effects on the psychological health of registered

nurses across practice settings.9-11

Lazarus and Folkman’s Transactional Model of

Stress and Coping12 provides the theoretical frame-

work for this study. When presented with a stressor,

it is the appraisal of the potential psychological

harm and the coping behaviors used that become

the integral components influ-

encing psychological well-being.

Postcode stress is posited to ini-

tiate processes for regulating

emotions, such as coping behav-

iors, that aim to maintain an

individual’s psychological health

and prevent manifestation of

stress-associated symptoms.10,12-14

The difference in coping behav-

iors used may offer an explana-

tion of why individuals have

different psychological outcomes (PTSD symptom

severity) after similar events.15-17

Distinct from moral distress, which occurs

when critical care nurses are unable to act on moral

decisions or judgments in practice, postcode stress

is the acute psychological response to unsuccessful

resuscitation participation with specific emotional

and physical stressors or antecedents.8,10-14,18 Physical

signs and sounds during resuscitation, such as color

changes, gasping, emesis, and indignities suffered by

patients are perceived as stressful by nurses.14 In the

extant literature, critical care nurses who participate

in cardiopulmonary resuscitations report feelings of

anxiety, grief, regret, anger, futility and helplessness,

which may further exacerbate their subsequent levels

of postcode stress.3,14,19-21

Critical care nurses demonstrate a variety of

coping behaviors to alleviate or often suppress emo-

tions created by stress.15,22,23 Critical and acute care

About the AuthorsDawn E. McMeekin was a DNP student at Case Western Reserve University, Cleveland, Ohio, when the study was done. She is now an advanced clinical education specialist at Baycare Health System, Dunedin, Florida. Ronald L. Hickman, Jr, is an associate professor, Carol G. Kelley is an assistant professor, and Sara L. Douglas is a professor, Case Western Reserve University.

Corresponding author: Dawn E. McMeekin, RN, DNP, CNE, Baycare Health System, 601 Main St, Dunedin, FL 34698 (e-mail: [email protected]).

Critical care nurses have frequent and cumulative expo-sures to unsuccess-ful cardiopulmonary resuscitations.



nurses exposed to traumatogenic events exhibit a

myriad of behavioral coping strategies used to pre-

vent psychological distress and maintain a state of

psychological well-being.15,16,23 Although these infor-

mal methods of coping are perceived to be effective

by critical and acute care nurses, empirical evidence

that these coping mechanisms

decrease the psychological well-being

of these nurses or retard symptoms

associated with PTSD is lacking.

Coping behaviors can be catego-

rized into 2 broad groups, effective and

ineffective behaviors. Effective coping

behaviors that decrease or eliminate

specific stress significantly decrease

traumatic stress, whereas ineffective

behaviors such as avoidance and

medicinal use significantly increase

psychological stress and decrease psychological

health.24-27 Therefore, it was postulated that critical

care nurses who experience repeated psychological

traumas from unsuccessful cardiopulmonary resus-

citation and use ineffective coping behaviors would

show higher states of psychological impairment,

which could manifest as symptoms of PTSD.

PTSD is a psychiatric disorder with specific

diagnostic criteria that can develop after exposure

to a single or repetitive traumatic event and that

displays symptoms with a range of severities.28 Crit-

ical care nurses who experience direct exposure to a

traumatic event have the potential for the develop-

ment of unresolved stress that can result in symptoms

of PTSD.10,29,30 Symptoms of PTSD after exposure to

a traumatic event are significantly more prevalent in

critical care nurses than in medical-surgical nurses.7

Mealer et al30 reported that 22% of nurses involved in

end-of-life issues had symptoms of PTSD, and 18%

met the diagnostic criteria for a clinical diagnosis

of PTSD. Thus, we hypothesize that PTSD symptoms

are likely to occur in critical care nurses as a result

of the repetitive stress associated with unsuccessful

cardiopulmonary resuscitations (eg, postcode stress)

and use of ineffective coping behaviors.

Methods Design

This descriptive correlational study explores

relationships among postcode stress, coping behav-

iors, and PTSD symptom severity in adult critical

care nurses who had participated in an unsuccessful

cardiopulmonary resuscitation within the past year.

Setting and SampleA convenience sample of 490 adult critical

care nurses who were subscribers to the American

Association of Critical-Care Nurses’ (AACN’s) weekly

eNewsline or were followers of AACN’s Facebook and

Twitter pages participated in this study. This study was

advertised for 4 weeks in July 2014. Participants were

eligible for this study if they were critical care nurses

practicing in an adult intensive care unit with at least

2 years of experience and they had participated in a

cardiopulmonary resuscitation attempt in which

the outcome was imminent death within the preced-

ing year. Based on the approximate number of sub-

scribers (100 000) to AACN’s electronic eNewsline,

the response rate was approximately 0.5%.

ProceduresBefore participants were recruited, approvals were

obtained from the university’s institutional review

board and AACN.

Eligible critical care nurses who viewed the

electronic advertisements disseminated by AACN

were instructed to access a hyperlink to the study’s

electronic surveys. Anonymous demographic and

survey data were collected electronically by using

the survey software from Qualtrics LLC. Completion

of the study questionnaires was estimated to take

Variable

Table 1Demographics and other sample characteristics

Sex Female Male

Racial identity White Hispanic Asian Black Other Native American

Practice location Urban community hospital Academic medical center Rural community hospital

Critical care practice setting Medical intensive care unit Coronary care unit Surgical intensive care unit Cardiovascular inensive care unit Intensive care unit float Neurological intensive care unit

Organizational debriefing support No Yes

393 (91.0)39 (9.0)

375 (86.2)19 (4.4)17 (3.9)12 (2.8)10 (2.3) 2 (0.5)

197 (45.4)185 (42.6) 52 (12.0)

145 (33.8)101 (23.5) 64 (14.9) 46 (10.7) 43 (10.0)30 (7.0)

290 (67.0)143 (33.0)

No. (%)

Coping behaviors can be catego-

rized into 2 broad groups, effective

and ineffective behaviors.


less than 20 minutes. An incentive ($5 Starbucks

gift card) was e-mailed to the first 100 people who

completed the study questionnaires.

InstrumentsPostcode Stress. The Post-Code Stress Scale (PCSS)

was administered to measure the magnitude of the

psychological stress associated with cardiopulmonary

resuscitation perceived by critical care nurses follow-

ing a cardiopulmonary resuscitation. The PCSS is a

14-item questionnaire that was developed to mea-

sure nurses’ levels of postcode stress after their par-

ticipation in an attempted cardiopulmonary

resuscitation. Participants endorse each item on a

5-point Likert scale with responses that range from 1

(does not bother at all) to 5 (bothers a lot). A total

postcode stress score was calculated by summing the

responses and ranged from 14 to 70, with higher

scores reflecting higher states of postcode stress.10

Prior reliability testing with a sample of critical

care nurses demonstrated good internal consistency

(Cronbach , 0.79).10 In the present study, the inter-

nal consistency reliability for the PCSS was 0.84.

Coping Behaviors. The Brief COPE inventory

(BCOPE), an abbreviated version of the COPE

inventory, was used to assess the coping behaviors

of critical care nurses exposed to unsuccessful car-

diopulmonary resuscitation. This instrument con-

tains 28 items and has 14 subscales (2 items per

subscale) that capture various coping behaviors.31

Each item of this instrument was endorsed by par-

ticipants using a 4-point Likert scale ranging from

1 (I have not been doing this at all) to 4 (I have

been doing this a lot). Total scores for each sub-

scale were calculated, and higher total subscale

scores indicate greater perceived use of a corre-

sponding coping behavior. The BCOPE has been

used extensively in examining coping behaviors

related to traumatic event stressors among health

care professionals with established internal reli-

ability (Cronbach ) of 0.60 to 0.86.29,32-35 In the

present study, 7 subscales (2 items each) containing

a total of 14 items of the BCOPE were thoughtfully

selected to attenuate participant burden and cap-

ture effective (active coping, instrumental support,

acceptance) and ineffective (self-distraction, denial,

behavioral disengagement, self blame) coping

behaviors.

PTSD Symptoms. PTSD symptom severity was

measured by the Impact of Event Scale–Revised

(IES-R). The IES-R is a 22-item self-report measure

used to assess the occurrence of symptoms of PTSD

as defined by the Diagnostic and Statistical Manual of

Mental Disorders (Third Edition).28 The IES-R has been

used extensively as a screening tool for PTSD in a

variety of populations, including nurses with an estab-

lished instrument reliability (Cronbach ) of 0.79 to

0.96, and a consistently high correlation with other

traumatic stress measurements.29,36,37 The response

format is based on a 5-point Likert scale of the sever-

ity of a specific distressing event. Responses range

from 0 (not at all) to 4 (extremely). Total scores of

the IES-R range from 0 to 88, with

higher total scores reflecting greater

severity of the PTSD symptoms.38

In addition to the battery of

psychosocial measures, this

research also generated data on

participants’ demographic charac-

teristics, such as sex, age, racial

identity, years of critical care expe-

rience, and practice location and

setting. Participants were also

asked an investigator-developed

single-item question on whether their practice insti-

tution offered nurses debriefing support for trau-

matic events.

Data AnalysisData were managed and analyzed by using SPSS

software version 21 (IBM SPSS Inc). When appropri-

ate, missing data were imputed by mean substitution.

Statistical assumptions were met for all statistical

tests reported. To examine the relationship between

postcode stress, PTSD symptom severity, and coping

behaviors, bivariate Pearson correlations were ana-

lyzed. Mann-Whitney tests, Student t tests, 1-way

analyses of variance, and a multiple linear regression

were used to examine whether the magnitude of

postcode stress and PTSD symptom severity differed

on the basis of specific demographic characteristics

and institutional debriefing support. Statistical sig-

nificance level ( ) of .05 or less was established a

priori for each statistical test.

Results Sample Characteristics

A total of 490 critical care nurses accessed the

electronic survey, and more than two-thirds (68%)

of these participants answered all the survey items.

The sample of critical care nurses was predominantly

female (91%), white (86.2%), had a mean age of

41.8 (SD, 12.4) years, and had a mean of 13.8 (SD,

11.5) years of work experience in a variety of critical

Posttraumatic stress disorder symptom severity was measured by the Impact of Event Scale–Revised.


care settings (Table 1). On average, 4 months

(SD = 6.0) had lapsed since the participants’ last

unsuccessful resuscitation. Participants in this study

represent 47 states and geographic regions. In this

sample, the mean score for postcode stress (postcode

stress severity) was 52.4 (SD, 9.5) and the mean

IES-R score (PTSD symptom severity) was 23.7

(SD, 19.6). The internal reliability coefficients and

distribution of scores of the study questionnaires

are provided in Table 2.

Demographic Characteristics, Postcode Stress, and PTSD Symptom Severity

Scores for postcode stress were significantly

higher (U = 3996.5, P = .001) for female participants

(median, 53.0) than for male participants (median,

48.0). Scores for PTSD symptom severity also were

significantly higher (U = 3996.5, P = .003) for female

participants (median, 20.0) than for male partici-

pants (median, 7.0).

Relationship of Postcode Stress, PTSD Symp-tom Severity, and Coping Behaviors

The primary aim of this study was to explore the

relationship between postcode stress, PTSD symptom

severity, and the coping behaviors of critical care

nurses. A weak (r = 0.20, P = .01) association between

postcode stress scores (postcode stress severity) and

IES-R scores (PTSD symptom severity) was demon-

strated. Statistically significant correlations were found

between the effective coping behavior of acceptance

(r = 0.24, P = .01), the ineffective coping behaviors

of self-distraction (r = 0.14, P = .01) and self-blame

(r = 0.16, P = .01), and postcode stress severity. PTSD

symptom severity was also correlated with all of the

7 coping behaviors: acceptance (r = 0.24, P = .01),

instrumental support (r = 0.46, P = .01), active coping

(r = 0.45, P = .01), denial (r = 0.69, P = .01), behavioral

disengagement (r = 0.69, P = .01), self-distraction

(r = 0.68, P = .01) and self-blame (r = 0.70, P = .01).

Institutional Support and Postcode Stress and PTSD Symptom Severity

It was our supposition that the availability of

institutional support to critical care nurses would

mitigate the severity of psychological distress (post-

code stress and PTSD symptom severity). Scores

for postcode stress were significantly lower (t = 2.91;

P = .001) for critical care nurses who had institu-

tional debriefing support available (mean, 50.5; SD,

9.2) than for those critical care nurses without

debriefing support (mean, 53.5; SD, 9.5). Consis-

tent with previous evidence was the finding that

IES-R scores (PTSD symptom severity) were signifi-

cantly higher (t = 6.30, P = .001) for nurses who had

institutional debriefing available (mean, 32.8; SD,

21.4) than for those critical care nurses with no

debriefing support (mean, 19.0; SD, 16.9).

Exploratory Model of Factors Associated With PTSD Symptom Severity

Given the associations among postcode stress,

coping behaviors, demographic characteristics,

and exposure to institutional debriefing support

and PTSD symptom severity, an exploratory predic-

tive model was examined to determine which of

these study variables were most influential on the

PTSD symptom severity in this sample. In this model,

10 predictors that operationalize postcode stress,

coping behaviors, demographic characteristics, and

institutional support were simultaneously regressed

on the participants’ IES-R scores, a measure of PTSD

symptom severity. This regression model accounted

for 76.2% of explained variance in the participants’

Table 2Psychometric properties of the psychological variables

Variable

Post-Code Stress Scale (range, 14-70)

Impact of Event Scale-Revised (range, 0-88)

Brief COPE Inventory

Ineffective categories (range 2-8) Self-distraction Denial Self-blame Behavioral disengagement

Effective categories (range 2-8) Active coping Instrumental support Acceptance

0.840

0.967

0.874

0.824

0.647

52.4 (9.5)

23.7 (19.6)

4.12.73.73.0

4.43.85.5

388

375

369

54.0 (16.0-70.0)

88.0 (0.0-88.0)

6.0 (2.0-8.0)6.0 (2.0-8.0) 6.0 (2.0-8.0) 6.0 (2.0-8.0)

6.0 (2.0-8.0)6.0 (2.0-8.0)6.0 (2.0-8.0)

RangeMean (SD)No. of nurses Cronbach

Score


Nurses’ simultaneous maladaptive or ineffec-tive coping behaviors blunt the effects of positive behaviors.

IES-R scores, (R2adj

= 0.76, F10, 361

= 113, P < .001)

and 5 statistically significant predictors of PTSD

symptom severity: postcode stress ( = .16, P < .001)

and 4 coping behaviors (ie, denial [ = .33, P < .001],

self-distraction [ = .24, P < .001], self-blame [ = .22,

P < .001], and behavioral disengagement [ = .18,

P < .001]). The model accounted for the participant’s

sex, access to institutional debriefing support, and

the 3 remaining coping behaviors (ie, active coping,

instrumental support, and acceptance).

Discussion This study demonstrated high levels of post-

code stress (mean score, 52.4) among respondents,

comparable to findings of a prior study (mean score,

52.5).11 In addition, the mean level of PTSD symptom

severity (mean score, 23.7) was higher than reported

in prior studies39,40 examining nurses’ responses to

traumatic events (mean score, 4-11.7).

As illustrated in these results, both effective and

ineffective coping behaviors of critical care nurses had

significant direct correlations with PTSD symptom

severity; however, the largest effects were inclusive to

all ineffective coping behaviors (r = 0.68-0.70). These

study findings are supported by previous studies

demonstrating that ineffective coping behaviors are

associated with higher PTSD symptom severity when

compared across various populations of health care

workers.24,27,41-44 It is postulated that critical care

nurses may use multiple behaviors simultaneously

and that maladaptive or ineffective coping behav-

iors blunt the effects of the positive behaviors. Cop-

ing behaviors demonstrated no significant

correlation with postcode stress; however, it may be

postulated that coping behaviors could be the influ-

ential link in the progression of acute stress states

such as postcode stress to states of chronic unre-

solved stress (PTSD symptom severity). Further

understanding of ineffective coping behaviors and

supportive strategies to promote effective coping

and psychological health are warranted.

In this study, critical care nurses who had insti-

tutional debriefing support available had significantly

lower postcode stress than critical care nurses who

lacked institutional debriefing support. However, the

same critical care nurses who had access to institu-

tional debriefing had a significantly higher magnitude

of PTSD symptom severity than did those critical

care nurses who lacked this support. In a Cochrane

review, Rose et al45 substantiated these findings and

concluded that at best debriefing shows no benefit

in decreasing PTSD and may actually perpetuate an

increased risk for PTSD.

The present study provides an exploratory pre-

dictive model that can be used to evaluate effective-

ness of interventions to blunt the effects of repetitive

exposures to traumatizing events such as an unsuc-

cessful cardiopulmonary resuscitation. As previously

described, the authors have identified postcode stress

severity and 4 maladaptive coping behaviors as sig-

nificant predictors to the severity of PTSD symptoms

in this national sample of critical care nurses. These

results, which have sufficient statistical power, estab-

lish an evidence base for future interventional

research and middle-range theory development in

this area. Although prior research has been conducted

in smaller samples and has had limited external

generalizability, the results of the present study are

consistent with the extant literature and overcome

the major limitations of prior research.1,24,27,41,45

Limitations This study has several limitations that warrant

mention. First, this study used a convenience sam-

ple to collect self-reported cross-sectional data and

involved the recollection of a past event (resuscita-

tion), which can result in recall bias. The second

limitation of this study was the use of nonprobabil-

ity sampling, which yielded

a relatively low response

rate (0.5 %) and a poten-

tially biased sample. Last,

the abbreviation of the

BCOPE to 7 subscales limits

the comparability of the

study results with results of

other studies and resulted

in reduction in the dimen-

sionality of coping behav-

iors captured. Future research should explore a more

comprehensive array of coping behaviors. Despite

these limitations, this study recognizes the psycho-

logical impact of exposures to unsuccessful cardio-

pulmonary resuscitation and underscores the need

for future research that explores strategies to miti-

gate the effects of repetitive psychological trauma

among critical care nurses.

Conclusion Critical care nurses are at the forefront of patient

care and are often the primary providers of cardio-

pulmonary resuscitation in acute and critical care

settings. An understanding of the development of

manifestations of postcode stress, such as PTSD symp-

toms, may help to identify resources that enhance

the health of critical care nurses and reduce


premature departure from the profession. A com-

mitment to AACN’s healthy work environment ini-

tiative will require future research to promote the

psychological health of critical care nurses. The

results of this national study provide valuable

insights that can support interventional research and

inform institutional policies to maintain a healthy

work environment and nursing workforce.



SEE ALSO For more about healthy work environments, visit the Criti-cal Care Nurse website, www.ccnonline.org, and read the article by Williams and Dahnke, “Clarification and Mitiga-tion of Ethical Problems Surrounding Withdrawal of Extra-corporeal Membrane Oxygenation” (October 2016).

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in the intensive care units? J Crit Care. 2009;24:408-414.2. Enohumah KO, Moerer O, Kirmse C, Bahr J, Neumann P,

Quintel M. Outcome of cardiopulmonary resuscitation in intensive care units in a university hospital. Resuscitation. 2006;71:161-170.

