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American Journal of
Critical Care
November 2015 • Volume 24, Number 6
SQUIRE 2.0
Guidelines
Patients’ Experience
of Delirium
CAM Validation
for Cardiac Patients
After Surgery
Physical Restraint
Use in a Dutch ICU
Acute and Primary
Care Providers’
Communication
Vasopressors and
Pressure Ulcers

Validity and Sensitivity
of 6 Pain Scales
Small-Bore Feeding
Tube Placement
Parents’ Participation
During Rounds
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Evidence-based interdisciplinary knowledge for high acuity and critical care
AMERICAN ASSOCIATION OF Editors in Chief
CRITICAL-CARE NURSES
President, KAREN MCQUILLAN, RN, MS, CNS-BC, CCRN, CINDY L. MUNRO, RN, PhD, ANP
CNRN; President-elect, CLAREEN WIENCEK, RN, PhD, Associate Dean for Research and Innovation, University of South Florida College of Nursing, Tampa, Florida
CACCHRNP,N C, HACFNN;P ;T Sreecar seutraerry,, DPAEUBLOAR AS.H M KCLECIANU, RLNE,Y M, SND,N APC, NASP-RBNC,, RICHARD H. SAVEL, MD
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SON, RN, PhD; MICHELLE KIDD, RN, MS, ACNS-BC, CCRN-K; Virginia Commonwealth University School of Nursing American Association of Critical-Care Nurses
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www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2015, Volume 24, No. 6 457
American Journal of
Critical Care
Evidence-based interdisciplinary knowledge
for high acuity and critical care
November 2015, Volume 24, No. 6
464
Abstracts of articles available exclusively online at
www.ajcconline.org
e86 Semiquantitative Cough Strength Score for Predicting Reintubation
After Planned Extubation
Jun Duan, Lintong Zhou, Meiling Xiao, Jinhua Liu, and Xiangmei Yang
e91 Peripheral Muscle Strength and Correlates of Muscle Weakness in
Patients Receiving Mechanical Ventilation
Linda L. Chlan, Mary Fran Tracy, Jill Guttormson, and Kay Savik
e99 Perceived Barriers to Anthropometric Measurements in Critically
Ill Children
Sharon Y. Irving, Stephanie Seiple, Monica Nagle, Shiela Falk, Maria Mascarenhas,
and Vijay Srinivasan
e108 Being There: Inpatients’ Perceptions of Family Presence During
Resuscitation and Invasive Cardiac Procedures
Renee Samples Twibell, Shannon Craig, Debra Siela, Sherry Simmonds, and
Cynthia Thomas
466
Critical Care Research SQUIRE 2.0 (Standards for Quality Improvement Report-
ing Excellence): Revised Publication Guidelines From a Detailed
Consensus Process
Greg Ogrinc, Louise Davies, Daisy Goodman, Paul Batalden, Frank Davidoff,
and David Stevens
On the Cover Coming in January …
Detail from “The Mind Settling” Chapman and colleagues examine family
Jacqueline Roliardi and nurse satisfaction with elimination of
14'' x 11'' all visitation restrictions in a mixed-profi le
Mixed media intensive care unit.
