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Coronavirus disease 19 (COVID-19) has posed unprecedented healthcare system challenges, some of which will lead to transformative change. It is obvious to healthcare workers and policymakers alike that an effective critical care surge response must be nested within the overall care delivery model. The COVID-19 pandemic has highlighted key elements of emergency preparedness. These include having national or regional strategic reserves of personal protective equipment, intensive care unit (ICU) devices, consumables and pharmaceuticals, as well as effective supply chains and efficient utilization protocols. ICUs must also be prepared to accommodate surges of patients and ICU staffing models should allow for fluctuations in demand. Pre-existing ICU triage and end-of-life care principles should be established, implemented and updated. Daily workflow processes should be restructured to include remote connection with multidisciplinary healthcare workers and frequent communication with relatives. The pandemic has also demonstrated the benefits of digital transformation and the value of remote monitoring technologies, such as wireless monitoring. Finally, the pandemic has highlighted the value of pre-existing epidemiological registries and agile randomized controlled platform trials in generating fast, reliable data. The COVID-19 pandemic is a reminder that besides our duty to care, we are committed to improve. By meeting these challenges today, we will be able to provide better care to future patients.

Burnout syndrome (BOS) occurs in all types of health-care professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other health-care professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care health-care professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care health-care professionals and diminish the harmful consequences of BOS, both for critical care health-care professionals and for patients.

During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

End-of-life care in the intensive care unit (ICU) was identified as an objective in a series of Task Forces developed by the World Federation of Societies of Intensive and Critical Care Medicine Council in 2014. The objective was to develop a generic statement about current knowledge and to identify challenges relevant to the global community that may inform regional and local initiatives. An updated summary of published statements on end-of-life care in the ICU from national Societies is presented, highlighting commonalities and differences within and between international regions. The complexity of end-of-life care in the ICU, particularly relating to withholding and withdrawing life-sustaining treatment while ensuring the alleviation of suffering, within different ethical and cultural environments is recognized. Although no single statement can therefore be regarded as a criterion standard applicable to all countries and societies, the World Federation of Societies of Intensive and Critical Care Medicine endorses and encourages the role of Member Societies to lead the debate regarding end-of-life care in the ICU within each country and to take a leading role in developing national guidelines and recommendations within each country.

OBJECTIVEThe purpose of this project was to examine the financial impact of adding nurse practitioners (NPs) to inpatient care teams at Vanderbilt University Hospital. BACKGROUNDNational initiatives targeting quality, safe, and cost-effective healthcare have created the optimal environment for NPs to showcase their abilities and contributions. Identifying outcomes that are directly affected by NPs and quantifying data in terms of dollars can be affirmation for the contribution of the NP practice. Value can be garnered in terms of revenue generation and cost-effectiveness of hiring NP providers; however, a considerable financial impact can be in cost avoidance and cost savings through NP-associated outcomes of care. METHODSThis was a retrospective, secondary analysis of return on investment after adding NPs to 5 teams. Software was used to abstract billing, acuity, and length of stay (LOS) data and NP-associated quality metrics. Billing data, LOS, and risk-adjusted LOS data for designated years before and after adding NPs were compared. RESULTSGross collections compared with expenses for 4 NP-led teams for 2 year time periods were 62%, 36%, and 47%, and +32%. Average risk-adjusted LOS for the 5 time periods after adding NPs decreased and charges decreased, thus demonstrating less resource use. Most clinical outcomes improved beyond preproject baselines. CONCLUSIONThis project demonstrated the value of adding NPs to inpatient care teams by means of generated revenue, reduction in LOS, and standardization of quality care.

• Background Moral distress is caused by situations in which the ethically appropriate course of action is known but cannot be taken. Moral distress is thought to be a serious problem among nurses, particularly those who practice in critical care. It has been associated with job dissatisfaction and loss of nurses from the workplace and the profession. • Objectives To assess the level of moral distress of nurses in a medical intensive care unit, identify situations that result in high levels of moral distress, explore implications of moral distress, and evaluate associations among moral distress and individual characteristics of nurses. • Methods A descriptive, questionnaire study was used. A total of 28 nurses working in a medical intensive care unit anonymously completed a 38-item moral distress scale and described implications of experiences of moral distress. • Results Nurses reported a moderate level of moral distress overall. Highest levels of distress were associated with the provision of aggressive care to patients not expected to benefit from that care. Moral distress was significantly correlated with years of nursing experience. Nurses reported that moral distress adversely affected job satisfaction, retention, psychological and physical well-being, self-image, and spirituality. Experience of moral distress also influenced attitudes toward advance directives and participation in blood donation and organ donation. • Conclusions Critical care nurses commonly encounter situations that are associated with high levels of moral distress. Experiences of moral distress have implications that extend well beyond job satisfaction and retention. Strategies to mitigate moral distress should be developed and tested.