3. Hinderer KA. Reactions to patient death: the lived experience of critical care nurses. Dimens Crit Care Nurs. 2012; 31(4):252-259.

4. Myrianthefs P, Kalafati C, Lemonidou C, et al. Efficacy of CPR in a general adult ICU. Resuscitation. 2003;57:43-48.

5. Gershengorn H, Li G, Kramer A, Wunsch H. Survival and functional outcomes after cardiopulmonary resuscitation in the intensive care unit. J Crit Care. 2012;27:421.e9-e17.

6. Pembeci K, Yildirim A, Turan E, et al. Assessment of the suc-cess of cardiopulmonary resuscitation attempts performed in a Turkish university hospital. Resuscitation. 2006; 68:221-229.

7. Mealer ML, Shelton A, Berg B, Rothbaum B, Moss M. Increased prevalence of post-traumatic stress disorder symptoms in criti-cal care nurses. Am J Respir Crit Care Med. 2007;175(7):693-697.

8. Fitzpatrick JJ, Campo TM, Graham G, Lavandero R. Certifi-cation, empowerment, and intent to leave current position and the profession among critical care nurses. Am J Crit Care. 2010;19(3):218-226.

9. Laws T. Examining critical care nurses’ critical incident stress after in hospital cardiopulmonary resuscitation (CPR). Aust Crit Care. 2001;14(2):76-81.

10. Cole FL, Slocumb EM, Mastey JM. A measure of critical care nurses’ post-code stress. J Adv Nurs. 2001;34(3):281-288.

11. Mastey JM, Cole FL. A theoretic perspective on postcode stress experienced by critical care nurses. J Crit Care. 1992; 21(3): 208-213.

12. Lazarus RS, Folkman S. Stress, Appraisal and Coping. New York, NY: Springer; 1984.

13. Stayt LC. Death, empathy and self preservation: the emotional labour of caring for families of the critically ill in adult inten-sive care. J Clin Nurs. 2009;18(9):1267-1275.

14. Issak C, Paterson B. Critical care nurses’ lived experience of unsuccessful resuscitation. West J Nurs Res. 1996;18:688-702.

15. Desbiens J, Fillion L. Coping strategies, emotional out-comes and spiritual quality of life in palliative care nurses. Int J Palliat Nurs. 2007;13(6):291-300.

16. Pelletier-Hibbert M. Coping strategies used by nurses to deal with the care of organ donors and their families. Heart Lung. 1998;27(4):230-237.

17. Hopkinson JB, Hallett CE, Luker KA. Everyday death: how do nurses cope with caring for dying people in hospital?

Int J Nurs Stud. 2005;42(2):125-133.18. Zuzelo PR. Exploring the moral distress of registered nurses.

Nurs Ethics. 2007;14(3):344-359.19. Page S, Meerabeau L. Nurses’ accounts of cardiopulmonary

resuscitation. J Adv Nurs. 1996;24(2):317-325.20. Ganz FD, Kaufman N, Israel S, Einav S. Resuscitation in general

medical wards: who decides? J Clin Nurs. 2013; 22(5/6): 848-855.21. Kelly J. Nurses’ and doctors’ perspectives on slow codes.

Nurs Ethics. 2008;15(1):110-112.22. Hays MA, All AC, Mannahan CE, Cuaderes EP, Wallace DP.

Reported stressors and ways of coping utilized by intensive care unit nurses. Dimens Crit Care Nurs. 2006;25(4):185-193.

23. Jaracz K, Gorna K, Konieczna J. Burnout, stress and styles of coping among hospital nurses. Rocz Akad Med Bialymst. 2005;50(1):216-219.

24. Buurman BM, Mank APM, Beijer HJM, Olff M. Coping with serious events at work: a study of traumatic stress among nurses. J Am Psychiatr Nurses Assoc. 2011;17(5):321-329.

25. Happell B, Reid-Searl K, Dwyer T, Caperchione CM, Gaskin CJ, Burke KJ. How nurses cope with occupational stress outside their workplaces. Collegian. 2013;20(3):195-199.

26. Schreuder JAH, Roelen C, Eacute, A.M, Groothoff JW, Van der Klink JJL, et al. Coping styles relate to health and work envi-ronment of Norwegian and Dutch hospital nurses: a compar-ative study. Nurs Outlook. 2012;60(1):37-43.

27. Von Rueden KT, Hinderer KA, McQuillan KA, et al. Secondary traumatic stress in trauma nurses: prevalence and exposure, coping, and personal/environmental characteristics. J Trauma Nurs. 2010;17(4):191-200.

28. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: Ameri-can Psychiatric Publishing; 1980.

29. Beck JG, Grant DM, Read JP, et al. The impact of event scale-revised: psychometric properties in a sample of motor vehicle accident survivors. J Anxiety Disord. 2008; 22(2): 187-198.

30. Mealer M, Burnham EL, Goode CJ, Rothbaum B, Moss M. The prevalence and impact of post traumatic stress disorder and burn-out syndrome in nurses. Depress Anxiety. 2009; 26(12):1118-1126.

31. Carver CS. You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med. 1997; 4(1): 92-100.

32. Jones FM, Fellows JL, Horne DJ. Coping with cancer: a brief report on stress and coping strategies in medical students deal-ing with cancer patients. Psychooncology. 2011; 20(2):219-223.

33. Shimizutani M, Odagiri Y, Ohya Y, et al. Relationship of nurse burnout with personality characteristics and coping behav-iors. Ind Health. 2008;46(4):326-35.

34. Wallbank S, Robertson N. Predictors of staff distress in response to professionally experienced miscarriage, stillbirth and neona-tal loss: a questionnaire survey. Int J Nurs Stud. 2013;50(8): 1090-1097.

35. Yusoff MSB. Health and environment: a multicenter study on validity of the 30-items brief cope in identifying coping strate-gies among medical students. Int Med J. 2010; 17(4): 249-253.

36. Ben-Ezra M, Palgi Y, Hamama-Raz Y, Soffer Y, Shrira A. Reac-tions to the 2011 Tohoku earthquake and tsunami: a prelimi-nary matching study comparing nurses and civilians. J Nerv Ment Dis. 2013;201(6):534-536.

37. Gates DM, Gillespie GL, Succop P. Violence against nurses and its impact on stress and productivity. Nurs Econ. 2011; 29(2): 59-67.

38. Weiss DS, Marmar CR. The Impact of Event Scale-Revised. In: Wilson J, Kena TM, eds. Assessing Psychological Trauma and PTSD. New York, NY: Guilford; 1997:399-411.

39. Gillespie GL, Gates DM. Using proactive coping to manage the stress of trauma patient care. J Trauma Nurs. 2013; 20(1): 44-50.

40. Komachi M, Kamibeppu K, Nishi D, Matsuoka Y. Secondary traumatic stress and associated factors among Japanese nurses working in hospitals. Int J Nurs. 2012;18(2):155-63.

41. Laranjeira CA. The effects of perceived stress and ways of coping in a sample of Portuguese health workers. J Clin Nurs. 2012; 21(11/12):1755-1762.

42. Gilbar O, Plivazky N, Gil S. Counterfactual thinking, coping strategies, and coping resources as predictors of PTSD diagnosed in physically injured victims of terror attacks. J Loss Trauma. 2010;15(4):304-324.

43. Chang CM, Lee LC, Connor KM, Davidson JR, Jeffries K, Lai TJ. Posttraumatic distress and coping strategies among res-cue workers after an earthquake. J Nerv Ment Dis. 2003; 191(6):391-398.

44. Clohessy S, Ehlers A. PTSD symptoms, response to intrusive

1.0 Hour Category BC E Notice to CE enrollees:



1. Examine the relationship among postcode stress, coping behaviors, and posttraumatic stress disorder

(PTSD) symptom severity after unsuccessful cardiopulmonary resuscitation (CPR).

2. Identify ineffective coping behaviors that may put critical care nurses at risk for PTSD symptom severity

following unsuccessful CPR.

3. Discuss the implications of the study fi ndings to the American Association of Critical-Care Nurses’ Healthy

Work Environments initiative.

To complete the evaluation for CE contact hour(s) for article #A1726023, visit www.ajcconline.org and click

the “CE Articles” button. No CE test fee for AACN members. This expires on March 1, 2019.


memories and coping in ambulance service workers. Br J Clin Psychol. 1999;38(3):251-265.

45. Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefi ng for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002(2):CD000560.


Brief Report


Background Intracranial pressure is measured continu-ously, and nursing behaviors have been associated with variations in the measurements.Methods A prospective pilot observational study was done to develop a comprehensive list of nursing behav-iors that affect patients’ intracranial pressure. Data on nurses were obtained by self-reports and video recording. Patient-level data were collected via chart abstraction, video recording, and patients’ monitors.Results Data on 9 patients and 32 nurses were analyzed. A total of 6244 minutes of data were video recorded. Intracranial pressure was changed because of a nursing intervention during 3394 observations. Compared with baseline levels, intracranial pressure was significantly higher if a nursing intervention was performed (odds ratio, 1.96; 95% CI, 1.71-2.24; P < .001).Conclusion Studying nursing behaviors is feasible. Synchronizing and analyzing mutually exclusive and exhaustive behaviors indicated that nursing behaviors have an effect on patients’ intracranial pressure. (Amer-ican Journal of Critical Care. 2017; 26:136-139)

A NOVEL APPROACH TO EXPLORE HOW NURSING CARE AFFECTS INTRACRANIAL PRESSUREBy DaiWai M. Olson, RN, PhD, CCRN, Camille Parcon, RN, Aljean Santos, RN, BSN, Guilla Santos, RN, BSN, Ryan Delabar, MD, and Sonja E. Stutzman, PhD


Value exists in understanding variations in nursing practice.1 Unfortunately, in neu-rocritical care units, no practical means exists to fully understand heterogeneity in practice. The purpose of this pilot study was to evaluate a novel method of acquir-ing observational data by synchronizing videotaping of nursing care with measure-ment of physiological variables. In this brief report, we focus on the method of

studying nursing care and its effect on intracranial pressure (ICP).

Background Each year more than 2 million persons in the

United States are at risk for secondary brain injury

after traumatic brain injury, hemorrhagic stroke, and

ischemic stroke.2 Changes in ICP are often used as a

marker for secondary brain injury. Research on how

nursing care exacerbates or reduces secondary brain

injury is minimal. Nurses create the context of care

in which a variety of medical and pharmacothera-

peutics are administered in the intensive care unit.

Critical care nurses are specifically educated to observe

for changes and trends in ICP, blood pressure, oxy-

genation, and neurological function that may signal

a change in intracranial dynamics and to intervene

when necessary.

Currently, the gold standard for ICP monitoring

is ventriculostomy: A hollow catheter is inserted

into the lateral ventricle and connected via tubing

to a pressure transducer that provides a digitized sig-

nal.3-5 Because ICP research

is directed by physicians and implemented by

nurses, studies have focused on interventions and

medications that can be used to reduce ICP;

little attention has been given to the timing of

nurses’ actions. The results of studies6,7 on the effects

of ICP monitoring on morbidity and mortality have

been mixed. However, these highly publicized stud-

ies6,7 did not include examination of the effectiveness

of ICP-lowering strategies or nursing care. Although

many investigators8-13 have examined nursing

behaviors associated with ICP, no consensus exists

on which nursing behaviors, medications, and

monitoring should be included in an ICP treat-

ment protocol.

Methods We performed a prospective pilot observational

study with convenience sampling of 10 patients

who required ICP monitoring and 32 neurocritical

care nurses who consented to participate. We used

a component central ner-

vous system (CNS) moni-

tor (Moberg Research, Inc)

to obtain videotapes and

data on vital signs simul-

taneously, Data were

obtained from the 32

nurses by using the Nurse

Experience Tool14 and

video recording via the

CNS monitor. The Nurse Experience Tool is a self-re-

port measure that is used to collect demographic

data specific to health care professionals (eg, educa-

tion, certification, years of experience). Patient-

level data were collected via chart abstraction,

video recording, and the CNS monitor.

The CNS monitor allows continuous acquisi-

tion of a patient’s physiological data directly from

the patient’s monitor. Use of the CNS monitor for

acquiring ICP data has been previously described.15

Data were coded for mutually exclusive and exhaus-

tive nursing care behaviors and linked to ICP values

by using observational software (Observer-XT; Nol-

dus, Inc). Observer XT software allows synchroni-

zation and coding of behaviors in multiple settings.

Additionally, the program can code, classify, and

perform some low-level statistics.

ProceduresAfter nurses provided informed consent for

participation in the pilot study, consent was requested

from the patients. The CNS monitor with video

recorder was connected to the bedside, and data

About the AuthorsDaiWai M. Olson is an associate professor, neurology and therapeutics, Sonja E. Stutzman is research program manager, and Guilla Santos is staff nurse, University of Texas Southwestern Medical Center, Dallas, Texas. Camille Parcon is a staff nurse, Baylor University Medical Center, Dallas, Texas. Aljean Santos is a registered nurse, Texas Woman’s University, Denton, Texas. Ryan Delabar is a medical resident, Washington University, St Louis, Missouri.

Corresponding author: DaiWai M. Olson, 5323 Harry Hines Blvd, Dallas, TX 75390-8855 (e-mail: DaiWai.Olson @UTSouthwestern.edu).


High-speed computers with enhanced video-taping can help syn-chronize physiological and observational data.


were recorded for 12 hours. Recording began after

patients provided consent and occurred during both

nursing shifts (AM and PM). Technological error

resulted in a corrupt videotape file for 1 patient

participant. The final data set included observa-

tions from 9 patients and 32 nurses. The data were

analyzed in 3 phases: coding behavior, scoring ICP

change, and exploring for associations.

Videotaped data were scored for mutually

exclusive and exhaustive nursing behaviors by using

Observer-XT software. Each video recording was inde-

pendently coded by 2 undergraduate nursing research

assistants. Nursing behaviors were categorized into

the following domains: neurophysiological, psycho-

social, injury prevention, and therapeutic milieu.16

ICP data were summarized for 1-minute inter-

vals. Each sample point was the mean ICP during

the previous 60 seconds. Change in ICP was scored

if the pressure changed at least 1 mm Hg. The data

from phase 1 and phase 2 were merged so that

each 1-minute observation provided information

on whether or not a nursing intervention occurred,

what intervention occurred, the ICP value, and the

change in ICP.

Results Among the 9 patient participants in the study,

7 had subarachnoid hemorrhage, 1 had intracere-

bral hemorrhage, and 1 had hemangiopericytoma.

Their mean age was 58.8 years (range, 45-73 years;

Table 1). Among the 32 nurse participants, 4 had an

associate/diploma degree, 26 had a bachelor of sci-

ence degree, and 2 had a master of science degree.

Nurses had a median of 6 years of nursing experience

and a median of 5.5 years of critical care experience.

During a total of 6244 minutes of data, nurses per-

formed 91 mutually exclusive and exhaustive behav-

iors in 5 behavior domains: 15 in neurophysiological,

35 in physiological, 9 in psychosocial, 11 in injury

prevention, and 21 in therapeutic milieu. Table 2

presents an example of the more common behaviors

and domains.

During 3394 observations, ICP changed from

the pressure of the preceding minute. Of these, 779

changes in ICP were associated with a nursing inter-

vention. The odds of observing a change in ICP was

significantly higher if a nursing intervention was per-

formed (odds ratio, 1.96; 95% CI, 1.71-2.24; P < .001).

The interrater reliability for scoring video was

examined under 2 conditions. In the first condition

(strict), verbatim coding was compared (eg, “adjust

EVD” is different from “zero EVD”). In the second

condition (lenient), coding adjusted for language

was compared (eg, “adjust EVD” is equivalent to

Variable

Table 1Patient demographics

a Unless indicated otherwise, all values are No. (%) of patients. b Not mutually exclusive.

Sex Female

Age, y Median Range Mean

Race White African American Other

Ethnicity Non-Hispanic Hispanic

Admitting diagnosis Subarachnoid hemorrhage Intracerebral hemorrhage Hemangiopericytoma

Medical historyb

Neurovascular condition Hypertension Pulmonary condition Type 2 diabetes Other

5 (56)

5645-7358.8

7 (78)1 (11)1 (11)

8 (89)1 (11)

7 (78)1 (11)1 (11)

9 (100)4 (44)3 (33)3 (33)3 (33)

Valuea

Domains

Table 2Behavior domains for key nursing behaviors

Neurophysiological

Physiological

Psychosocial

Injury prevention

Therapeutic milieu

Leveling external ventricular drainZeroing external ventricular drainClamping external ventricular drainDraining cerebrospinal fluidRaising head of bedLowering head of bedRaising bedLowering bed

Suctioning patientIntubationExtubationBathing patientFeeding patientHygiene measuresInserting urinary catheterAssisting with radiography/imaging

Family presentFamily talkingStaff talking

Turning patientApplying restraintsRemoving restraints

Turning off the lightsTurning on the lights

Nursing behaviors


“zero EVD”). The kappa statistic for strict criteria

ranged from 0.10 to 0.13, indicating slight agree-

ment. The kappa values for lenient criteria ranged

from 0.44 to 0.51, indicating moderate agreement.

Discussion High-speed computers with enhanced video-

taping can be used to synchronize physiological and

observational data. This synchronization allows

continuous observation of behaviors without a human

presence. The marginal interrater reliability most

likely reflects the need to provide coders with a pick

list of behaviors that may increase or decrease ICP.

Video-recorded observations may have the advan-

tage of a lower risk for observer effect (Hawthorne

effect). Unlike the human eye, the camera is able

to record and store multiple observations for later

scoring. A human observer might have difficulty

determining sequence, especially during simultane-

ous behaviors. The use of video recording is cost-

effective when no nursing care is being provided;

the video recorded data can be fast-forwarded past

the inactive period and no pay is required for a human

observer. This capability also facilitates longer peri-

ods of observation wherein the task of observing

can be delegated to technology.

Limitations The limitations of this study were positioning

of the CNS camera, synchronizing physiological

data to video data, interrater reliability lower than

expected, lack of audio data, level of nursing experi-

ence between coders, inadequate training for

Observer-XT software, and low quality of video data.

The positioning of the camera of the CNS monitor

restricted the field of view and impeded the ability

to observe nursing behavior. Efforts to compensate

for this limitation include changing the placement

and angle of the camera. The methods used to syn-

chronize video and CNS monitor data limited accu-

racy to within a 6-second period, a situation that

might have affected the interrater reliability.

Conclusions Our findings indicate the feasibility of using

videotaped data synchronized with physiological

measurements to evaluate the impact of nursing

behaviors on patients’ vital signs (ie, ICP). The

results provide evidence that nursing care may affect

ICP and that value exists in using technology as a

tool for exploring the effect of nursing behaviors.

The benefit of using Observer XT with the CNS

monitor is that researchers can definitively link

changes in ICP to specific nursing behaviors. These

results will be used to guide future research on which

behaviors are most closely associated with an increase

or a decrease in ICP.

ACKNOWLEDGMENTSWe thank the clinical team in the intensive care unit, especially the nurses who were willing to be videotaped throughout this study.