To view other works by
Jacqueline Roliardi
Visit her online gallery,
http://jackieroliardiart.artspan.com or at
On The Edge Gallery in Scottsdale, AZ. WESTERPNR PUINBLTIS. HDINIGG IATSASOLC. IAETVIOENNTS
AMERICAN JOURNAL OF CRITICAL CARE® (Print ISSN 1062-3264, Online ISSN 1937-710X) is published bi monthly (January, March, May, July, September, Nov ember)
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458 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2015, Volume 24, No. 6 w ww.ajcconline.org
American Journal of
Critical Care
474
Delirium Assessment Lived Experience of the Intensive Care Unit for Patients Who
Experienced Delirium

Karen Whitehorne, Alice Gaudine, Robert Meadus, and Shirley Solberg
480
Validation of the Confusion Assessment Method in Detecting
Postoperative Delirium in Cardiac Surgery Patients
Nina Smulter, Helena Claesson Lingehall, Yngve Gustafson, Birgitta Olofsson, and
Karl Gunnar Engström
488
Patient Safety Use of Physical Restraints in Dutch Intensive Care Units:
A Prospective Multicenter Study
Arendina W. van der Kooi, Linda M. Peelen, Rosa J. Raijmakers, Renée L. Vroegop,
Danique F. Bakker, Hilâl Tekatli, Mark van den Boogaard, and Arjen J.C. Slooter
496
Standardizing Communication From Acute Care Providers to Primary
Care Providers on Critically Ill Adults
Kerri A. Ellis, Ann Connolly, Alireza Hosseinnezhad, and Craig M. Lilly
501
Pressure Ulcer Management Vasopressors and Development of Pressure Ulcers in Adult Critical
Care Patients
Jill Cox and Sharon Roche
514
Critical Care Evaluation Validity and Sensitivity of 6 Pain Scales in Critically Ill,
Intubated Adults
Mamoona Arif Rahu, Mary Jo Grap, Pam Ferguson, Patty Joseph,
Sarah Sherman, and R. K. Elswick, Jr
525
Nutrition in Critical Care Verifying Placement of Small-Bore Feeding Tubes:
Electromagnetic Device Images versus Abdominal Radiographs
Vera Bryant, Jean Phang, and Kevin Abrams
532
Pediatric Critical Care Increasing Parental Participation During Rounds in a Pediatric Cardiac
Intensive Care Unit
Angela Blankenship, Sheilah Harrison, Sarah Brandt, Brian Joy, and Janet M. Simsic
460 539 545
Editorial Patient Care Page ECG Puzzler
Tough and Competent Family Presence During Bedside ECG Alarm Management
Richard H. Savel and Invasive Procedures Michele M. Pelter, Teri M. Kozik,

Cindy L. Munro Linda Bell Salah S. Al-Zaiti, and Mary G. Carey

463 540 547
Clinical Pearls Clinical Evidence Review Education Directory
The “Cold Cord”: A Review of
512
Evidence-Based Review Therapeutic Hypothermia for
Visit AJCC’s Web site, www.ajcconline.org,
and Discussion Points Traumatic Spinal Cord Injuries to submit a manuscript or for author
Ronald L. Hickman Brett Tracy, Rochelle Armola, and guidelines, full text of selected articles,
OnlineNOW articles, digital edition
Jennifer Micham
access, eLetters, links to AACN’s online
continuing education tests, and more.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2015, Volume 24, No. 6 459
E
ditorial
T C
OUGH AND OMPETENT
By Richard H. Savel, MD, and Cindy L. Munro, RN, PhD, ANP
I
t was a Friday afternoon: January 27, 1967, to be their spacecraft, and, of greatest complexity and
precise. The United States and the Soviet Union importance, developing techniques to successfully
were in the middle of the Cold War. As a part of rendezvous spacecraft with each other (mandatory
this ideological standoff, these 2 superpowers were for a successful moon landing), all with much less
engaged in a heated space race—a race that the United computing power than each of us now carry in our
States was losing. The Soviet Union had successfully smartphones.
launched the first artificial space satellite, Sputnik 1, in
1957, and had beaten us by putting the first man in Apollo 1: Pressure to Succeed
space, the first man in orbit, the first woman in space, It was in this context—during the Cold War,
and enabling the first person to perform a space walk. the space race, and immense pressure to get to the
A visionary and bold response was articulated by moon within the decade—that astronauts Virgil
President John F. Kennedy in 1961. Later, in 1962, he “Gus” Grissom, Edward White, and Roger Chaffee
expanded his remarks: “This nation should commit were working in their Apollo space capsule at Cape
itself to achieving the goal, before the decade is out, Canaveral Air Force Station Launch Complex 34.