Recently, studies focusing on ward-based nurse screenings for sepsis have also demonstrated benefit. A study from Norway targeted early identification of in-hospital sepsis by ward nurses [8]. As part of the Mid-Norway Sepsis Study, the study assessed the impact of a bundle intervention consisting of a flow chart for sepsis identification and physician notification and a clinical tool for triage of patients exhibiting signs of sepsis and organ failure. Additionally, a 4-h training course was provided to all nurses and nursing students working on the wards that included content on pathophysiology, signs of sepsis, and treatment recommendations, including the importance of fluid resuscitation, antibiotic therapy, and monitoring and communication of patient vital signs and condition status changes. In comparison to a pre-intervention group of 472 patients with confirmed blood stream infection during a 2-year period, 409 patients with confirmed blood stream infection in a 2-year post-intervention period were found to have higher odds of surviving 30 days (odds ratio (OR) 2.7, 95% confidence interval (CI) 1.6-4.6), lower probability of developing severe organ failure (0.7, 95% CI 0.4-0.9), and, on average, 3.7 days (95% CI 1.5-5.9 days) shorter length of stay [8]. Another nurse-based early recognition and response program integrated an early sepsis screening tool into the electronic health record, screening and response protocols, and education and training of nurses with twice-daily screening of hospitalized patients and was found to be associated with reductions of inpatient sepsis-associated death rates [9]. These studies demonstrated significant differences not only in sepsis treatment but also length of stay and survival rates-positive outcomes that have not been consistently demonstrated in other studies of nurse-led screening or protocol use. A recent multihospital quality improvement program focused on early detection and treatment of sepsis on general medical-surgical wards. Sixty sites engaged in a collaborative implementation process that used a basic screening tool and guidance for routine severe sepsis screening, monitoring, and feedback, and a structured scripted communication framework using the SBAR (situation, background, assessment, and recommendation) technique aimed to improve communication [10]. Key to the success of the initiative was an understanding that the training and experiences of ED, ICU, and ward nurses varies, necessitating that nurse education contain critical assessment skills to determine when to suspect a new or worsening infection. The role of nurses in quality improvement of sepsis care is significant. As nurses spend the majority of time with patients, their role in the recognition and treatment of patients with sepsis is critical to improving sepsis-related outcomes [11, 12]. Educating all staff about sepsis management and the translation of guidelines into clinical practice can enhance the nurses' ability to identify sepsis and implement early therapy measures [13]. Additionally, ensuring adequate education for nursing staff is a vital component to establishing highly functional sepsis screening and sepsis management protocols (Table 1). Table 1 Key components of implementing nurse-led sepsis protocols Use the international sepsis guidelines as a performance improvement initiative to identify gaps in care and specific areas for improvement. For example, track data related to sepsis care, including: [black circle] Time to blood cultures [black circle] Time to antibiotics [black circle] Time to lactate levels [black circle] Time to fluid bolus goals [black circle] Compliance with all elements of the 3-h bundle [black circle] Compliance with all elements of the 6-h bundle Enlist administrative and physician stakeholder support to develop and pilot a nurse led sepsis protocol initiative Provide a unit-, hospital-, and system-wide educational campaign that considers the varying level of nursing training and experience Enlist nurse champions to spearhead the nurse-led protocol Conduct ongoing data review and provide results to nursing staff and key stakeholders Further refine processes based on ongoing audit data and feedback Adapted from Kleinpell et al. [12] Targeting early recognition of sepsis with use of multifaceted performance improvement initiatives has been demonstrated to improve compliance with sepsis performance measures with associated reductions in hospital mortality in patients with severe sepsis and septic shock in ICU and ward settings [8, 9, 14]. However, as sepsis remains a leading cause of mortality in critically ill patients worldwide, additional studies are needed to determine the most effective way to achieve sepsis bundle targets, including the incorporation of nurse-led screening and treatment protocols.

Background Therapeutic music has been shown to reduce stress and anxiety, while boosting mood and overall well-being in numerous settings. Building on the success of Vanderbilt University Medical Center’s (VUMC) Therapeutic Music Program, and in collaboration with AARP Tennessee and the Blair School of Music at Vanderbilt, a community-based therapeutic music program was introduced, focusing on community assisted living centers and Veteran audiences. Objective To evaluate the experience and perceptions of Veteran and senior citizens to live therapeutic music performances in order to guide future program development and music selection. Methods Performances were held at a local Veterans Affairs Medical Center and assisted living facilities, involving 42 participants. Student musicians performed music pieces with violin, piano, saxophone, and vocals. After each performance, audience members completed an anonymous survey. Results Survey results revealed that 93% (n = 39) of participants recognized music as a significant or moderately significant part of their lives. Most participants enjoyed a wide variety of instruments and genres (60%, N = 24). Participants appreciated the live performance, vocal pieces, and the atmosphere it created. Conclusions Data on preferred genres and instruments can guide the selection of musicians for other therapeutic programs. Furthermore, insights into the most enjoyable parts of the performance can inform customization of future music performances to help better address the needs of different audiences.