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Cardiovascular Critical Care

Background Diabetes is a common comorbid condition in patients with heart failure and is strongly associated with poor outcomes. Patients with heart failure who have diabetes are more likely to be obese than are those without diabetes. Obesity is positively associated with survival in patients with heart failure, but how comorbid diabetes influences the relationship between obesity and favorable prognosis is unclear.Objective To explore whether the relationship between body mass index and survival differs between patients with heart failure who do or do not have diabetes. Methods The sample consisted of 560 ambulatory patients with heart failure (mean age, 66 years; mean body mass index, 32; diabetes, 41%). The association between body mass index and all-cause mortality was examined by using multivariate Cox proportional hazards regression after adjustments for covariates. Results In patients without diabetes, higher body mass index was associated with a lower risk for all-cause mortality after adjustments for covariates (hazard ratio, 0.952; 95% CI, 0.909-0.998). In patients with diabetes, body mass index was not predictive of all-cause death after adjustments for covariates. Conclusion Obesity was a survival benefit in heart failure patients without comorbid diabetes but not in those with comorbid diabetes. The mechanisms underlying the dif-ference in the relationship between obesity and survival due to the presence of diabetes in patients with heart failure need to be elucidated. (American Journal of Critical Care. 2017; 26:140-148)

OBESITY PARADOX: COMPARISON OF HEART FAILURE PATIENTS WITH AND WITHOUT COMORBID

DIABETESBy Kyoung Suk Lee, RN, PhD, MPH, Debra K. Moser, RN, PhD, Terry A. Lennie, RN, PhD, Michele M. Pelter, RN, PhD, Thomas Nesbitt, MD, MPH, Jeffrey A. Southard, MD, and Kathleen Dracup, RN, PhD


Overall mortality rates due to cardiovascular disease have significantly declined since the early 2000s. However, mortality rates in heart failure have not signifi-cantly changed.1 Many efforts have been made to identify factors that might be associated with the outcomes of heart failure. For example, even though obesity is a major risk factor for heart failure and other cardiovascular diseases, it is ben-

eficial for survival among patients who have heart failure.2-6 In contrast, diabetes is a common comorbid condition7,8 related to adverse outcomes in heart failure.2,7,8 A recent meta-analysis2 indicated that diabetes is associated with a 59% increased risk for all-cause mortality in patients with heart failure.

How the presence of diabetes influences the

relationship between obesity and the outcomes of

heart failure is not clear because patients with heart

failure who have diabetes are more likely to be obese

and have worse outcomes than do those without

diabetes.2,7,8 A better understanding of the impact of

comorbid diabetes on the relationship between obe-

sity and survival among patients with heart failure

may indicate appropriate clinical recommendations

for the subgroup of patients with heart failure who

also have obesity and diabetes. Therefore, in this

study we explored whether the relationship between

body mass index (BMI; calculated by dividing weight

in kilograms by height in meters squared) and sur-

vival differs in patients with heart failure who do

or do not have comorbid diabetes.

Methods We conducted a secondary analysis of the data

from the Rural Education to Improve Outcomes in

Heart Failure (REMOTE-HF) trial,9 which was designed

to improve self-care in heart failure patients living

in rural areas by providing an educational and coun-

seling intervention. The primary focus of the inter-

vention was to encourage patients to use a diary to

monitor daily signs and symptoms of fluid overload

in order to detect early signs and symptoms of heart

failure exacerbation and prevent delay in seeking

care. The detailed study methods used in the parent

study have been described.9

In brief, patients with a diagnosis of heart fail-

ure with either preserved or reduced systolic function

were recruited from 12 clinics and hospitals in 3

states in the United States. Patients were eligible for

enrollment if they lived in a rural area, as defined

by the US Census Bureau10; had been hospitalized

in the preceding 6 months because of exacerbation

of heart failure; and spoke English. Patients were

excluded from consideration if they were currently

enrolled in a heart failure dis-

ease management program,

were not living independently

(ie, were living in a nursing

home or an assisted living

facility), or had life-threaten-

ing comorbid conditions,

such as untreated malignant

neoplasm or kidney failure

requiring dialysis. Patients were

also excluded if they were judged to have cognitive

impairment as indicated by results of the Mini-Cog

examination11 and a clock-drawing test.12

The institutional review boards of the partici-

pating centers approved the protocol, and all study

participants provided written consent to participate.

Eligible patients were randomized into 3 groups (ie,

usual care and 2 intervention arms) and followed

up for 24 months after the baseline data collection.

Research staff who performed data collection (eg,

death and other psychological variables of interest),

verification, and classification had no knowledge of

About the AuthorsKyoung Suk Lee is an assistant professor, Chungnam National University, College of Nursing, Dae Jeon, South Korea. Debra K. Moser is a professor, the Gill Endowed Chair of Nursing, and a codirector of the RICH Heart Program, University of Kentucky, College of Nursing, Lexington, Kentucky, and a professor of cardiovascular nursing, University of Ulster, Belfast, Ireland. Terry A. Lennie is a professor and a codirector of the RICH Heart Program, University of Kentucky, College of Nursing. Michele M. Pelter is an assistant professor and Kathleen Dracup is a professor emeritus, University of California San Francisco, School of Nursing, San Francisco, Cali-fornia. Thomas Nesbitt is a professor and associate vice chancellor for strategic technologies and alliances, and Jeffrey A. Southard is an associate clinical profes-sor of medicine, and director of the transcatheter aortic valve replacement program, University of California, Davis, California.

Corresponding author: Kyoung Suk Lee, RN, PhD, MPH, Assistant Professor, Chungnam National University, College of Nursing, 6 Moonhwa 1-dong, Jungu, Dae Jeon 301-747, South Korea (e-mail: [email protected]).

Survival advantages of obesity in patients with heart failure who have diabetes have not been studied.



any patient’s group assignment. Of the 620 patients

enrolled in the parent study, we included 560 patients

(90.3%) who had complete data on all of the vari-

ables of interest (eg, BMI, levels of B-type natriuretic

peptide [BNP] and serum creatinine, and depressive

symptoms) and a BMI of 18.5 or greater. We excluded

patients with a BMI less than 18.5 (n = 8) because of

a potential for cachexia.

MeasuresAll-Cause Death. After the baseline assessment,

patients were followed up for up to 24 months (mean,

604 days). Data on all-cause death were obtained

from physicians or patients’ family members at each

data collection point (3, 12, and 24 months) and were

verified and confirmed by review of medical records

or death certificates by research staff.

Body Mass Index. At baseline, trained research

nurses measured weight and height of each patient.

BMI was categorized as normal weight (18.5-24.9),

overweight (25-29.9), or obese (≥ 30) on the basis

of definitions of the World Health Organization.13

Diabetes. At baseline, research nurses interviewed

patients to inquire about the diagnosis of diabetes

and confirmed patients’ responses by review of

medical records.

Covariates. Baseline demographic and clinical

variables were collected by research nurses at each

site before patients were randomly assigned to groups.

Research nurses obtained information about age,

sex, marital status, prescribed medications, left ven-

tricular ejection fraction, and

serum levels of creatinine via

interview or review of medical

records. A blood sample to

determine the plasma level of

BNP was obtained via venipunc-

ture by the research nurse during

baseline data collection. Each

patient’s New York Heart Associ-

ation (NYHA) functional class

was determined by a research

nurse by using a structured inter-

view process. The Charlson Comorbidity Index14

was used to assess comorbid conditions. Each comor-

bid condition was assigned a value according to the

relative risk of 1-year mortality associated with that

disease. The sum of the values yields Charlson

Comorbidity scores.

Depressive symptoms were measured by using

the Patient Health Questionnaire-9.15 Each item

corresponds to 1 of the 9 symptoms of the major

depressive disorder criteria of the Diagnostic and

Statistical Manual of Mental Disorders (Fourth Edition).

Patients are asked to rate each item on a scale of 0

to 3. Total scores range from 0 to 27, and higher

scores indicate more severe symptoms. Scores of 5

to 9, 10 to 14, 15 to 19, and 20 or greater indicate

mild, moderate, moderately severe, and severe levels

of depressive symptoms, respectively.

Statistical Analyses. Continuous data are presented

as means and standard deviations for normally dis-

tributed variables or as medians and interquartile

ranges for nonnormally distributed variables (eg,

levels of creatinine and BNP) and categorical vari-

ables as numbers and percentages. Comparisons

for continuous variables among BMI groups were

performed by using analysis of variance followed

by the Fisher least significant difference test or the

Kruskal-Wallis test for post-hoc pairwise comparison

as appropriate. A 2 test was used to compare cate-

gorical variables among BMI groups.

Survival curves were stratified by the presence or

absence of diabetes and plotted by using the Kaplan-

Meier method with the log-rank test for comparison

among 3 BMI groups (ie, normal weight, overweight,

and obese). The association between BMI (BMI groups

and continuous value of BMI) and all-cause mortality

was examined by using multivariable Cox propor-

tional hazards regression. Adjustment was made for

baseline characteristics including age, NYHA func-

tional class, depressive symptoms, plasma level of

BNP (log-transformed), and serum level of creatinine

(log-transformed). These covariates were chosen

because they are associated with survival in patients

with heart failure. A variable indicating intervention

group assignments was also entered into the model

to control for the intervention effect on all-cause

mortality. SPSS, version 20.0, software (IBM Corp)

was used for all statistical analyses, and P less than

.05 was considered statistically significant.

Results Sample Characteristics

The sample characteristics and comparison

between patients with and without diabetes are sum-

marized in Table 1. Overall, the study participants were

mainly male (59.8%), white (89.6%), overweight or

obese (79.8%), and had NYHA functional class of I/II

(64.3%). The mean age of the total sample was 66

years with a range of 23 to 92 years. Participants had

mild levels of depressive symptoms according to the

Patient Health Questionnaire-9 cutpoint of 5.

Of a total of 560 patients, 231 (41.3%) concom-

itantly had diabetes. Patients with diabetes had greater

BMI and more comorbid conditions than did patients

Survival was com-pared among normal weight, overweight, and obese patients

with and without diabetes.


without diabetes. Compared with patients without

diabetes, a higher proportion of patients with diabe-

tes were prescribed diuretics.

Table 2 shows a comparison of sample charac-

teristics among normal-weight, overweight, and

obese patients according to the presence or absence

of diabetes. Among patients without concomitant

diabetes, obese patients were younger and more

depressed, and had lower plasma concentrations of

BNP than did their normal-weight and overweight

counterparts. The proportion of patients who were

prescribed diuretics was higher in obese patients

with diabetes than in normal-weight or overweight

patients with diabetes.

Among patients with concomitant diabetes,

normal-weight patients were older than obese

patients and less depressed than overweight and

obese patients. Normal-weight patients were less

likely to be classified as NYHA III/IV and less likely

to be prescribed angiotensin-converting enzyme

inhibitors or angiotensin receptor blockers than

were the other 2 BMI groups.

All-Cause DeathsA total of 112 deaths occurred during the mean

follow-up of 604 days; 65 deaths (58.0%) (cardiac

death 39 and noncardiac 26) occurred in patients

without diabetes, and 47 (42.0%) (cardiac death

26 and noncardiac 21) in patients with diabetes.

Kaplan-Meier estimates showed that the risk of

death differed among the 3 BMI groups without

diabetes ( 2 = 17.0; log-rank test P < .001), but not

among the 3 BMI groups with diabetes ( 2 = 2.7;

log-rank test P = .10) (see Figure).

Characteristic

Table 1Sample characteristics (N = 560)a

Age, mean (SD), y

Female, No. (%) of patients

Marital status, No. (%) of patients Single/divorced/widow Married/cohabitating

BMI,b mean (SD)

BMI categories, No. (%) of patients Normal weight (BMI 18.5-24.9) Overweight (BMI 25-29.9) Obese (BMI 30)

Ethnicity, No. (%) of patients White Minority

NYHA class, No. (%) of patients I/II III/IV

LVEF < 40%,c No. (%) of patients

Charlson Comorbidity Index, mean (SD)

BNP, median (IQR), pg/mL

Creatinine, median (IQR), mg/dL

Depressive symptoms, mean (SD)

Medications,d No. (%) of patients ACEIs or ARBs -Blockers Diuretics

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BMI, body mass index; BNP, B-type natriuretic peptide; HF, heart failure; IQR, interquartile range; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association.

SI conversion factor: To convert creatinine to μmol/L, multiply by 88.4. a Because of rounding, not all percentages total 100.b Calculated as weight in kilograms divided by height in meters squared.c Data on LVEF available for only 554 patients, 324 with no diabetes and 230 with diabetes.d Data on ACEIs or ARBs available for only 556 patients (327 with no diabetes and 229 with diabetes), and data on -blockers and diuretics available for

only 559 patients (328 with no diabetes, 231 with diabetes).

.10

.58

< .001

< .001

< .001

.15

.24

.48

< .001

.60

< .001

.10

.20

.61< .001

65 (11.9)

96 (41.6)

96 (41.6)135 (58.4)

35.2 (9.1)

22 (9.5) 55 (23.8)154 (66.7)

202 (87.4) 29 (12.6)

142 (61.5) 89 (38.5)

113 (49.1)

4.2 (1.7)

177.0 (80.0-431.0)

1.2 (1.0-1.5)

8.2 (6.4)

175 (76.4)184 (79.7)211 (91.3)

67 (13.8)

129 (39.2)

145 (44.1)184 (55.9)

30.0 (7.9)

91 (27.7)106 (32.2)132 (40.1)

300 (91.2) 29 (8.8)

218 (66.3)111 (33.7)

169 (52.2)

2.7 (1.5)

197.0 (71.5-495.0)

1.1 (0.9-1.4)

7.0 (6.4)

234 (71.6)267 (81.4)258 (78.7)

66 (13.1)

225 (40.2)

241 (43.0)319 (57.0)

32.2 (8.8)

113 (20.2)161 (28.7)286 (51.1)

502 (89.6) 58 (10.4)

360 (64.3)200 (35.7)

282 (50.9)

3.3 (1.8)

184.5 (72.0-461.8)

1.1 (0.9-1.4)

7.5 (6.4)

409 (73.6)451 (80.7)469 (83.9)

PDiabetes(n = 231)

No diabetes (n = 329)

Total (N = 560)


Tables 3 and 4 show the results of Cox regression

analyses on the association of BMI (categorical and

continuous variable, respectively) with all-cause death.

Patients Without Concomitant Diabetes. When BMI

categories were entered in the univariate Cox regres-

sion model (Table 3), the association between BMI

categories and all-cause death was significant in

patients without diabetes. Compared with obese

patients, normal-weight and overweight patients

were at 3.5-fold and 2.4-fold higher risk for all-cause

mortality, respectively (normal-weight group hazard

ratio [HR], 3.529; 95% CI, 1.827-6.817; and over-

weight group HR, 2.399; 95% CI, 1.221-4.711). In a

multivariate model, BMI categories remained inde-

pendently associated with all-cause mortality. The

risk for all-cause death in normal-weight patients

was increased by 271% in comparison with that of

obese patients (HR, 2.710; 95% CI, 1.295-5.673).

However, risks for all-cause mortality did not differ

between overweight and obese patients. Among the

covariates included in the analysis, NYHA functional

class and BNP level were independent predictors of

all-cause death.

When BMI was entered as a continuous value,

BMI was predictive of all-cause death among patients

without diabetes (HR, 0.931; 95% CI, 0.892-0.972)

in a univariate model (Table 4). After adjustments for

covariates, BMI was an independent predictor of all-

cause death in patients without diabetes, with 5%

lower risk of all-cause death per increase of 1 in BMI

(HR, 0.952; 95% CI, 0.909-0.998). Among the covari-

ates included in this analysis, older age, NYHA func-

tional class III/IV (vs class I/II), and higher levels of

BNP were related to increased risk for all-cause death.

Characteristic

Table 2Comparison of sample characteristics according to body mass index categories (N = 560)

Age,a,b mean (SD), y

Female, No. (%) of patients

Marital status, No. (%) of patients Single, divorced, or widow Married or cohabitating

Body mass index,a,b,e mean (SD)

Ethnicity, No. (%) of patients White Minority

NYHA class,b No. (%) of patients I/II III/IV

LVEF < 40%,g No. (%) of patients

Charlson Comorbidity Index, mean (SD)

BNP,a,b median (IQR), pg/mL

Creatinine, median (IQR), mg/dL

Depressive symptoms,a,b mean (SD)

Medications,h No. (%) of patients ACEIs or ARBsb

-Blockers Diureticsa

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BNP, B-type natriuretic peptide; NYHA, New York Heart Association; HF, heart failure; IQR, interquartile range; LVEF, left ventricular ejection fraction.

SI conversion factor: To convert creatinine to μmol/L, multiply by 88.4. a Comparison of the 3 BMI groups: P < .05 within patients without diabetes.b Comparison of the 3 BMI groups: P < .05 within patients with diabetes c,d,f Post hoc least significant difference pairwise comparison: BMI groups with different superscripts (c,d,f) are significantly different from one another.e Calculated as weight in kilograms divided by height in meters squared.g Data on LVEF available for only 554 patients, 324 with no diabetes and 230 with diabetes.h Data on ACEIs or ARBs available for only 556 patients (327 with no diabetes and 229 with diabetes), and data on -blockers and diuretics available for

only 559 patients (328 with no diabetes, 231 with diabetes).

63 (11.7)d

63 (40.9)

65 (42.2)89 (57.8)

39.6 (7.8)f

134 (87.0) 20 (13.0)

93 (60.4)61 (39.6)

68 (44.4)

4.3 (1.8)

158.0 (61.8-330.5)

1.2 (1.0-1.6)

8.6 (6.4)d

124 (81.0)123 (79.9)142 (92.2)

70 (9.2)c

22 (40.0)

20 (36.4)35 (63.6)

27.6 (1.3)d

49 (89.1) 6 (10.9)

40 (72.7)15 (27.3)

30 (54.5)

4.1 (1.4)

211.0 (97.0-569.0)

1.1 (1.0-1.5)

8.3 (7.1)d

38 (70.4)45 (81.8)47 (85.5)

69 (14.8)c

11 (50.0)

11 (50.0)11 (50.0)

23.3 (1.3)c

19 (86.4) 3 (13.6)

9 (40.9)13 (59.1)

15 (68.2)

3.9 (1.2)

464.0 (113.5-851.5)

1.2 (1.0-1.4)

4.9 (3.7)c

13 (59.1)16 (72.7)

22 (100.0)

61 (14.0)d

50 (37.9)

55 (41.7)77 (58.3)

37.3 (7.2)f

116 (87.9) 16 (12.1)

83 (62.9)49 (37.1)

65 (50.0)

2.6 (1.6)

115.0 (42.5-357.8)

1.0 (0.9-1.2)

8.5 (6.9)d

100 (76.9)108 (82.4)112 (85.5)

71 (12.7)c

36 (34.0)

49 (46.2)57 (53.8)

27.4 (1.4)d

102 (96.2) 4 (3.8)

73 (68.9)33 (31.1)

57 (54.3)

2.7 (1.5)

173.5 (71.8-399.5)

1.1 (0.9-1.4)

5.6 (5.5)c

76 (71.7)90 (84.9)76 (71.7)

71 (11.7)c

43 (47.3)

41 (45.1)50 (54.9)

22.4 (1.8)c

82 (90.1) 9 (9.9)

62 (68.1)29 (31.9)

47 (52.8)

3.0 (1.4)

327.0 (148.0-707.0)

1.0 (0.8-1.4)

6.5 (6.1)c

58 (63.7)69 (75.8)70 (76.9)

Obese (n = 154)

Obese (n = 132)

Overweight (n = 55)

Overweight (n = 106)

Normal weight (n = 22)

Normal weight (n = 91)

No diabetes (n = 329) Diabetes (n = 231)


Patients With Concomitant Diabetes. When BMI

categories were entered in the univariate Cox

regression model (Table 3), the categories were not

associated with all-cause death in patients with

diabetes. This nonsignificant association between

BMI categories and all-cause death was reproduced

Figure Kaplan-Meier curves show survival probability in normal-weight, overweight, and obese patients according to the presence or absence of diabetes.