of landing a man on the moon and returning him Grissom and White were veterans of space: the for-
safely to the Earth” as well as the famous words “We mer having been involved in both Mercury and Gem-
choose to go to the moon in this decade and do the ini missions, and the latter having performed the first
other things, not because they are easy, but because American spacewalk. Chaffee, the rookie, was a dec-
they are hard…”1 orated naval aviator. On that day, these men were
The United States had successfully completed performing what was known as a “plugs out” sim-
Project Mercury,2 proving we could put a human ulation test to demonstrate whether the spacecraft
into space, and Project Gemini,3 in which early Amer- would function properly using its internal power and
ican space pioneers (in a spacecraft just large enough life support systems. This was not considered to be a
to contain 2 people) demonstrated how to actually hazardous test.
do the work of astronauts. Through trial, error, per- The astronauts entered the space capsule at around
severance, and tachycardia, these men learned how 1 PM and worked in their cramped quarters for hours.
to perform such tasks as working in space, navigating There were problems, including strange odors and, of
greater concern, significant trouble with the commu-
nication system. Grissom was noted for having said
©2015 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2015182 “How are we going to get to the moon if we can’t
460 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2015, Volume 24, No. 6 www.ajcconline.org
“
The single greatest lesson from Apollo 1 that
”

endures for us today is a lesson of leadership.

talk between 2 or 3 buildings?”4 Their simulated His speech articulated what became known as “The
countdown continued into the early evening. Kranz Dictum” 5:
At 6:31 PM, the fateful words “Fire! Fire in the
Spaceflight will never tolerate carelessness,
cockpit!” were transmitted over the communications
incapacity, and neglect. Somewhere, some-
system. Seventeen seconds later, all 3 astronauts were
how, we screwed up. It could have been in
dead. America’s space program came to an abrupt
design, build, or test. Whatever it was, we
halt. The United States had lost its first casualties in
should have caught it. We were too gung ho
the race for the moon. Catastrophe had occurred not
about the schedule and we locked out all of
during a complex mission thousands of miles from
the problems we saw each day in our work.
earth, but here on terra firma during a routine test.
Not one of us stood up and said, “Dammit,
Multiple investigations were launched, and the
stop!“ I don't know what [the] committee
entire Apollo space program was frozen. There
will find as the cause, but I know what I find.
would not be another manned spaceflight until
We are the cause! We were not ready! We did
October 1968, some 21 months later. From a tech-
not do our job!
nical standpoint, the problems are now well known.4
From this day forward, Flight Control will
The space capsule was routinely filled with pressur-
be known by two words: “Tough“ and “Com-
ized 100% oxygen, the escape hatches opened in,
petent.“ Tough means we are forever account-
and some wiring had lost insulation. A complete
able for what we do or what we fail to do.
redesign of the spacecraft would be required, with
We will never again compromise our respon-
hatches that opened outwards and with an atmo-
sibilities. Every time we walk into Mission
sphere that was no longer pure oxygen, along with
Control we will know what we stand for.
many other complex design changes. But in addi-
Competent means we will never take any-
tion to a redesign of the spacecraft, a significant reas-
thing for granted. We will never be found
sessment of the entire administrative culture at the
short in our knowledge and in our skills. Mis-
National Aeronautics and Space Administration
sion Control will be perfect. When you leave
(NASA) also would be required.
this meeting today you will go to your office,
and the first thing you will do there is to write
The Kranz Dictum
“Tough and Competent” on your black-
The single greatest lesson from Apollo 1 that
boards. It will never be erased. Each day when
endures for us today is a lesson of leadership. At the
you enter the room, these words will remind
time, the flight director was Eugene Francis “Gene”
you of the price paid by Grissom, White, and
Kranz. On the Monday following the fire and death
Chaffee. These words are the price of admis-
of the astronauts, Kranz gathered up his team. One
sion to the ranks of Mission Control.5,6
can only imagine the immense psychological and
emotional weight and pressure he must have felt. Kranz provided leadership during a dark, dif-
On his watch, the United States had lost 3 of its fin- ficult time for America. He did not wither and
est members of the astronaut corps, and it had hap- become defeated by the challenges that faced him.