DiabetesNo diabetes

Time (days to follow-up)

Surv

ival

pro

bab

ility

Obese

Normal weight

Overweight

800600400200

Log-rank test P < .001

0

0.0

0.2

0.4

0.6

0.8

1.0

MATT: Author would like graphs to be same height and width. I have no idea how to do that while keeping curves in correct locations relative to axes. Maybe stretch the right graph vertically to match left graph and move labels at right to below curves so that width of right graph can match width of left graph?

Time (days to follow-up)

Surv

ival

pro

bab

ility

Obese

Normal weight

Overweight

800600400200

Log-rank test P = .10

0

0.0

0.2

0.4

0.6

0.8

1.0

Characteristic

Table 3Cox regression model for the effect of body mass index categories (normal weight, overweight, obese) on all-cause mortality according to presence or absence of diabetes

Univariate model Body mass indexa categories (vs obese)

Normal weight

Overweight

Multivariate model Age

NYHA class III/IV (vs I/II)

Intervention groups (vs control group) Intervention arm I Intervention arm II

Depressive symptoms

B-type natriuretic peptideb

Creatinineb

Body mass index categories (vs obese) Normal weight Overweight

Abbreviation: NYHA, New York Heart Association.a Calculated as weight in kilograms divided by height in meters squared.b Values of B-type natriuretic peptide and creatinine were log-transformed.

1.049-5.024

0.481-2.027

1.009-1.070

1.433-4.928

0.786-3.6830.607-3.185

1.021-1.123

0.976-1.604

0.630-3.281

0.783-5.0780.376-1.787

.10

.04

.97

.01

.002

.40

.18

.44

.005

.08

.39

.22

.15

.62

2.296

0.988

1.039

2.657

1.7011.390

1.071

1.251

1.438

1.9940.820

1.827-6.817

1.221-4.711

0.999-1.044

2.194-6.753

0.677-2.1780.428-1.494

0.992-1.079

1.055-1.680

0.621-2.655

1.295-5.6730.983-4.196

.001

<.001

.01

.06

< .001

.42

.52

.48

.11

.02

.50

.03

.01

.06

3.529

2.399

1.022

3.849

1.2140.800

1.035

1.331

1.284

2.7102.031

95% CI95% CI PP Hazard ratioHazard ratio

No diabetes Diabetes


in the multivariate model. Among covariates, age,

NYHA functional class, and depressive symptoms

were predictive of all-cause death.

When entered as a continuous value, BMI was

not predictive of all-cause death in patients with

diabetes in either univariate or multivariate models

(Table 4). Among covariates, older age, NYHA func-

tional class III/IV (vs class I/II), and higher levels of

depressive symptoms were associated with an increase

in risk for all-cause mortality.

Discussion We found that obesity was an independent

predictor of longer survival in patients with heart

failure who did not have concomitant diabetes.

However, in patients with concomitant diabetes,

obesity was not an independent predictor of sur-

vival. In most studies in which BMI was associated

with survival, diabetes was controlled or was not

considered,16-19 although diabetes is an important

comorbid condition associated with obesity and

poor prognosis in heart failure.2,7,8 Our findings

add to the literature because diabetes was taken

into account as an effect modifier of the relationship

between obesity and survival.

The lack of an association between higher

BMI and survival has been observed in heart failure

patients with comorbid diabetes in other studies.20-22

Our results update those findings in 2 aspects. In

the study of Pinho et al,21 the sample consisted solely

of heart failure patients with reduced ejection frac-

tion, whereas we found the same relationship in

patients with either preserved or reduced ejection

fraction. In the study of Adamopoulos et al,20 the

sample was from the Digitalis Investigation Group

trial in which the data were collected before

-blockers were a standard therapy for heart failure;

we found the same relationship in patients in the

era of -blocker treatment.

Our finding that obesity was associated with

longer survival in heart failure patients without dia-

betes, but not in heart failure patients with diabetes,

is intriguing. However, the mechanism of this inter-

esting finding is poorly understood. In an epidemio-

logical study23 in which participants were followed

up for 25 years, cardiovascular mortality was com-

pared between normal-weight participants and over-

weight or obese participants with and without risk

factors associated with obesity (ie, hypertension,

diabetes, and hypercholesterolemia). Of the 3 obesity-

related risk factors, the presence of diabetes alone

was not associated with an increase in cardiovascular

mortality among overweight or obese participants

compared with normal-weight participants without

the 3 obesity-related risk factors. However, in patients

who had diabetes along with hypertension or hyper-

cholesterolemia or both, the risk for cardiovascular

mortality was significantly greater in overweight and

obese participants than in normal-weight partici-

pants.23 These findings indicate that the significant

positive relationship between BMI and poor disease

prognosis is only intact when this relationship is

investigated in the context of diabetes in conjunc-

tion with other factors related to metabolic

Characteristic

Table 4Cox regression model for the effect of body mass index (continuous variable) on all-cause mortality according to presence or absence of diabetes

Univariate model Body mass indexa

Multivariate model Age

NYHA class III/IV (vs I/II)

Intervention groups (vs control group) Intervention arm I Intervention arm II

Depressive symptoms

B-type natriuretic peptideb

Creatinineb

Body mass indexa

Abbreviation: NYHA, New York Heart Association. a Calculated as weight in kilograms divided by height in meters squared.b Values of B-type natriuretic peptide and creatinine were log-transformed.

0.929-1.000

1.002-1.063

1.623-5.495

0.709-3.2030.539-2.762

1.018-1.111

0.984-1.549

0.690-3.298

0.935-1.009

.05

.04

< .001

.55

.29

.63

.01

.07

.30

.13

0.964

1.032

2.985

1.5071.221

1.063

1.234

1.508

0.971

0.892-0.972

1.002-1.047

2.164-6.711

0.663-2.1400.419-1.463

0.990-1.076

1.066-1.698

0.605-2.515

0.909-0.998

.001

.03

< .001

.42

.59

.44

.14

.01

.56

.04

0.931

1.024

3.802

1.1910.783

1.032

1.346

1.234

0.952

95% CI95% CI PP Hazard ratioHazard ratio

No diabetes Diabetes


disturbances (eg, hypertension). Therefore, among

heart failure patients most likely to have metabolic

abnormalities, diabetes may attenuate the protective

effect on mortality of being overweight or obese.

Adamopoulos et al20 have suggested that diabetes

is a stronger predictor of mortality than is obesity

and thus might negate a favorable effect of obesity

on the outcome. This suggestion may be supported

by the opposite relationships of BNP with diabetes

(positive relationship) and with obesity (negative

relationship). Thus, the positive impact of obesity

on survival may be cancelled out by the negative

impact of diabetes.

BNP, a neurohormone released from cardiomy-

ocytes in response to stretching of the ventricular

wall, is a significant predictor of poor prognosis in

heart failure.24 Consistent with our findings, in other

studies,4,25 BNP levels decreased with increasing BMI.

Although circulating BNP levels are lower in over-

weight or obese patients than in underweight to

normal-weight patients, levels of BNP are predictors

of mortality in all BMI groups.4,25,26 The prognostic

values of BNP associated with poor prognosis may

differ among BMI groups. Horwich et al26 reported

that the cutoff values of BNP associated with 1-year

mortality were smaller in obese patients with heart

failure (343 pg/mL) than in underweight to nor-

mal-weight patients with heart failure (590 pg/mL).

Because diabetes contributes to an increase in levels

of BNP,27,28 the cutoff values of BNP related to mor-

tality may change in the presence of comorbid dia-

betes in patients with heart failure. Although we do

not know the additive effect of comorbid diabetes

on increase in BNP concentration, the association

between BNP and survival in heart failure patients

with diabetes may be weaker than the association in

heart failure patients without diabetes. In our study,

BNP levels were predictive of all-cause mortality in

heart failure patients without diabetes, but not those

with diabetes.

However, some findings suggest that diabetes is

not a stronger predictor for mortality than is obesity.

In patients with acutely decompensated heart failure,

simultaneous entry of diabetes and BMI in the Cox

regression model indicates that BMI is an indepen-

dent predictor of mortality, whereas diabetes is not.4

Thus, the mechanism of the lack of the paradoxical

protective role of higher BMI in heart failure patients

with diabetes is not clearly understood.

Although diabetes is a common comorbid con-

dition in patients with heart failure,7,8 no systematic

investigations to improve the management of heart

failure patients with concomitant diabetes have been

done.29 Our findings suggest that management of

subgroups of heart failure patients, such as those with

diabetes, should include consideration of unique

aspects of the patients’ comorbid conditions.

Limitations Obesity was defined on the basis of BMI in our

study. A range of methods to assess adiposity are

available, including waist circumference, waist-to-hip

ratio, skinfold thickness, dual-energy x-ray absorp-

tiometry, and bioelectrical impedance analysis.30

Although dual-energy x-ray absorptiometry and bio-

electrical impedance analysis are reliable techniques

for assessing body composition, they are costly and

their availability is limited.30 Anthropometric tech-

niques such as BMI, waist circumference, and waist-to-

hip ratio are easy to measure but have limited accuracy

and reliability due to assessors’ skills.30 However,

some studies16,31 have indicated

that BMI is a reliable measure-

ment for assessment of body

fat in persons who are not

actively engaged in bodybuild-

ing exercise. We did not collect

data on changes in body weight

or unintentional weight loss.

However, we excluded patients

who were underweight in our analysis to minimize

the potential effect of cachexia. Some research32-35

suggests that cardiorespiratory fitness is a potential

confounding factor that explains the obesity para-

dox in heart failure. However, we did not collect

data on physical fitness. Because data on metabolic

control of diabetes were not collected, the effect of

glycemic control in diabetic patients on outcomes

could not be assessed.

Conclusion In conclusion, obesity was associated with longer

survival in heart failure patients without comorbid

diabetes but not in patients with comorbid diabetes.

More studies are needed to understand the underly-

ing mechanisms of the difference in the relationship

between obesity and survival in patients with heart

failure who have diabetes in order to effectively

improve the patients’ outcomes. Our findings sug-

gest the importance of considering the uniqueness

of subgroups of patients with heart failure in man-

agement because patients with heart failure are a

heterogeneous group.

FINANCIAL DISCLOSURESThis research was supported by RO1HL083176, Improving

Different subgroups of patients with heart failure require different management.


Self-Care Behavior and Outcomes in Rural Patients With Heart Failure, from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research.


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3. Oreopoulos A, Padwal R, Kalantar-Zadeh K, Fonarow GC, Norris CM, McAlister FA. Body mass index and mortality in heart failure: a meta-analysis. Am Heart J. 2008;156(1):13-22.

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8. Aguilar D, Deswal A, Ramasubbu K, Mann DL, Bozkurt B. Comparison of patients with heart failure and preserved left ventricular ejection fraction among those with versus without diabetes mellitus. Am J Cardiol. 2010;105:373-377.

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16. Clark AL, Fonarow GC, Horwich TB. Waist circumference, body mass index, and survival in systolic heart failure: the obesity paradox revisited. J Card Fail. 2011;17(5):374-380.

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19. Fonarow GC, Srikanthan P, Costanzo MR, Cintron GB, Lopa-tin M; ADHERE Scientific Advisory Committee and Investi-gators. An obesity paradox in acute heart failure: analysis of body mass index and inhospital mortality for 108 927 patients in the Acute Decompensated Heart Failure National Registry. Am Heart J. 2007;153(1):74-81.

20. Adamopoulos C, Meyer P, Desai RV, et al. Absence of obe-sity paradox in patients with chronic heart failure and dia-betes mellitus: a propensity-matched study. Eur J Heart Fail. 2011;13(2):200-206.

21. Pinho E, Lourenco P, Silva S, et al. Higher BMI in heart fail-ure patients is associated with longer survival only in the absence of diabetes. J Cardiovasc Med (Hagerstown). 2015;16(8):576-582.

22. Khalid U, Ather S, Bavishi C, et al. Pre-morbid body mass index and mortality after incident heart failure: the ARIC study. J Am Coll Cardiol. 2014;64(25):2743-2749.

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25. Stavrakis S, Pakala A, Thomas J, Chaudhry MA, Thadani U. Obesity, brain natriuretic peptide levels and mortality in patients hospitalized with heart failure and preserved left ven-tricular systolic function. Am J Med Sci. 2013; 345(3): 211-217.

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27. van der Horst IC, de Boer RA, Hillege HL, Boomsma F, Voors AA, van Veldhuisen DJ. Neurohormonal profile of patients with heart failure and diabetes. Neth Heart J. 2010; 18(4): 190-196.

28. Magnusson M, Melander O, Israelsson B, Grubb A, Groop L, Jovinge S. Elevated plasma levels of Nt-proBNP in patients with type 2 diabetes without overt cardiovascular disease. Diabetes Care. 2004; 27(8):1929-1935.

29. von Haehling S, Lainscak M, Doehner W, et al. Diabetes mellitus, cachexia and obesity in heart failure: rationale and design of the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF). J Cachexia Sarcope-nia Muscle. 2010;1(2):187-194.

30. Cornier MA, Despres JP, Davis N, et al; American Heart Asso-ciation Obesity Committee of the Council on Nutrition; Physi-cal Activity and Metabolism; Council on Arteriosclerosis; et al. Assessing adiposity: a scientific statement from the American Heart Association. Circulation. 2011;124(18): 1996-2019.

31. Wang Y, Rimm EB, Stampfer MJ, Willett WC, Hu FB. Com-parison of abdominal adiposity and overall obesity in pre-dicting risk of type 2 diabetes among men. Am J Clin Nutr. 2005;81:555-563.

32. Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. Fitness vs fatness on all-cause mortality: a meta-analysis. Prog Cardiovasc Dis. 2014;56(4):382-390.

33. Clark AL, Fonarow GC, Horwich TB. Impact of cardiorespira-tory fitness on the obesity paradox in patients with systolic heart failure. Am J Cardiol. 2015;115:209-213.

34. Lavie CJ, Cahalin LP, Chase P, et al. Impact of cardiorespira-tory fitness on the obesity paradox in patients with heart failure. Mayo Clin Proc. 2013;88(3):251-258.

35. Lavie CJ, McAuley PA, Church TS, Milani RV, Blair SN. Obe-sity and cardiovascular diseases: implications regarding fitness, fatness, and severity in the obesity paradox. J Am Coll Cardiol. 2014;63(14):1345-1354.




Background Electromagnetic devices to guide feeding tube placement such as the CORTRAK Enteral Access System have shown promising results; however, research-ers in recent studies have expressed concern that a higher level of user expertise may be required for safe use.Objectives To review adverse events related to CORTRAK- assisted feeding tube insertion reported in the Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database.Methods A retrospective, secondary analysis of the MAUDE database was performed to evaluate adverse events (ie, injury or death of patient) related to CORTRAK.Results Fifty-four adverse events between January 1, 2006 and February 29, 2016 were identified and reviewed. Most events (98%) involved feeding tube placement in the lungs (37%, left lung; 46%, right lung; 15%, not speci-fied). Lung complications included pneumothorax (77%) and pneumonitis (21%). Death occurred in 17% of lung placements. Clinicians failed to recognize placement in 89% of CORTRAK insertion tracings reviewed.Conclusions Lung placement is not unique to CORTRAK and is an inherent risk of all feeding tube insertions. In known or suspected lung placement, feeding tubes should be removed and radiography performed to assess for pneumothorax. Clinicians must observe closely for lung placement and discriminate lung from gastric place-ment on insertion tracings. Clinicians require specialized training and experience to develop competency in using the CORTRAK device, although the exact amount of expe-rience needed is unknown. (American Journal of Critical Care. 2017; 26:149-156)

CORTRAK-ASSISTED FEEDING TUBE INSERTION:A COMPREHENSIVE REVIEW OF ADVERSE EVENTS IN THE MAUDE DATABASEBy Annette M. Bourgault, RN, PhD, CNL, Lillian Aguirre, CNS, DNP, CCRN, CCNS, and Joseph Ibrahim, MD


Small-bore, styleted feeding tubes are used to provide nutrition to acute and critically ill patients, yet safe placement of such tubes at the bedside remains a challenge.1,2 Insertion of feeding tubes may be performed blindly, with visualization using ultra-sound or endoscopy, or with use of a real-time visual aid such as an electromagnetic placement device. Practice guidelines recommend radiographic confirmation as the

gold standard to verify placement of all feeding tubes in adults.3-6

Some researchers have expressed

concern that COR-TRAK requires a

high level of user expertise to be

used safely.

CORTRAK Enteral Access System (EAS), manu-

factured by CORPAK MedSystems, Inc (recently

acquired by Halyard Health), is a device that aids

in feeding tube insertion by using an electromag-

netic signal. It is the only device currently approved

by the US Food and Drug Administration (FDA) to

confirm tip location of feeding tubes placed by qual-

ified operators using the device, in lieu of a radio-

graph.7 The CORTRAK device uses

an electromagnetic signal that is

sent by a transmitter at the distal

end of the feeding tube stylet to a

receiver unit, which is positioned

on the patient’s chest at the xiphoid

process (corresponding to the base

of the diaphragm) with the patient

lying supine. The signal is then

triangulated and the tip of the

styletted feeding tube is tracked

on a portable monitor as the tube

is orally or nasally inserted and

advanced to the desired location in the gastrointes-

tinal tract.8,9 The newest version, CORTRAK 2 EAS

(marketed in 2012), provides both an anterior and a

lateral depth positioning screen, allowing the user to

view left/right and anterior/posterior tube migration.9

Typical anterior-view CORTRAK insertion trac-

ings based on normal anatomical structures can be

observed in Figure 1. The anterior view is divided

into quadrants that represent the left and right side

of the patient’s body (vertical axis) and the diaphragm

(horizontal axis).9 On the insertion tracing, feeding

tubes viewed to the right of the vertical axis typically

indicate placement in the right main bronchus. Devi-

ation to the left side of the vertical axis may occur with

either placement in the left main bronchus (unin-

tended) or gastric placement (intended); however,

left lung placement is typically visualized in the

upper left quadrant. In addition to the anterior view,

a lateral view provides 3-dimensional visualization

to assist with assessment of lung placement. The ana-

tomical position of the lungs is anterior (closer to

the chest wall) when compared with gastric or post-

pyloric placement.

When a feeding tube is misdirected into the

pulmonary system, the benefit of CORTRAK is a

real-time visual tracing, which when interpreted

properly, prompts users to withdraw the tube and

reinsert it into the esophagus.10,11 Despite this advan-

tage, in a recent review of studies of electromagnetic

placement devices, researchers expressed concern

that a higher level of user expertise may be required

for safe use of this device.12 Because other verifica-

tion methods for blindly inserted feeding tubes, such

as pH measurement, capnography, visualization

of gastric aspirate, and assessment for respiratory

distress lack validity, it is imperative to establish an

accurate and reliable method for verifying feeding

tube insertion at the bedside. Auscultation (air bolus)

and water bubbling methods should no longer be

used for verification of feeding tube placement

because those methods are inaccurate.1,2,13 The COR-

TRAK electromagnetic placement device has shown

promising results for accurate placement of feeding

tubes in the small bowel when operated by highly

trained and experienced users.14 A documented

growing clinical concern regarding safe use led to

our review of CORTRAK-related adverse events to

gain a better understanding.

Purpose The purpose of this study was to review adverse

events related to the use of CORTRAK for feeding

tube insertion as reported in the FDA’s Manufacturer

and User Facility Device Experience (MAUDE)

About the AuthorsAnnette M. Bourgault is an assistant professor, University of Central Florida, College of Nursing, and a nurse scien-tist, Orlando Health, Orlando, Florida. Lillian Aguirre is a clinical nurse specialist in trauma critical care, Orlando Regional Medical Center, a part of Orlando Health, Orlando, Florida. Joseph Ibrahim is trauma medical director and associate program director, Orlando Regional Medical Center, a part of Orlando Health.

Corresponding author: Annette M. Bourgault, RN, PhD, CNL, University of Central Florida College of Nursing, 12201 Research Parkway, Suite 300, Orlando, FL 32826 (e-mail: [email protected]).


database.15 The web-based MAUDE database is a

voluntary, open-access data repository of events.

Clinicians can submit adverse event reports related

to the use of medical devices. An adverse event is

defi ned as an incident that has resulted in death or

serious injury to a patient. The manufacturer has the

opportunity to provide a narrative follow-up for each

report. Examples of verbatim event descriptions from

the MAUDE database have been reported.12

Methods A retrospective, secondary analysis of the MAUDE

database was performed for the past 10 years. This

time period was selected because the MAUDE data-

base retains reports for a 10-year period. Inclusion

criteria included reports that indicated use of COR-

TRAK for feeding tube insertion from January 1, 2006

to February 29, 2016. Eighty reports were located when

the term CORTRAK was entered into the MAUDE

database under the brand name heading. When

CORPAK was used as a search term under the man-

ufacturer heading, a total of 273 results were retrieved.

All 273 reports were manually reviewed, and an

additional 10 reports were identifi ed and met inclu-

sion criteria. An advantage of performing a second-

ary search using the manufacturer’s name was the

ability to capture reports with spelling errors and less

frequently used terminology. The following brand-

name headings were used by the 10 additional reports

located under CORPAK: Keofeed tube (3); Cortak

2 EAS SYS (1), Cortrax enteral feeding tube (1),

CORPAK II enteral access system keofeed (1), Corfl o

feeding tube with transmitting stylet (1), Corfl o

NG tube (2), and Cortrack enteral access system (1).

Other search terms (electromagnetic sensing device

and enteral feeding tube) were used with no additional

reports located. A total of 90 CORTRAK adverse event

reports were located for the period from January 1,

2006 to February 29, 2016; 36 reports were excluded

from the fi nal analysis because they did not meet

inclusion criteria (Figure 2). Event descriptions were

reviewed in detail to ensure that all included reports

used the CORTRAK device. Our review examined all

fi elds, including comments from clinicians who sub-

mitted the report and responses by the manufacturer,

CORPAK MedSystems, Inc.

Results A total of 54 adverse events related to CORTRAK-

assisted insertions of feeding tubes as reported in

the MAUDE database were reviewed (Figure 3). The

location of these occurrences is unknown. Ninety-

eight percent (53/54) reported feeding tube placement

in the lung; 37% (20/54) of tubes were placed in

the left lung, 46% (25/54) were placed in the right

lung, and another 15% (8/54) of tubes were placed

in the lung with the specifi c lung laterality not dis-

closed. The majority of lung placements resulted in

complications: pneumothorax in 77% (41/53),

pneumonitis in 21% (11/53), and 1 unidentifi ed

complication. Tension pneumothorax was reported

in 2 cases. Seventeen percent (9/53) of tubes with

lung placement led to the patient’s death. Patients’

deaths were attributed to both pneumothorax and


Figure 1 CORTRAK insertion tracings: anterior view.

Reprinted with permission of CORPAK MedSystems, Inc.

Left mainstem bronchus Right mainstem bronchus Gastric


pneumonitis. One report indicated an abnormal

placement other than the lung; the feeding tube was

inserted into the trachea, resulting in tracheal hem-

orrhage and death.

In 89% (48/54) of the reports, information

about the insertion tracing was either omitted or

the user failed to recognize placement outside the

gastrointestinal tract in the insertion tracing. Two

users indicated that they had aborted the feeding

tube attempt following lung placement observed

on the insertion tracing. Seven percent (4/54) of

users indicated device-related issues that made it

impossible for them to view the insertion tracing

(artifact [2], out of range [1], not detected [1]).

Three of the 4 described illegible insertion tracings

were retrieved by the manufacturer, who indicated

that they showed placement of the tube either in a

lung or outside the gastrointestinal tract. One report

indicated that the use of CORTRAK was aborted

because no insertion tracing was detected, and the

feeding tube was inserted blindly; manufacturer

assessment of the device determined that it was

functioning normally and questioned user error.

The report just described was included in this review

because it is unknown if the injury occurred while

CORTRAK was in use. Another user reported duode-

nal placement on the insertion tracing, although

Figure 2 Inclusion/exclusion criteria for CORTRAK adverse event reports.

Total CORTRAK reports 90

Included 54

Deaths 10

Injuries 44

Excluded 36

Faulty tube 12

Tube removed: no injury

3

Duplicate record 9

Stylet error message 2

Not related to CORTRAK feeding tube insertion

7

Pediatric 3

Figure 3 CORTRAK adverse events reported in Manufacturer and User Facility Device Experience (MAUDE) database. Abbreviations: admin, administration; med, medication; pneumo, pneumothorax.

Adverse events 54

Left lung 20

Right lung 25

Lung not identified 8

Trachea 1

Injury 0

Injury 6

Injury 24

Injury 14

Death 1

Death 2

Death 1

Death 6

Formula/med admin

1

Formula/med admin

3

Formula/med admin

1

Formula/med admin

2

Formula/med admin

1

Formula/med admin

3

Pneumo 5

Pneumo 11

Pneumo 0

Pneumo 22

Pneumo 1

Pneumo 2

Bleeding 1

Not identified 1


radiography confirmed lung placement; unfortu-

nately, no response from the manufacturer was

available at the time of this review.

Fifty percent (27/54) of the reports indicated

that no insertion tracing was provided by the clinician

for the manufacturer to review, although attempts

had been made to retrieve this information.

Discussion Lung placement is the most frequent adverse

event reported in the MAUDE database that leads

to injury or death of patients after placement of a

feeding tube. Almost half of the identified lung

placements were reported as in the left lung. The

right main bronchus is anatomically wider, shorter,

and more vertical than the left main bronchus,16 so

the frequency of reported left lung placements is an

unexpected finding. When the CORTRAK insertion

tracing deviates toward the left quadrant during feed-

ing tube insertion, inexperienced clinicians may

overlook this finding if they anticipate gastrointes-

tinal placement. The advantage of having real-time

insertion data is the ability to recognize early devi-

ation of the feeding tube into either main bronchus

and to withdraw the tube before it advances into

the lung.

It is unknown why clinicians failed to respond

to the abnormal insertion tracings, although lack

of experience may have played a role. A few reports

described artifact in the insertion tracings that led

clinicians to doubt their interpretation of the data.

Moreover, 20% (11/54) of the reports indicated that

formula and/or medications had been instilled

through the feeding tube. It is possible that some

adverse events could have been avoided if a second

trained clinician had performed an assessment or

if radiographic confirmation had been performed

when there was concern about the position of the

tube. The manufacturer indicated that insertion

tracings were not consistent with gastrointestinal

placement in 4 of the 11 reports and insertion trac-

ings were unavailable for the manufacturer to

review for the remainder of the reports.

Lung placement is not unique to CORTRAK

and is an inherent risk of all feeding tube insertions,

especially in critically ill patients, who often have a

decreased level of consciousness and/or a decreased

gag reflex, both of which are barriers to insertion of

feeding tubes in the gastrointestinal tract.17 At least

6 of the adverse event reports identified multiple

insertion attempts, and all 6 resulted in pneumotho-

races. The majority of adverse events reported in the

MAUDE database suggested that users were unable

to identify feeding tube placement outside of the

gastrointestinal tract. As described by Metheny and

Meert,12 skill of the clinician is an important vari-

able to consider for CORTRAK-assisted insertions

of feeding tubes. It is important to point out, how-

ever, that errors in confirmation of feeding tube

placement have also been made by misinterpretation

of radiographs,12,18 often when interpretation was

performed by someone other than a trained radiolo-

gist. Institutions reporting favorable outcomes of

use of CORTRAK to insert feeding tubes have recom-

mended the use of superusers.10,17,19 Superusers are

clinicians who have received specialized training on

the CORTRAK system. These superusers develop and

maintain their expertise by performing CORTRAK-

assisted feeding tube insertions on a regular basis.

Additional research is necessary to determine the

optimal level of training and expertise for CORTRAK

superusers to develop and maintain competency.

Metheny and Meert12 also suggested that ana-

tomical abnormalities, a confounding variable for

all feeding tube insertions, may be unknown or

underrecognized by clinicians. In a retrospective

study of 188 tubes placed by using CORTRAK, Bry-

ant et al20 reported that 2% (3/188) resulted in lung

placement errors. Feeding tubes were inserted by

trained nurses, although the amount of training and

experience with feeding tube insertion was inconsis-

tent; nurses received 30 to 120 minutes of classroom

training, but some had no supervised clinical place-

ments.20 Bryant et al reported

that all 3 lung placements were

not identified on the CORTRAK

insertion tracings, and yet these

feeding tubes were confirmed

to be in the lung by radiogra-

phy. When the radiograph was

obtained, the distal tips of all 3

feeding tubes were visualized in

the lower left quadrant of the

CORTRAK insertion tracing,

which is an unexpected location

for tubes placed in the lung.

CORTRAK insertion tracings

were also retrospectively and independently viewed

by 2 nurse researchers who confirmed the tube’s

position in the lower left quadrant. Unfortunately,

Bryant et al did not discuss the patients’ anatomy,

the position of the CORTRAK receiver unit, or the

timing of initiation of the CORTRAK tracing, all of

which influence the insertion tracing.

Most adverse events were lung placements that led to pneumotho-races or inadvertent feeding/medication administration into the lungs.


An institutional process should

be developed for procedural docu-

mentation and performance improvement

opportunities.

Recommendations for Practice Patient safety is the primary consideration if

there is any doubt about possible lung intubation.

In the event of known or suspected lung placement,

the feeding tube should be removed and a radio-

graph obtained to assess for pneumothorax before

continuing with feeding tube insertion.6 Although

CORTRAK has been approved by the FDA for confir-

mation of feeding tube placement,7 clinical judg-

ment should guide practice.

We also recommend that institutional policies

include confirmation by a second superuser in addi-

tion to an alternate validated confirmatory method

when there is any uncertainty about feeding tube

placement. Alternative confirmatory methods iden-

tified in the American Association of Critical-Care

Nurses (AACN) practice alert on verification of feed-

ing tube placement in adults include observation

for signs of respiratory distress, capnography, pH

measurement of aspirate, and/or visual observation

of aspirate.6

The manufacturer’s response to a number of

reports in the MAUDE database stated that the

insertion tracing showed either lung placement or

was atypical of gastrointestinal placement, which

indicated that the user failed to identify or respond

to the incorrect tube placement. Moreover, clinicians

should observe the real-time CORTRAK insertion

tracing for the duration of the tube

insertion process rather than rely-

ing on the stationary graphic that

is produced when the tube is in

its final position. Use of simula-

tion to mimic real-life situations

may be beneficial for training and

competency assessment of supe-

rusers for this high-risk skill.21

Additionally, an institutional

process should be developed for

procedural documentation and

performance improvement oppor-

tunities. A copy of the CORTRAK

insertion tracing should be included

in the patient’s permanent record for all CORTRAK-

assisted insertions of feeding tubes. Furthermore, an

electronic file of the insertion tracings should be

saved with the patient’s record to allow retrospective

review following adverse events. To ensure availabil-

ity of insertion tracings following feeding tube inser-

tion, it is important that the clinician use the accounts

mode of operation. Two MAUDE reports stated that

CORTRAK was operated in the anonymous mode.

Unfortunately, the anonymous operation mode

retains insertion tracings in a temporary file for

viewing on the placement screen, so once the user

exits the placement screen, tracings are unavailable

for retrospective analysis. The anonymous mode

allows clinicians to bypass data entry, such as login

ID and patient identifiers. Because feeding tube

insertion is not an emergent procedure and clini-

cians using the device require training, the accounts

mode should be considered a standard of practice.

Institutions can develop policies to mitigate any

concerns about security of patient data entered into

the CORTRAK device. Use of the accounts mode

will ensure that insertion tracings can be retrieved

at a later time if required.

In a number of reports, the manufacturer’s

response indicated that the insertion tracing was

not initiated when the tube insertion began. One

response indicated that the insertion tracing may

also appear to be delayed because of improper posi-

tioning of the receiver unit. Because positioning of the

receiver unit is critical to the accuracy of the insertion

tracing, it is important to include this information

as part of the CORTRAK user training. Additionally,

the tracing should be initiated once the feeding

tube has been inserted 5 to 10 cm into the patient

to readily identify any deviation into the lung.9

Training of CORTRAK users has been variable

and poorly described in the literature. Training

often included a combination of didactic and clini-

cal observation of CORTRAK-assisted insertions of

feeding tubes. Didactic training ranged from policy

review and a training video11 to classroom educa-

tion 30 to 120 minutes in length.20,22 Competency

assessment of CORTRAK-assisted insertions of feed-

ing tubes fluctuated from 0 to 10 clinical observa-

tions,20 although 2 or 3 observations appeared to

be most common.11,22,23

As with any medical device, if there are concerns

about the safety or functionality of the product, the

device should be removed from service until it can

be assessed and/or repaired.

Recommendations for Adverse Events Reporting

We emphasize safe clinical practice and proper

use of the CORTRAK device by trained users to pre-

vent adverse events. Yet, when an adverse event

occurs, users of a device contributing to or causing

serious injury or death of a patient must submit a

report to the FDA and the manufacturer. Forms to

create FDA device reports are located online.24

The FDA MAUDE database can be a valuable

tool to obtain device-related information; however,


the device reports often lack essential details to deter-

mine the cause of the event.25 After a thorough review

of all adverse events (deaths and injuries) related to

CORTRAK-assisted insertion of feeding tubes, we

recommend that health care providers include the

following additional information in the required

fields to improve the quality of these reports:

• Clinician’s interpretation of CORTRAK inser-

tion tracing.

• Experience of the clinician inserting the feed-

ing tube.

• Secondary review of the insertion tracing by

an experienced CORTRAK user (if applicable).

• Any barriers to optimal placement of the

receiver unit, such as high body mass index, ana-

tomical abnormalities, bulky abdominal dressings,

or devices such as a halo vest.

Conclusions A retrospective, secondary analysis of the FDA’s

MAUDE database was done to review adverse events

related to the use of CORTRAK for feeding tube

insertion. The majority of adverse events were lung

placements that led to pneumothoraces or inadver-

tent feeding/medication administration into the

lungs. Clinicians need to become skilled at inter-

pretation of CORTRAK insertion tracings, remain

alert for lung placement errors (particularly anterior

and lateral views), and maintain documentation of

successful and failed attempts at feeding tube inser-

tion. Risk for lung placement and pneumothoraces

is inherent to feeding tube insertions and is not spe-

cific to use of the CORTRAK device.

It is important to note that MAUDE database

reports are voluntary and thus events are most likely

underreported. The number of errors in CORTRAK-

assisted feeding tube placements reviewed in this

analysis is most likely an underestimation of the

actual number of such events. A device itself cannot

guarantee safe practice; use of the CORTRAK device

has yielded accurate placement results with highly

trained and experienced users. Additional research

is indicated to evaluate the amount of training and

clinical expertise required for safe and competent

use of this device.



SEE ALSO For more about feeding tube placement visit the Critical Care Nurse website, www.ccnonline.org, and read the AACN Practice Alert, “Initial and Ongoing Verification of Feeding Tube Placement in Adults” (April 2016).

REFERENCES1. Bourgault AM, Heath J, Hooper V, et al. Methods used by

critical care nurses to verify feeding tube placement in clin-ical practice. Crit Care Nurse. 2015;35(1):e1-e7.

2. Metheny NA, Stewart BJ, Mills AC. Blind insertion of feed-ing tubes in intensive care units: a national survey. Am J Crit Care. 2012;21(5):352-360.

3. Itkin M, DeLegge MH, Fang JC, et al. Multidisciplinary prac-tical guidelines for gastrointestinal access for enteral nutri-tion and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interven-tional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Gastroenterology. 2011;141(2):742-765.

4. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.

5. National Health System. Patient safety alert: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. National Health Service Web site. http://www.nrls.npsa.nhs.uk/resources/?EntryId45 = 129640. March 2011. Accessed December 5, 2016.

6. American Association of Critical-Care Nurses (AACN). Initial and Ongoing Verification of Feeding Tube Placement in Adults. http://www.aacn.org/wd/practice/content/feeding-tube-practice-alert.pcms?menu=practice. 2016. Accessed December 5, 2016.

7. US Food and Drug Administration (FDA). CORTRAK Enteral Access Device approval letter K091637. Silver Spring, MD: FDA; September 8, 2009.

8. CORPAK MedSystems, Inc. and Royal College of Nursing, CORTRAK Trainee Booklet. CORTRAK Training website. http://www.cortrakuktraining.com/downloads/CORT1401 %20trainee%20brochure%2013.1.15.pdf. 2015. Accessed December 5, 2016.

9. CORPAK MedSystems, Inc. CORTRAK 2 Enteral Access System Operator’s Manual. Buffalo Grove, IL: CORPAK Medsystems Inc; 2011.

10. Rivera R, Campana J, Hamilton C, et al. Small bowel feeding tube placement using an electromagnetic tube placement device: accuracy of tip location. JPEN J Parenter Enteral Nutr. 2011;35(5):636-642.

11. Gray R, Tynan C, Reed L, et al. Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique? Nutr Clin Pract. 2007; 22 (4):436-444.

12. Metheny NA, Meert KL. Effectiveness of an electromagnetic feeding tube placement device in detecting inadvertent respiratory placement. Am J Crit Care. 2014;23(3):240-248.