pened during a routine simulation session. Instead, he met these challenges head on. He became
This could have easily been a statement of inspired and inspired others. He went on to become
his resignation. Instead, however, Kranz found an one of America’s great heroes, successfully leading
opportunity to offer inspiration and leadership. the team on Apollo 11 that landed the first humans
on the moon and providing inspirational leadership
About the Authors to the team that saved the crew during the Apollo
Richard H. Savel is coeditor in chief of the American Journal 13 crisis—a situation that was a hair’s breadth away
of Critical Care. He is director, surgical critical care at from becoming another fatal disaster.7
Maimonides Medical Center and a professor of clinical
medicine and neurology at the Albert Einstein College of
Medicine, both in New York City. Cindy L. Munro is coeditor Parallels to Critical Care
in chief of the American Journal of Critical Care. She is as-
For those of us working in intensive care, there
sociate dean for research and innovation at the University
of South Florida, College of Nursing, Tampa, Florida. is much to be gained by contemplating these events.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2015, Volume 24, No. 6 461
“
We must not get caught up in the conflict;
”

we must seek to manage it.
First of all, when we find ourselves in a challenging competent because it is our price of admission
situation—something guaranteed in health care and to being part of the intensive care team. To para-
clearly even more commonplace in critical care—we phrase President Kennedy, we do not do what we
should think back to the leadership demonstrated do because it is easy; we do what we do because it is
by Kranz. One could easily imagine him shying meaningful, because it is important, and “because it
away from the daunting situation that faced him. is hard.” We should all take a moment to remember
We critical care professionals are entrusted with the the profound message of inspiration, leadership, pas-
lives of our patients in much the same way NASA sion, and courage that arose from the ashes of the
was with the lives of the astronauts. When we are tragedy that was Apollo 1.
working with a family situation that may be chal-
The statements and opinions contained in this editorial
lenging, we must remember that we have chosen
are solely those of the coeditors in chief.
to do these things because they are noble, because
they are worthy, because they are hard. When we FINANCIAL DISCLOSURES
are working with our colleagues to implement new None reported.
guidelines or protocols to enhance the care and out-
comes of our patients, we must not expect it will eLetters
be easy. It is better if we expect it to be challenging. Now that you’ve read the article, create or contribute to an
online discussion on this topic. Visit www.ajcconline.org
When we encounter conflict—no matter what kind and click “Submit a response” in either the full-text or PDF
of conflict it is—we must stay focused. We must not view of the article.
get caught up in the conflict; we must seek to man-
age it.8 We must take the high road.
REFERENCES
1. John F. Kennedy Presidential Library. http://www.jfklibrary.
Our Search for Inspiration org. Accessed September 3, 2015.
2. Swenson, LS Jr, Grimwood, JM, Alexander, CC. This New
The search for inspiration in critical care nursing
Ocean: A History of Project Mercury. NASA; 1966.
and medicine is of paramount importance. It is the 3. Shayler D. Gemini: Steps to the Moon. London: Springer;
2001.
why. It is why we do what we do. It is why we get
4. Apollo 204 Accident: Report of the Committee on Aero-
up each day. It is why people continue to pursue nautical and Space Sciences, U.S. Senate, with Additional
Views. 1968. http://klabs.org/richcontent/Reports/Failure_
critical care as a profession. We work as a team to
Reports/as-204/senate_956/index.htm. Accessed September
provide comfort, to save lives, to fight death, to win. 3, 2015.
5. Kranz G. Failure Is Not an Option: Mission Control from
As critical care practitioners, it is not necessary for
Mercury to Apollo 13 and Beyond. New York, NY: Simon &
us to search for meaning in our professional lives; Schuster; 2000.