13. Metheny N, McSweeney M, Wehrle, MA, et al. Effectiveness of the auscultatory method in predicting feeding tube loca-tion. Nurs Res. 1990;39(5):262-267.

14. Gerritsen A, van der Poel MJ, de Rooij T, et al. Systematic review on bedside electromagnetic-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes. Gastrointest Endosc. 2015;81(4):836-847.

15. US Food and Drug Administration (FDA). Manufacturer and User Facility Device Experience (MAUDE) Database. FDA website. http://www.fda.gov/MedicalDevices/DeviceRegula-tionandGuidance/PostmarketRequirements/ReportingAd-verseEvents/ucm127891.htm. Accessed December 5, 2016.

16. Hansen JTA, Netter FHI. Netter’s Clinical Anatomy. 3rd ed. Philadelphia, PA: Saunders; 2014.

17. Koopmann MC, Kudsk KA, Szotkowski MJ, et al. A team-based protocol and electromagnetic technology eliminate feeding tube placement complications. Ann Surg. 2011; 253 (2):287-302.

18. Rollins H, Arnold-Jellis J, Taylor A. How accurate are X-rays to check NG tube positioning? Nurs Times. 2012;108(42):14-16.

19. Powers J, Luebbehusen M, Spitzer T, et al. Verification of an electromagnetic placement device compared with


abdominal radiograph to predict accuracy of feeding tube placement. JPEN J Parenter Enteral Nutr. 2011;35(4):535-539.

20. Bryant V, Phang J, Abrams, J. Verifying placement of small-bore feeding tubes: electromagnetic device images versus abdominal radiographs. Am J Crit Care. 2015;24(6):525-531.

21. Hagler D, Wilson R. Designing nursing staff competency assessment using simulation. J Radiol Nurs. 2013;32(4): 165-169.

22. Powers J, Fischer MH, Ziemba-Davis M, et al. Elimination of radiographic confirmation for small-bowel feeding tubes in critical care. Am J Crit Care. 2013;22(6):521-527.

23. October TW, Hardart GE. Successful placement of postpy-loric enteral tubes using electromagnetic guidance in criti-cally ill children. Pediatr Crit Care Med. 2009;10(2):196-200.

24. US Food and Drug Administration (FDA). Mandatory Report-ing Requirements: Manufacturers, Importers and Device User Facilities. http://www.fda.gov/MedicalDevices/DeviceRegula-tionandGuidance/PostmarketRequirements/ReportingAdver-seEvents/ucm2005737.htm. 2015. Accessed December 5, 2016.

25. Gurtcheff SE. Introduction to the MAUDE database. Clin Obstet Gynecol. 2008;51(1):120-123.


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Background Radiography is the accepted gold standard for testing feeding tube placement; however, an electro-magnetic tube-placement device (ETPD) is sometimes used in lieu of radiography for this purpose. High success rates have been reported when the device was used by well-trained individuals. However, authors previously described 20 cases that occurred between 2007 and 2012 in which clinicians voluntarily reported inability to detect inadvertent tube insertions in the respiratory tract while using an ETPD.Objective To describe case reports to the US Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database between 2013 and 2015 regarding inadvertent respiratory placement of feeding tubes by operators using an ETPD. Methods The MAUDE database was searched for cases dated from January 1, 2013, through December 31, 2015, along with selected brand names. A total of 34 cases (25 after removal of duplicates) were located in which a feeding tube was inserted into the respiratory tract during insertions assisted by an ETPD. Results Sites of the malpositioned tubes included the right lung (n = 13), left lung (n = 6), unspecified lung (n = 4), and bronchus (n = 2). A pneumothorax occurred in 17 of the 25 misplacements; feedings were administered in 6 cases.Conclusions Many case reports involved clinicians fail-ing to recognize tube misplacements in the respiratory tract while using an ETPD. These reports provide evidence that not all clinicians can use the device effectively to detect malpositioned tubes. Thus, one must continue to question the wisdom of eliminating radiographic confirmation of tube position before starting feedings. (American Journal of Critical Care. 2017; 26:157-161)

UPDATE ON EFFECTIVENESS

OF AN ELECTROMAGNETIC FEEDING TUBE–PLACEMENT

DEVICE IN DETECTING RESPIRATORY PLACEMENTSBy Norma A. Metheny, RN, PhD, and Kathleen L. Meert, MD


The gold standard for detecting inadvertent placement of a feeding tube in the lung is radiography. However, because of its cost, possible delay of feedings while wait-ing for radiography, and risk for radiation exposure in children, clinicians continue to search for alternative methods to confirm correct placement. Manufacturers of a commercially available electromagnetic device (CORTRAK 2 Enteral Access System;

CORPAK MedSystems) assert that their device can provide “confident placement without X-ray.”1

The prevalence of tube placements in

the lung is unknown as no central report-

ing site is required.


Authors of 2 clinical studies2,3 concluded that use

of an electromagnetic tube-placement device (ETPD)

may preclude the need for radiographs to detect

inadvertent respiratory placement of feeding tubes;

however, these authors also indicated that their pos-

itive results were partly dependent on the skill level

of the individuals who placed the tubes. The extent to

which less highly trained clinicians can use the device

to detect inadvertent respiratory misplacements is

difficult to determine because there is no required

central reporting site for adverse events. Furthermore,

little information is available about the extent of

training required to use an ETPD effectively.

One report4 described difficulty experienced by

a variety of intensive care unit clinicians (eg, registered

nurses, physicians, and dietitians)

in using tracings from an ETPD to

determine when tubes were placed

postpylorically. These individuals

had undergone a 3-hour in-service

training session with a represen-

tative from the ETPD manufac-

turer, followed by 3 attempted

placements under direct supervi-

sion of an expert before being

allowed to place tubes independently with the device.

The authors of the report concluded that additional

training of providers on use of the device and inter-

pretation of the tracings or formation of a dedicated

tube-insertion team is needed.4

Some useful anecdotal information about adverse

events associated with medical devices in public,

private, and nonprofit hospitals is available on the

Food and Drug Administration’s Manufacturer and

User Facility Device Experience (MAUDE) database

website.5 In a 2014 publication,6 authors described

20 cases in which operators of an ETPD inadvertently

inserted feeding tubes into the respiratory tract

(these cases were reported between January 1, 2007,

and December 31, 2012). It should be noted that

the MAUDE database represents voluntary reports

of adverse events and thus cannot be used alone to

establish rates of events or evaluate a change in event

rates over time.5

In a retrospective study of an ETPD’s effective-

ness in determining tube location in 188 patients in

an acute care facility during 1 year (January 1, 2012,

through December 31, 2012), Bryant et al7 found

that 4 patients (2.1%) experienced inadvertent respi-

ratory placements. Nurses using the device did not

recognize the inadvertent respiratory placement of

the tubes (3 in the right lung and 1 in the left lung);

a pneumothorax that required insertion of a chest

tube occurred in 2 of the 4 patients. All the regis-

tered nurses who placed the tubes had documenta-

tion of some degree of initial training using the

ETPD; however, no documented evidence of stan-

dardized training or competency was reported.7

The purpose of this article is to summarize events

reported to the MAUDE database from 2013 through

2015 in which feeding tubes were inadvertently

placed in the respiratory tract while operators were

using an ETPD.

Methods The MAUDE search table5 was located on the

internet, and the time interval of the search was

entered (January 1, 2013, through December 31,

2015). Brand names were entered into the appro-

priate segment of the table to search for cases in

which operators using an ETPD inadvertently posi-

tioned tubes in the respiratory tract. Entering the

brand names “Cortrak” and “Cortrack,” we found

34 results indicating tube misplacements into the

lung or bronchus. These 34 cases were then screened

for duplications. Initial screening was based on nar-

rative similarity, exact matching of event dates, and

About the AuthorsNorma A. Metheny is a professor of nursing and holds the Dorothy A. Votsmier Endowed Chair in Nursing at Saint Louis University School of Nursing, St Louis, Missouri. Kathleen L. Meert is a professor of medicine in the Department of Pediatrics, Wayne State University, and chief, Division of Critical Care Medicine, Children’s Hospital of Michigan, Detroit, Michigan.

Corresponding author: Norma A. Metheny, RN, PhD, Saint Louis University School of Nursing, 3525 Caroline Mall, St Louis, MO 63104 (e-mail: [email protected]).


Serious complica-tions occurred in 17 of 25 patients whose caregivers failed to detect pulmonary placement of tubes using an ETPD.

duplicate identification report numbers. Duplicate

numbered reports were eliminated when event dates

and narratives also matched. Profiles were further

screened for exact matches by equipment model or

catalog number, manufacturing and device return

dates, as well as device operator and reporter iden-

tity details. Where duplicate reports were found, the

MAUDE identification number for the profile hav-

ing the most complete and/or detailed description

was retained.

Results Following these procedures, 25 profiles remained

in the database, and all involved feeding tubes inad-

vertently positioned in the respiratory tract by oper-

ators using an ETPD. Because the MAUDE database

relies on voluntary reports, this number should not

be construed as the incidence of malpositioned tubes

during this period. Placement sites of the malposi-

tioned feeding tubes included the right lung (n = 13),

left lung (n = 6), unspecified lung (n = 4), and bronchus

(n = 2). Seventeen of the 25 respiratory placements

resulted in a pneumothorax. Six of the 25 patients

received feedings via the malpositioned tubes. A ver-

batim description of 9 of the 25 cases is presented

in the Table. Space limitations in this brief report

prevented inclusion of all 25 cases; therefore, we

selected cases that provided the most detailed infor-

mation about whether feedings were administered

via the tube and/or specific patient outcomes.

Discussion Because the case reports varied in the amount

of detail provided, it is difficult to determine circum-

stances that may have contributed to the tube mis-

placements. One issue raised by Bryant et al7 is the

level of training provided to the clinicians who use

the ETPD. Only 2 of the 25 events identified in our

search alluded to training of personnel. One event

referred to the operator as a “Cortrak team nurse”

(implying a higher level of training than for a non-

team member). The description provided in case 4

(see Table) indicates that the method of placement

used was “consistent with training and policy”;

however, the extent of training was not described.

Several cases referred to difficulty experienced by

the operators in interpreting images displayed on the

device’s screen. For example, in case 4, the operator

indicated that the final tracing from the device was

consistent with duodenal placement even though

radiography showed bronchial placement with an

apical pneumothorax. In case 7, the event report stated

that the “feeding tube appeared to be in stomach

according to the screen”; however, a radiograph

showed the tube was actually in the left lung. Finally,

in case 8, although 2 nurses reportedly confirmed

proper placement using the ETPD, a later review of

the device’s tracings revealed the tube was in the lung

(unfortunately, this was not done until 4 hours after

feedings were initiated and symptoms developed).

Patient outcomes from the tube misplacements

were variable. As noted in case 5 (see Table), no

adverse outcome occurred in a patient whose tube,

inadvertently placed in the bronchus, was removed

immediately after detection by radiography (thus

avoiding introduction of feedings via the tube).

However, as indicated earlier, 17 of 25 patients had

a pneumothorax develop after their tube insertions.

In case 1 (see Table), the patient

coded but was resuscitated after

needle decompression and chest

tube placement to treat a tension

pneumothorax. Emergent chest

tube insertion was also required

for the patient described in case 7.

The patient described in case 6

had a decline in respiratory status

and became febrile after receiving

medications and tube feeding into

the chest cavity. Antibiotics and

ventilation were required for the

patient described in case 8, after the introduction

of feedings into the lung. The operator in case 9

indicated that death of the terminally ill patient was

accelerated by feed being administered via a naso-

gastric tube inadvertently positioned in the lung.

LimitationsA weakness of our review is our inability to

identify the prevalence of inadvertent respiratory

tube misplacements during use of an ETPD. To do

so, we would need to know the number of tubes

placed during the identified time period, as well

as the number of times they were incorrectly posi-

tioned in the lung. As indicated earlier, there is no

central reporting site for such complications. In

addition, we are unable to report standardized

training requirements for placement of tubes with

an ETPD because, to our knowledge, such require-

ments have not been identified.

Conclusion Numerous case reports involve clinicians using

an ETPD failing to recognize tube misplacements in

the respiratory tract.5-7 These reports provide evidence

that not all clinicians can use the device effectively to


detect malpositioned tubes. Thus, we and others

continue to question the wisdom of eliminating

radiographic confirmation of tube position before

starting feedings.6,7



SEE ALSO For more about feeding tube placement, visit the Critical Care Nurse website, www.ccnonline.org, and read the AACN Practice Alert, “Initial and Ongoing Verification of Feeding Tube Placement in Adults” (April 2016).

REFERENCES1. CORPAK MedSystems. CORTRAK fact sheet. http://www

.corpakmedsystems.com/supplement-material/cortrak-fact-sheet/. Accessed November 16, 2016.

2. Powers J, Luebbehusen M, Spitzer T, et al. Verification of an electromagnetic placement device compared with abdominal radiograph to predict accuracy of feeding tube placement. JPEN J Parenter Enteral Nutr. 2011;35(4):535-539.

Case No., event date Event type Event description

TableVerbatim description of 9 events

1 06/27/2013

2 08/16/2013

3 11/06/2013

4 02/07/2014

5 04/10/2014

6 08/08/2014

7 08/22/2014

8 07/16/2015

9 08/21/2015

Abbreviations: KUB, kidney-ureter-bladder radiograph; NG, nasogastric; pt, patient; RN, registered nurse.

Death

Injury

Death

No answer provided

Injury

Injury

Injury

Injury

Death

“During a placement of a cortrak feeding tube, a left lung placement was noted as confirmed by x-ray. The radiologist notified the physician of a tension pneumothorax. The patient coded but was resuscitated after a needle decompression and chest tube placement. No feed was administered into the lung. The patient did expire a few days after placement but was unrelated to tube placement.”

“Cortrak-assisted nasogastric tube feeding attempted 4 times and in all cases followed the same path. The cli-nician was not able to aspirate, and no x-ray was done to confirm placement. The patient was fed into the lung and developed respiratory complications. The tube was then confirmed as being in the lung.”

“Cortrak-assisted nasogastric tube insertion done. The nasogastric tube was placed in the right lung and feed was started.”

“A small-bore feeding tube was placed in this patient using the cortrak enteral feeding tube placement device. Method of placement was consistent with training and policy. Final tracing from cortrak device was consistent with duodenal placement. After obtaining KUB and chest x-ray, it was determined that the tube was bronchially placed. Patient was in no distress. The tube was removed. Patient had no physical decom-pensation of the intubation; however, a small apical pneumothorax was seen on the chest film, which did resolve in approximately 3 days.”

“A nasogastric tube placement using the cortrak on (b)(6) 2014, which resulted in placement in the right mainstem bronchus. It was detected in confirmation x-ray and removed immediately. No injury to pt. The pt had tolerated the procedure and did not exhibit signs or symptoms of distress.”

“The patient had a feeding tube placed using the cortrak system. The tube was placed in the lung in error. Medications and tube feeding were administered through the tube prior to the discovery that the tube was in the chest cavity. Patient had a decline in respiratory status and became febrile. The tube was removed. Shortly after the patient’s vital signs continued to decline and required a code blue resuscitation. The patient’s current status is unknown. No other information is available including the hospital name, product code, and lot number.”

“Dobhoff feeding tube was being inserted by RN using cortrak electronic guidance. Feeding tube appeared to be in stomach according to screen. KUB x-ray reading showed placement was in the left lung. The physi-cian was notified by radiologist. Dobhoff was removed (b) (6) at 0920 and patient developed a pneumotho-rax which required emergent chest tube insertion.”

“Cortrak NG feeding tube was inserted into the left lung while using a cortrak during tube placement. No as-pirate was noted but 2 nurses confirmed proper placement on Cortrak device. Patient fed but when patient starting looking unwell discussed with medical team and feed was stopped 4 hours later. A chest x-ray was done and the report was inconclusive of tube position. Upon cortrak review, it was revealed that the tube was in the lung. Patient ventilated and commenced on antibiotics.”

“A nasogastric feeding tube (ngt) was inadvertently placed into the lung of a patient resulting in a pneumo-thorax. Patient had terminal cancer; however, the clinician reported that the imminent death was acceler-ated by feed being inserted into the lung as a result of the ngt being placed in the lung. The clinician used a cortrak during the placement.”

3. Koopman MC, Kudska KA, Szotowski MJ, Rees SM. A team-based protocol and electromagnetic technology eliminate feeding tube placement complications. Ann Surg. 2011;25(3): 297-302.

4. Boyer N, McCarthy MS, Mount CA. Analysis of an electro-magnetic tube placement device versus a self-advancing nasal jejunal device for postpyloric feeding tube placement. J Hosp Med. 2014;9:23-28.

5. US Food and Drug Administration. Manufacturer and User Facility Device Experience Database (MAUDE). http://www .fda.gov/MedicalDevices/DeviceRegulationandGuidance /PostmarketRequirements/ReportingAdverseEvents /ucm127891 .htm. Accessed November 16, 2016.

6. Metheny NA, Meert KL. Effectiveness of an electromagnetic feeding tube placement device in detecting inadvertent respiratory placement. Am J Crit Care. 2014;23(3):240-248.

7. Bryant V, Phang J, Abrams K. Verifying placement of small-bore feeding tubes: Electromagnetic device images versus abdominal radiographs. Am J Crit Care. 2015;24(6):525-530.



https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=3263752









Left lung, pneumothorax

Lung

Right lung

Bronchial placement, apical pneumothorax

Right main bronchus

Lung

Left lung, pneumothorax

Lung

Lung, pneumothorax

WebsiteTube site

Commentary

ELECTROMAGNETIC TUBE-PLACEMENT DEVICE: THE REPLACEMENT FOR THE RADIOGRAPHIC GOLD STANDARD?By Julia Park, DO, Sylvia Krzeminski, MD, Joshua Tan, DO, MPH, Meghana Bandlamuri, and Richard W. Carlson, MD, PhD

Enteral feeding has been practiced for more

than 3500 years. The earliest records docu-

ment the use of reeds by the ancient Egyp-

tians, Indians, and Chinese to supplement

nutrition with various elements, such as

wine, milk, whey, and barley.1,2 During World War

I, enteral techniques were used to force-feed prison-

ers on hunger strikes.3,4 In the latter context, enteral

feeding was often regarded as inhumane and brutal.3,4

It was not until the 1960s and 1970s that the use

of enteral feeding for nutritional supplementation

in medical settings became widespread.5 During the

1980s, percutaneous endoscopic gastrostomy (PEG)

tubes were used to enable enteral feedings in adults.

Before this, the PEG tube procedure had been lim-

ited to pediatric units for feeding neurologically

impaired infants.6 Nasoduodenal tubes and nasoga-

stric tubes currently are used in intensive care units

and extended-care facilities. Although some clini-

cians prefer nasoduodenal tubes, morbidity, dura-

tion of mechanical ventilation, and length of stay

in the intensive care unit may not differ significantly

between nasoduodenal and nasogastric tubes.7-9

Placement of nasoenteric tubes is generally

accomplished at the bedside. However, conditions

such as anatomic deformities, presence of endotra-

cheal tubes or tracheostomies, and coughing may

complicate insertion and may lead to nasal trauma,

sinusitis, or malposition. Patients with poor protec-

tive reflexes, such as gag and cough, may be more

prone to silent misplacement of nasotracheal can-

nulas.10 This may be of particular concern because

many critically ill patients have ineffective protective

reflexes because of sedating medications, altered

mental status, and other support devices. Physical

examination and clinical signs of misplacement

may be misleading in these settings. Accordingly,

radiographic verification of the tube placement has

been the gold standard.10

Clinicians have sought other reliable and facile

techniques for “blind” placement of nasoduodenal

tubes. The development of the electromagnetic tube-

placement device (ETPD), also termed the CORTRAK

(CORPAK MedSystems), has been heralded as a safe

and simple way to place nasoduodenal tubes, with-

out the need for endoscopy or radiology.11-15 Initial

studies suggested that this method is associated with

a high rate of successful placement with few compli-

cations. However, subsequent reports16,17 documented

lower success rates and a small but significant risk of

serious and, occasionally, life-threatening complica-

tions. It is within this context that we comment on

the 2 studies18,19 on this topic published in this edi-

tion of the journal.

Both Bourgault et al18 and Metheny and Meert19

reviewed the Food and Drug Administration’s Manu-

facturer and User Facility Device Experience (MAUDE)

database, which consists of voluntary reports of

complications with the use of ETPD. Bourgault et

al18 reviewed records in the MAUDE database cover-

ing the period from 2006 to 2016 and found 54

adverse events related to respiratory placement of

the feeding tube. Pneumothorax occurred in 41

instances, with 9 associated deaths. Metheny and

Meert19 reviewed the MAUDE database for the period

from 2013 through 2015 and found 25 complica-

tions, all of which involved respiratory placement. Of

these, 17 cases were complicated by pneumothorax,

with several deaths.

Previous studies suggested ETPD as an alternative

to radiography to document successful placement. ©2017 American Association of Critical-Care Nursesdoi:https://doi.org/10.4037/ajcc2017680



“ Clinicians have sought other reliable and facile

techniques for blind placement of nasoduodenal tubes. ”

The findings of Metheny and Meert19 and Bourgault

et al18 suggest the CORTRAK has limitations related

to inadequate training and to interpretation and

practice. Bourgault et al suggest that additional

research may be needed to determine operator

competence. In addition, Bourgault et al highlight

technical guides for use of the ETPD. Interpretation

of the CORTRAK data is complex and subject to error.

The major limitation of these 2 reports is that

both are retrospective analyses that involved solely

voluntary reports. Thus, an inherent selection bias

may result in an inability to assess the true incidence

of complications with this device. We suggest that

these studies may therefore underestimate the true

complication rate of the ETPD.20,21

There is a debate whether postpyloric feeding

decreases the risk for aspiration pneumonia. Nev-

ertheless, the ETPD represents an advancement in

technology and may be a useful tool to manage

nutritional supplementation in selected patients.

We agree that further research is needed to identify

both the appropriate length of training as well as

the education needed to use the ETPD effectively.

In conclusion, we recommend that the ETPD

should be used with proper training and radio-

graphic confirmation to avoid the occasional but

life-threatening complications.20,22,23



REFERENCES1. Vassilyadi F, Panteliadou AK, Panteliadis C. Hallmarks In

the history of enteral and parenteral nutrition: from antiq-uity to the 20th century. Nutr Clin Pract. 2013;28(2):209-217.

2. Chernoff R. An overview of tube feeding: from ancient times to the future. Nutr Clin Pract. 2006;21(4):408-410.

3. Williams EA. Gags, funnels and tubes: forced feeding of the insane and of suffragettes. Endeavour. 2008; 32(4): 134-140.

4. Dock LL. Forcible feeding in English prisons. 1910. Am J Nurs. 2014;114(11):51.

5. Bistrian BR. Brief history of parenteral and enteral nutrition in the hospital in the USA. Nestlé Nutr Ser Clin Perfor Pro-gramme. 2009;12:127-136.

6. Ponsky JL. The development of PEG: how it was. J Interv Gastroenterol. 2011;1(2):88-89.

7. Ho KM, Dobb GJ, Webb SAR. A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Intensive Care Med. 2006;32(5):639-649.

8. Marik PE. Enteral nutrition in the critically ill: myths and misconceptions. Crit Care Med. 2014;42(4):962-969.

9. Marik PR, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care. 2003;7(3):R46-R51.

10. Merrell P. Prevention of NG tube misplacement: nursing practices. Perspectives. 2012;9(4):1, 4-7.

11. Gabriel S, Ackermann R, Castresana M. A new technique for placement of nasoenteral feeding tubes using external magnetic guidance. Crit Care Med. 1997;25(4):641-645.

12. Koopmann M, Kudsk K, Szotkowski M, Rees S. A team-based protocol and electromagnetic technology eliminate feeding tube placement complications. Ann Surg. 2011; 253(2): 287-302.

13. Rivera R, Campana J, Hamilton C, Lopez R, Seidner D. Small bowel feeding tube placement using an electro-magnetic tube placement device: accuracy of tip location. JPEN J Parenter Enteral Nutr. 2011;35(5):636-642.

14. October T, Hardart G. Successful placement of postpyloric enteral tubes using electromagnetic guidance in critically ill children. Pediatr Crit Care Med. 2009;10(2):196-200.

15. Taylor S. Confirming nasogastric feeding tube position versus the need to feed. Intensive Crit Care Nurs. 2013; 29(2): 59-69.

16. Powers J, Fischer M, Ziemba-Davis M, Brown J, Phillips D. Elimination of radiographic confirmation for small-bowel feeding tubes in critical care. Am J Crit Care. 2013; 22(6): 521-527.

17. Gray R, Tynan C, Reed L, et al. Bedside electromagnetic- guided feeding tube placement: an improvement over tra-ditional placement technique? Nutr Clin Pract. 2007; 22(4): 436-444.

18. Bourgault AM, Aguirre L, Ibrahim J. CORTRAK-assisted feeding tube insertion: a comprehensive review of adverse events in the MAUDE database. Am J Crit Care. 2017; 26(2): 149-156.

19. Metheny MA, Meert KL. Update on effectiveness of an elec-tromagnetic feeding tube–placement device in detecting respiratory placements. Am J Crit Care. 2017; 26(2): 157-161.

20. Roberts S, Echeverria P, Gabriel S. Devices and techniques for bedside enteral feeding tube placement. Nutr Clin Pract. 2007;22(4):412-420.

21. Smithard D, Barrett N, Hargroves D, Elliot S. Electromagnetic sensor-guided enteral access systems: a literature review. Dysphagia. 2015;30(3):275-285.

22. Metheny N, Meert K. Effectiveness of an electromagnetic feeding tube placement device in detecting inadvertent respiratory placement. Am J Crit Care. 2014;23(3):240-247.

23. Bryant V, Phang J, Abrams K. Verifying placement of small-bore feeding tubes: electromagnetic device images versus abdominal radiographs. Am J Crit Care. 2015; 24(6): 525-530.


About the AuthorsJulia Park, Joshua Tan, and Sylvia Krzeminski are residents at the Maricopa Medical Center in Phoenix, Arizona. Meghana Bandlamuri is a student at the Maricopa Medical Center. Richard W. Carlson is a faculty member at the Maricopa Medical Center, and is affiliated with the Uni-versity of Arizona College of Medicine, and the Mayo Clinic College of Medicine, Scottsdale, Arizona.

Corresponding author: Richard W. Carlson, MD, PhD, Mar-icopa Medical Center, 2601 E Roosevelt St, Phoenix, AZ 85008 (e-mail: [email protected]).

PREVENTING VENOUS THROMBOEMBOLISM: THE ROLE OF NURSING WITH INTERMITTENT PNEUMATIC COMPRESSIONBy Nancy Dunn, RN, MS, and Rebecca Ramos, RN, MSN, ACNS-BC

Clinical Evidence Review A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.

Venous thromboembolism (VTE) is known to be a

preventable event among hospitalized patients.

Although thromboprophylaxis can reduce the inci-

dence of VTE in hospitalized patients, it remains underused

because of fear of bleeding.1 Mechanical prophylaxis is an

effective therapy that uses intermittent pneumatic com-

pression (IPC) with sequential compression devices (SCD)

and has no risk for bleeding.2 However, researchers also

report adherence issues, so the full potential for SCD

therapy to reduce VTE remains unknown.

Affecting 350 000 to 600 000 Americans annually,1 VTE

is a term used to describe deep vein thrombosis (DVT) or

pulmonary embolus (PE). VTE is a potentially preventable

cause of morbidity and mortality in hospitalized patients

who are at increased risk because of surgery, prolonged

immobilization, use of certain medications, and presence

of other conditions such as obesity, heart failure, and cancer.

VTE is estimated to be among the most common prevent-

able causes of hospital death.1 Additionally, the treatment

of nonfatal symptomatic VTE and long-term associated

morbidities are connected to considerable health care costs.

Thus the PICO (patient/problem, intervention, compari-

son, outcomes) question of interest for this review was

2-fold. First, what is the effectiveness of IPC in reducing

DVT and PE in hospitalized patients? Second, what is the

adherence to IPC by nurses and hospitalized patients?

Method The Cumulative Index of Nursing and Allied Health

Literature (CINAHL) and MEDLINE were searched by using

the following key words: intermittent pneumatic compression

devices, nursing, adherence, venous thromboembolism, prevention,

and hospitalized patients. The review was limited to articles

published from 2000 to 2016.

Results Effectiveness

For the question of IPC effectiveness, Table 1 summa-

rizes 2 level A studies and 1 level B study (Table 2). For

inpatients at risk, thromboprophylaxis can reduce VTE by

30% to 65% and has a low incidence of bleeding compli-

cations.1 A 2013 meta-analysis concluded that IPC therapy

of the lower limbs can be as effective as pharmacological

thromboprophylaxis.2 Using 70 trials involving a total of

16 164 hospitalized patients, researchers found that IPC

was more effective than no IPC in reducing DVT and PE.

IPC was more effective than TED (thromboembolic deter-

rent) stockings alone in reducing DVT. IPC appeared to be

as effective as pharmacological prophylaxis in reducing

PE and was associated with a reduced risk of bleeding.

However, significant heterogeneity in the risk of DVT

between trials was apparent, and when data were pooled,

IPC appeared to be as effective as pharmacological throm-

boprophylaxis in DVT reduction. Adding pharmacological

thromboprophylaxis to IPC further reduced DVT risk

compared with the use of IPC alone, with no significant

difference in mortality.

These conclusions support the pathogenesis of VTE

according to Virchow’s triad. The triad attributes VTE to

venous stasis, hypercoagulability, and endothelial damage.

IPC directly enhances venous blood flow and fibrinolytic

activity, particularly crucial for immobile hospitalized

patients. IPC is essential with trauma or stroke patients,

in whom pharmacological thromboprophylaxis is contra-

indicated because of the risk of bleeding. A systematic

review4 of 5 randomized controlled trials with 1072 trauma

patients indicated that all demonstrated a reduction in ©2017 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ajcc2017504



Table 1Summary of evidence on effectiveness of sequential compression devices

Meta-analysis; N = 16 164 medical surgical patients (70 trials)

Randomized controlled trial; N = 2876 stroke patients (94 centers)

Systematic review; N = 1072 trauma patients (5 trials)

DesignReference

A

B

A

Level of evidence

Ho et al2

CLOTS Trial Collaboration3

Ibrahim et al4

IPC more effective than no IPC in reducing DVT-ARR 9.4% (95% CI, 7.9%-10.9%) and PE-ARR 1.6% (95% CI, 0.9%-2.3%)

IPC more effective than TEDS alone in reducing DVT-RR 0.61 (95% CI, 0.39-0.93) but not PE-RR 0.64 (95% CI, 0.21-1.95)

IPC as effective as pharmacological therapy in reducing PE-RR 1.19 (95% CI, 0.62-2.29) and DVT-RR 0.93 (95% CI, 0.69-1.26)

IPC combined with pharmacological therapy further reduced DVT-RR 0.54 (95% CI, 0.32-0.91) but not PE and mortality compared with IPC alone

IPC more effective than no IPC in reducing DVT-ARR 3.6% (95% CI, 1.4%-5.8%)

IPC reduced DVT in trauma patients with Injury Severity Score > 9

IPC reduced DVT in patients with hip fracture IPC of calf/thigh more effective than plantar IPC after

lower extremity traumaIPC of thigh/calf not as effective as IPC of calf/foot but

difference was not statistically significant

Abbreviations: ARR, absolute risk reduction; DVT, deep vein thrombosis; IPC, intermittent pneumatic compression; PE, pulmonary embolism; RR, relative risk; TEDS, thromboembolic disease stockings; VTE, venous thromboembolism.

Results

Table 2American Association of Critical-Care Nurses evidence-leveling systema

Level

A

B

C

D

E

M

Meta-analysis of multiple controlled studies or metasynthesis of qualitative studies with results that consistently support a spe-cific action, intervention, or treatment

Well-designed controlled studies, both randomized and non-randomized, with results that consistently support a specific action, intervention, or treatment

Qualitative studies, descriptive or correlational studies, integra-tive reviews, systematic reviews, or randomized controlled trials with inconsistent results

Peer-reviewed professional organizational standards, with clinical studies to support recommendations

Theory-based evidence from expert opinion or multiple case reports

Manufacturer’s recommendation only

Description

a From Armola et al,5 with permission.

VTE using IPC. The CLOTS3 randomized controlled

trial demonstrated an absolute reduction of DVT risk

in stroke patients. For very high risk patients with

multiple risk factors, using a combination of IPC

and pharmacological thromboprophylaxis is optimal.

The disposable sleeves used in IPC are inexpensive

($180 each)2 compared with the cost of symptomatic

VTE ($7700-$10 800) and PE ($9500-$16 600).1

Immediate application of IPC for patients with

contraindication to pharmacological protection is

best practice and should be used until combined

therapy can be initiated.

Given the effectiveness of mechanical prophylaxis,

nurses must pay particular attention to the applica-

tion and maintenance of SCD therapy and should

consider it just as important as pharmacological

interventions, especially in those patients in whom

pharmacological therapy is contraindicated.

AdherenceFor the question on adherence, Table 3 summa-

rizes 1 level A study and 3 level C studies (Table 2).

In a systematic review and meta-analysis of 8 studies

targeting adherence to SCDs, Craigie et al6 found that

25% of surgical patients did not have proper SCD

therapy applied, putting the patients at risk for VTE.

In a prospective observational study7 from 2002 with

1343 observations in 227 patients, researchers found

that only 19% of high-risk trauma patients had SCDs

applied and functioning. In a 2013 observational

study8 conducted in 4 adult ICUs, other researchers

reported that 49% of patients had errors in their IPC

devices and 13% had IPC as the only means of VTE

prophylaxis. In more than half of the observations

(51%), the patients had no IPC sleeves on their legs.

About the AuthorsNancy Dunn is the clinical excellence coordinator and Rebecca Ramos is the stroke clinical nurse specialist at Salem Health, An OHSU Partner in Salem, Oregon.

Corresponding author: Nancy Dunn, RN, MS, Salem Health, Salem, OR 97310 (e-mail: [email protected]).


Table 3Summary of evidence on adherence to sequential compression devices

Systematic review; N = 8 studies meeting criteria with various numbers of patients and IPC adherence

Prospective observational study; N = 227 patients with 1343 observations

Observational study; N = 108 patients with 966 observations

Descriptive study; N = 147 patients and 29 nurses in surgical intensive care unit

DesignReference

A

C

C

C

Level of evidence

Craigie et al6

Cornwell et al7

Elpern et al8

Kim and Lee9

25% of surgical patients did not have proper SCD therapyPatients did not like device, sleep disturbance, device not

being replaced or turned on by nurses, or device being too hot or noisy

19% had the SCD properly applied and functioning 95% of noncompliance was that the SCD was not properly

applied

49% observations showed improper IPC adherenceIn 13% of observations, IPC was the only means of prophylaxis51% of misapplications related to improper placement of

sleeves on legs15% of observations had no IPC device in place

Difficulty with application of SCDs/stockingsSkin breakdown before placement Patients complained of discomfort from tightnessFit issues: length and circumferenceLack of knowledge among nurses about minimum

application time

Abbreviations: IPC, Intermittent pneumatic compression; SCD, sequential compression device.

Barriers

Recommendations These adherence defects are troublesome given

the nurse’s role to apply, maintain, and monitor

SCD therapy. The SCD defects pose a crucial oppor-

tunity for improvements and further research on

adherence. We must ask the question why and

what are the barriers to SCD therapy? The direct

causes are primarily related to misapplication and

monitoring for continuous use. In a 2014 descrip-

tive study,9 nursing barriers for applying SCDs

and stockings included skin breakdown, espe-

cially around the ankle and knee, for 44.8% of

the patients. Additionally, nurses sought out infor-

mation on effective minimum application time

because of their clinical experience of difficulty

in applying SCDs and stockings on patients with

decreased levels of consciousness. Another major

concern were patients’ complaints related to

SCD discomfort (tightness, bothersome, pain

due to pressure, and sleep disruption). Along

with patients’ complaints, Craigie et al6 found a

disturbing report of devices not being replaced

or turned on by nurses. The issue of patient refusal

can be attributed to discomfort with improper

fitting, as well as the actual product material

creating too much heat. Pagella et al10 found that

certain products with “breathable material” were

reported as more tolerable by patients and thus

were associated with greater adherence. Nurses are

in a position to inform and educate patients on the

importance of continuous use as well as to evalu-

ate vendors’ best practices for patient adherence.

In their practice alert, the American Associa-

tion of Critical-Care Nurses addresses the impor-

tance of the role that nurses have to “ensure that

mechanical devices are fitted properly and in use

at all times, except when being removed for clean-

ing or inspection of skin.”11 This recommendation

is consistent with the conclusion by Koo et al12

that optimal fitting and monitoring for continu-

ous use supports the American College of Chest

Physicians guidelines to ensure proper use of and

optimal adherence with mechanical prophylaxis.

Clearly the evidence points to the important

role that acute care nurses play in maintaining

IPC therapy. Starting with application, measure-

ment of the leg circumference, and selecting SCD

sleeves that fit properly can optimize comfort.

Research also suggests that nurses should be

vigilant in their practice of applying and reap-

plying IPC devices after procedures, baths, and

during chair activities; IPCs should be removed

only when the patient is ambulating. Last, nurses

are the central key to patient adherence. When non-

compliant patients were asked why they were not

wearing their SCDs (n = 362), the most common

reason was “the nurse said I don’t need them any-

more.”13 This reason was followed by “I just got

back in bed and no one reapplied them” (n = 59)

and “I’ve been walking” (n = 63). Patients who are

sitting are not actively ambulating. The American

College of Obstetricians and Gynecologists recom-

mends that SCDs be used “continuously until

ambulation or discharge.”13 More observational


studies are needed to fully understand the barriers to

IPC compliance.

VTE prevention is the responsibility of both

health care providers and nurses. More nursing

research is necessary to advance evidence-based prac-

tice standards for the application and maintenance

of SCD therapy and patient education to improve

adherence. In the meantime, we must teach nurses

that their role in effective mechanical prophylaxis

therapy is just as important as taking vital signs.



REFERENCES1. Maynard G. Preventing Hospital-Associated Venous Throm-

boembolism: A Guide for Effective Quality Improvement. 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No. 16-0001-EF.

2. Ho K, Tan J. Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboem-bolism in hospitalized patients. Circulation. 2013;128:1003-1020.

3. Dennis M, Sandercock P, Reid J, Graham C, Forbes J, Murray G. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised con-trolled trial. Lancet. 2013;382:516-524.

4. Ibrahim M, Ahmed A, Mohamed WY, El-Sayed Abu Abduo S. Effect of Compression Devices on Preventing Deep Vein

Thrombosis Among Adult Trauma Patients: A Systematic Review. Dimens Crit Care Nurs. 2015;34(5):289-300.

5. Armola R, Bourgault A, Halm M, et al. Upgrading AACN’s evidence leveling hierarchy. Am J Crit Care. 2009;18: 405-409.

6. Craigie S, Tsui J, Agarwal A, Sandset PM, Guyatt GH, Tikki-nen KA. Adherence to mechanical thromboprophylaxis after surgery: a systematic review and meta-analysis. Thromb Res. 2015;136(4):723-726.

7. Cornwell E III, Chang D, Velmahos G, et al. Compliance with sequential compression device prophylaxis in at-risk trauma patients: a prospective analysis. Am Surg. 2002; 68:470-472.

8. Elpern E, Killeen K, Patel G, Senecal PA. The application of intermittent pneumatic compression devices for thrombo-prophylaxis. Am J Nurs. 2013;113(4):30-36.

9. Kim H, Lee E. Major difficulties and information needs recog-nized by nurses in applying graduated compression stock-ing and intermittent pneumatic compression for deep vein thrombosis prophylaxis. J Clin Nurs. 2014;24:308-311.

10. Pagella P, Cipolle M, Sacco E, Matula P, Karoly E, Bokovoy J. A randomized trial to evaluate compliance in terms of patient comfort and satisfaction of two pneumatic compres-sion devices. Orthop Nurs. 2007;26(3): 169-174.

11. American Association of Critical-Care Nurses. AACN practice alert: preventing venous thromboembolism in adults. Crit Care Nurse. 2016;36(5):e20-e23.

12. Koo K, Choi J, Ahn J, Kwon JH, Cho KT. Comparison of clinical and physiological efficacies of different intermittent sequential pneumatic compression devices in preventing deep vein thrombosis: a prospective randomized study. Clin Orthop Surg. 2014;6:468-475.

13. Brady M, Carroll AW, Cheang KI, Straight C, Chelmow D. Sequential compression device compliance in postoperative obstetrics and gynecology patients. Obstet Gynecol. 2015; 125/1:19-25.


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SIMILAR ECG FEATURES IN 2 DIFFERENT DIAGNOSESBy Michele M. Pelter, RN, PhD, Teri M. Kozik, RN, PhD, CNS, CCRN, Salah S. Al-Zaiti, RN, PhD, CRNP, CCRN,

and Mary G. Carey, RN, CNS, PhD

©2017 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ajcc2017477

Michele M. Pelter is an assistant professor at the the Department of Physiological Nursing at University of California, San Francisco, California. Teri M. Kozik is a nurse researcher at St. Joseph’s Medical Center, Stockton, California. Salah S. Al-Zaiti is an assistant pro-fessor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pennsylvania. Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York.

ECG Puzzler A regular feature of the American Journal of Critical Care, the ECG Puzzler addresses electrocardiogram (ECG) interpretation for clinical practice. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature.

Yes No NA

Yes No NA

Yes No NA

Yes No NA

Yes No NA

Yes No NA

Yes No NA

Yes No NA

Scenario: This 12-lead electrocardiogram (ECG) was

obtained from a 75-year-old man who arrived at the

emergency department with chest pain and shortness of

breath. He had been bedbound for several weeks

because of his symptoms. He has no history of coronary

artery disease, but has significant risk factors including:

diabetes, hypertension, and cigarette smoking. Clinical

findings include: blood pressure, 222/109 mm HG;

respiratory rate, 24/min; brain natriuretic (BNP), 1866

pg/ml (reference < 100); troponin I, 0.073 ng/mL (refer-

ence < 0.04); ejection fraction 45%, and elevated blood

urea nitrogen and creatinine. Before admission, the

patient was taking daily; aspirin, insulin, -blocker,

ACE inhibitor, and diuretic.

II

II

IN

N

N

N

N

N

N

N

N

N

N

N

N

N

N

N

N

N

N

Rate 58 BPM 10mm/mv

N

III aVF

aVL

aVR

V2

V3 V

6

V5

V4V

1

Interpretation Questions:

1. Is the ECG properly calibrated (10 mm) and are leads properly placed?

If no, interpret cautiously.

2. Is this a sinus rhythm (one P wave preceding every QRS complex)?

If no, check for number of P waves in relation to QRS complexes.

3. Is the heart rate (R-R interval) normal (60-100/min)?

If no, check for supra-ventricular or ventricular arrhythmias.

4. Is the QRS complex narrow (duration < 110 milliseconds [ms] in V1)?

If no, check for bundle branch blocks (BBBs), pacing, or ventricular arrhythmia.

5. Is the ST segment deviated (> 2 mm in V2-V

3, or > 1 mm in other leads)?

If yes, check for similar deviations in contiguous cardiac territories.

6. Is the T wave inverted in relation to the QRS (> 0.5 mV)?

If yes, check for ST deviation or conduction abnormalities.

7. Is the QT interval lengthened (> 450 ms [men] or > 470 ms [women])?

If yes, check for ventricular arrhythmias or left ventricular hypertrophy.

8. Is R- or S-wave amplitude enlarged (S wave V1 + R wave V

5 > 35 mm)?

If yes, check for axis deviation or other chamber hypertrophy criteria.


InterpretationSinus bradycardia with T wave inversion in the left

lateral leads, lengthened QT interval, Q wave present in

V1 with poor R wave progression in the anterior leads plus

the presence of fragmented QRS (fQRS) complexes in the

inferior leads, suggesting prior infarction. The Puzzler uses

the common criteria of Sokolow-Lyon for detecting left ven-

tricular hypertrophy (LVH) on the ECG, by simply adding

the S wave in V1 to the R wave in V

5. If the total exceeds

35 mm, then LVH is suspected with a sensitivity of 22%

and a specificity of 100%. Of note, the sensitivity is low

so there are other ECG criteria available that increase sensi-

tivity, but at the same time decrease specificity (eg, Cornell

Voltage Criteria, sensitivity, 42%; specificity, 95%).

Rationale There are 2 primary diagnoses to consider: acute coro-

nary syndrome and/or heart failure, both supported by the

presenting symptoms, clinical history, elevated troponin I,

elevated BNP (heart failure), T-wave inversion, and frag-

mented QRS complexes. The ECG features support either

diagnosis as well because the T wave inversion > 2 mm, as

seen in leads V5, V

6, I, and aVF suggests acute ischemia or

could be present as secondary repolarization changes due to

LVH. The presence of fragmented QRS complexes occurs due

to alterations in depolarization within the ventricles, and can

be seen with myocardial scarring (ie, infarction), ischemia, or

myocardial fibrosis as seen in hypertrophy, cardiomyopathy,

or systemic diseases with cardiac involvement (ie, rheumatoid

arthritis, sarcoidosis).

Management A definitive diagnosis in the early phase of care for this

patient is complex; hence vigilant monitoring of his vital signs,

symptoms, and ECG for dynamic ST-T wave changes indicative

of arrhythmias and/or ischemia is warranted. Immediate man-

agement in this patient should focus on ensuring adequate

oxygenation via supplemental oxygen, and reducing myocar-

dial demand by reducing the blood pressure and anginal

symptoms with guideline-based pharmacological therapies.

The final discharge diagnosis for this patient was deter-

mined to be heart failure. The patient was discharged to a

skilled nursing facility for rehabilitation that included physi-

cal therapy, and dietary and smoking secession counseling.

Answers:1. Yes, proper gain indicated (10 mm/mV upper right corner).

2. Yes, there is one P wave per QRS complex.

3. No, the heart rate is bradycardic at 58/min.

4. Yes, the QRS duration is narrow but there is QRS fragmentation in leads II, III, and aVF (seen as notching in the

nadir of the S wave), and a delta wave in lead II.

5. No, the ST segments are not deviated.

6. Yes, the T wave is inverted in V5, V

6, leads I, and aVL.

7. Yes, the QT interval is lengthened (452 ms V6).

8. No, there are no signs of chamber hypertrophy using the criteria provided.


II

II

IN

N

N

N

N

N

N

N

N

N

N

N

N

N

N

N

N

N

N

Rate 58 BPM 10mm/mv

N

III aVF

aVL

aVR

V2

V3 V

6

V5

V4V

1

Shimon Abboud, PhDGemma Aburn, RN, BN (Hons)Thomas S. Ahrens, DNSRobert John Anderson, RN, BAN, CCRNWendy G. Anderson, MDRichard Arbour, RN, MSN, CCRN, CNRN, CCNS Rochell R. Armola, RN, MSN, CCRNWendy Austin, RN, PhDOmar Badawi, PharmDPolly Bailey, MSNTim Baillie, BSc, MBBS, FRACPKatherine G. Baker, RN, MNRick D. Bassett, RN, MSN, APRN, ACNS-BC, CCRNRenea L. Beckstrand, RN, PhD, CCRN, CNEMerilyn Beken, PG diploma HSE Julie Benbenishty, RN, MSNBronagh Blackwood, RN, PhDStijn Blot, PhDLeanne M. Boehm, RN, PhD, ACNS-BCAnnette M. Bourgault, PhDRichard D. Branson, MSc, RRT Donna Quinton Brown, RNVera Bryant, DNP, ARNP, ACNP-BC, CCRN, CNRN, SCRNMaurizia Capuzzo, MDRichard W. Carlson, MD, PhDDevin Carr, RN, DNP, ACNS-BC, NEA-BCGerald Chanques, MD, PhDDennis J. Cheek, PhDJared Chiarchiaro, MDHenry Cohen, PharmD, BCPP, CGPAngela Smith Collins, DSNGillian Colville, DClinPsychC. Connolly, MDVicki Cope, PhDDamon B. Cottrell, RN, DNP Jill M. Cox, PhDJudy E. Davidson, RN, DNP Michael John Davis, PhDFreda DeKeyser Ganz, RN, PhDJohn W. Devlin, PharmDTrudy Dwyer, PhDMelissa Dyo, NP, PhDDoug Elliott, RN, PhDE. Wesley Ely, MD, MPHMarie Engwall, MNSc, CCNA, RNTVincent Fan, MD, MPHThomas Farley, RN, MS, NPSonya A. Flanders, RN, MSN, ACNS-BC, CCRNDorothy Cecelia Foglia, RN, PhDJohn F. Fraser, MBChB, PhDRalph J. Fuchs, MD

Dale N. Glaser, PhDVicki Good, RN, MSN, CENP, CPPSMaria Gudmundsdottir, PhDUlf Guenther, MDJanice Gullick, RN, PhDPritha Gupta, MDJill L. Guttormson, RN, PhD David N. Hager, MD, PHDMargo A. Halm, RN, PhD, APRN-BC, CCRNShannan Hamlin, RN, PhD Naomi E. Hammond, RN, MN, MPHJulie Boyer Hanley, RN, MSN, CCRNGerard B. Hannibal, RN, MSN, PCCNJ. Steven Hata, MDSamantha Higer, MSTheresa Hoadley, RN, PhD Kristin Hofsø, RN, PhDVan K. Holden, MDCarol Holt, RN, PhD, CNS Barbara J. Holtzclaw, RN, PhD Nancy Iafrati, RN, MS, FNP-BCFlerida Imperial-Perez, MNVivek N. Iyer, MDAaron M. Joffe, DOPeter Johansson, PhDChristina Jones, PhDDaryl Jones, MD, BSc(Hons), MBBS, PhD, FRACP, FCICM Deborah J. Jones, RN, PhD Biren B. Kamdar, MD, MBA, MHSNancy Kentish-Barnes, PhDElizabeth Anne Kiss, DNPRuth M. Kleinpell, PhDMelissa P. Knauert, MD, PhDBrian Kopp, PharmD Anna E. Krupp, RN, MS, CCNS, CCRNCarl J. Lavie, MDJane S. Leske, PhDDoris Leung, RN, PhDC. Preston Lewis, RN, DNP, CCRNJuan Felipe Lucena, MDMaureen A. Madden, RN, MSN Paula R. Mahon, PhDRalph Mangusan, MSN, RN-BC, PCCN, CWCNMary-Jeanne Manning, MSN, APRN, PNP-BC, CCRNJennifer McAdam, RN, PhDNatalie S. McAndrew, RN, MSN, ACNS-BC, CCRNHeather McClendon, BSNAnthony W. McGuire, RN, PhD, ACNP-BC, CCRNCatherine McKenzie, PhDSharon McKinley, RN, PhD

Cathy L. Michaels, RN, PhDLorraine C. Mion, RN, PhDNeda Mirbagher-Ajorpaz, PhDSultan Mosleh, PhDMarc Moss, MDJulie A. Nauser, RN, PhDPatricia J. Ohtake, PhD, PTPamela V. O'Neal, PhDRobert Jan Osse, MD, PhDTracy Ann Pasek, RN, MSN, CCRNCynthia Peden-McAlpin, PhD, ACNS, BCMavilde Luz Gonçalves Pedreira, RN, PhDAmy Petrinec, RN, PhDJan Powers, PhDAnita C. Reinhardt, PhDAndrew Thomas Reyes, RN, PhDKathy C. Richards, RN, PhDKathleen, PhDBenjamin K. Scott, MDSue Sendelbach, PhDCurtis N. Sessler, MDRadhika Shah, MDArif M. Shaik, MDFrederick E. Sieber, MDDebra Siela, PhDJonathan M. Siner, MDOrla Smith, PhDPamela L. Smithburger, MS, PharmDPieter R. Stella, MD, PhDJoanna Stollings, PharmDNancy A. Stotts, EdDKatie Swafford, RN, MSN, CNS-BC, CCRNChristina Szabo, RN, PhD, CCRN, CNRNNahla Tayyib, RN, PhD Karen A. Thomas, PhDHilaire J. Thompson, PhDLyvonne Tume, RN, PhDTürkan Turan, PhDDavid W. Unkle, RN, MSN, APN Amanda van Beinum, MScMark van den Boogaard, RN, PhDCatherine VanGilder, MBA, MT, CCRACorey Ventetuolo, MDAvelino C. Verceles, MDJudy Verger, PhDDavid L. Vines, MHS, RRTKathleen M. Vollman, MSNDorothy M. Wade, PhDTeresa A. Wavra, RN, MSNMeghan M. Weese, RN, MSN, CPNDewi Williams, PharmDAnn Williamson, RN, PhDKristy Winters, ACNP-BC, NP-CKristin Rebecca Wise, MDCheryl Zambroski, RN, PhD

Acknowledgment of ReviewersThe AJCC coeditors express their gratitude to the following reviewers for their scientific expertise and constructive advice in the review of manuscripts for the American Journal of Critical Care during 2016.


FLORIDAPlantation42nd Annual Spring SeminarDate: April 1, 2017. Place: Renaissance Hotel. Address: 1230 S Pine Island Rd, Plantation, FL 33324. Keynote Speakers: Clareen Wiencek, Kendra Menzies-Kent, Douglas Houghton, Elizabeth Lavelle. Sponsor: Broward County Chapter of AACN. Contact: Patty Kelly. Phone: (954) 722-8020. E-mail: [email protected]. Fee: Before March 14: member, $75 and nonmember, $100. After March 14, member, $100 and nonmember, $125. At the door: member, $125 and nonmember, $150. Credits: 6.5 CEUs.

ILLINOISChicagoCertification in Legal Nurse Consulting (5-day seminar and online)Date: May 15-19, 2017. Place: Hyatt Regency Lisle near Naperville. Keynote Speaker: Vickie L. Milazzo. Sponsor: Vickie Milazzo Institute. Address: 5615 Kirby Dr, Suite 425, Houston, TX 77005-2448. Contact: Vickie L. Milazzo. Phone: (800) 880-0944. Fax: (713) 942-8075. E-mail: [email protected]. Website: www.LegalNurse.com. Fee: Varies. Credits: 25.3 CEUs (5-day seminar); 40 CEUs (online).

IOWADes MoinesReview Course for CertificationDate: April 24-26, 2017. Place: Iowa Methodist Medical Center, Des Moines, IA. Keynote Speaker: Vicki Milledge. Sponsor: Central Iowa Chapter of AACN. Contact: Deb Hennings. Phone: (515) 371-4684. E-mail: [email protected]. Fee: TBD. Discount given for AACN members.

MARYANDTowsonCritical Care Nursing-The Future is Now!Date: March 15-16, 2017. Place: Sheppard Pratt Conference Center. Address: 6501 N Charles St,

Towson, MD 21204. Keynote Speakers: Karen McQuillan, Paula McCauley, Kathryn Von Rueden, Dr George Ruiz, Katrina Coleman. Sponsor: Chesapeake Bay Chapter of AACN. Contact: Jean Little. Phone: (410) 353-2607. E-mail: [email protected]. Fee: TBD.

NEVADALas VegasPediatric Critical Care and Emergency NursingDate: October 31-November 3, 2017. Place: Tropicana. Spon-sor: Contemporary Forums. Address: 3478 Buskirk Ave, #242, Pleasant Hill, CA 94523. Contact: Kristen Mulholand. Phone: (800) 377-7707. Fax: (925) 828-1950. E-mail: info @cforums.com. Website: www.contemporaryforums.com. Fee: TBD. Credits: TBD.

Las VegasAdvanced Critical Care and Emergency NursingDate: November 1-4, 2017. Place: Tropicana. Sponsor: Con-temporary Forums. Address: 3478 Buskirk Ave, #242, Pleas-ant Hill, CA 94523. Contact: Kristen Mulholand. Phone: (800) 377-7707. Fax: (925) 828-1950. E-mail: [email protected]. Website: www.contemporaryforums.com. Fee: TBD. Credits: TBD.

NATIONWIDEState: OngoingOne Day CCRN Review CramDate: 2017. Place: San Francisco (March), Los Angeles (March), New York (March, October) Columbus (April), Chicago (April), Charlotte (May), Boston (May), Richmond (May), Atlantic City (October). Keynote Speakers: Laura Gasparis Vonfrolio, RN, PhD, Lee Taylor Vaughan, RN, EJD, MSN, CCRN-CSC. Sponsor: Education Enterprises. Address: 31 Yeomalt Ave, Staten Island, NY 10312. Contact: Laura Gasparis Vonfrolio, RN, PhD. Phone: (800) 331-6534. Fax: (718) 317-0858. E-mail: [email protected]. Website: www.GreatNurses.com. Fee: As low as $99. Credits: 8 CEUs.

For AJCC Education Directory submission information phone (800) 809-2273, ext 532; or e-mail, [email protected].

Education Directory


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