6. Murray C, Bly Cox C. Apollo: The Race to the Moon. New
we have more meaning in our lives in one day than
York, NY: Simon & Schuster; 1989.
many have in a lifetime. Our problem is not one of 7. Lovell J, Kluger J. Apollo 13 (Previously published as Lost
Moon). New York: Houghton Mifflin Company; 1994.
finding meaning, but of reminding ourselves—and
8. Savel RH, Munro CL. Conflict management in the intensive
each other—how important what we do on a daily care unit. Am J Crit Care. 2013;22(4):277-280.
basis really is.
In conclusion, as part of our commitment to
this profession, we must continually remind our- To purchase electronic or print reprints, contact American
Association of Critical-Care Nurses, 101 Columbia, Aliso
selves to be “tough and competent”: tough on
Viejo, CA 92656. Phone, [phone] or [phone]
ourselves because our patients deserve it, and (ext 532); fax, [phone]; e-mail, [email protected].
462 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2015, Volume 24, No. 6 www.ajcconline.org
Clinical Pearls
Putting Evidence-Based
Care in Your Hands
Mary Jo Grap, RN, PhD, ACNP, 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.
Assessing Pain for Patients Who Are Patients’ Perspectives on Family Presence
Unable to Communicate
Patients’ families often want to be at the bedside of hospitalized
Pain is difficult to assess in noncommunicative patients loved ones during crisis events or invasive procedures. Health care
professionals
who are being treated with mechanical ventilation or
have mixed views
are sedated and unable to report pain. Use of a valid
about having
and reliable tool to assist health care providers in the man-
family members
agement of pain in critically ill, sedated, and non-commu-
present during in-
nicative patients is paramount. Arif Rahu and colleagues
vasive procedures,
evaluated the validity and sensitivity of 6 pain scales to
but little is known
identify the most appropriate measure of pain in noncom-
about patients’
municative patients (ie, those who were mechanically venti-
perceptions of
lated and sedated). They found the following:
family presence.
• All pain scales had moderate to high correlations
Twibell and col-
with the patient’s self-report during suctioning.
leagues examined
• All scales were sensitive in capturing the patient’s
this question and
pain response in all phases.
found the following:
• Both subjects and investigators rated pain higher on
• Most hospitalized adults experiencing crisis events prefer family
FACES scale.
presence, yet patient preferences may vary with the nature of the events.
• Caregivers must be cautious in using the FACES scale
• Having family “be there” during resuscitations and unplanned
because subjectivity may lead to over- or undertreating pain.
invasive cardiac procedures was described by patients as being both diffi-
cult and beneficial.
See Article, pp 514-524 • Patients worried about their families getting in the way of the
efforts of the health care team.
• Patients wanted to have control over family members’ behav-
iors during witnessed events but did not express concerns about
Barriers to Obtaining Anthropometric confidentiality.
• Integrating family facilitators into family-centered care and devel-
Measurements in the PICU
oping hospital policies could alleviate decisional burdens on patients,
provide support for families, and reduce anxiety of health care teams.
A n thropometric measurements (eg, weight, stature,
head circumference) are vital for safe care in pedi- See Article, pp e108-e115
atric intensive care units (PICUs). Teams of PICU
personnel should evaluate their practice and determine if
barriers to obtaining anthropometric measurements exist Intensive Care Unit–Acquired Weakness
in their environment and if so, develop innovative ways
to remove these barriers from the provision of care. Irving Intensive care unit–acquired weakness is a frequent complication of
and colleagues explored barriers to obtaining anthropo- critical illness because of patients’ immobility and prolonged use of
metric measurements and determined: mechanical ventilation. Understanding the causes, pathophysiology,
• Ordering providers and nurses vary in their per- and risks factors of ICU-acquired weakness is important for prevention.
ceptions on the importance of these measurements. A study by Chlan and colleagues sought to describe daily measurements
• Estimated and/or reported measurements have a of peripheral muscle strength in patients receiving mechanical ventilation
high likelihood of error and may have a harmful impact and explore relationships among factors that influence intensive care
on patient care. unit–acquired weakness. They found the following:
• Organization- and unit-based support to establish • Patients receiving mechanical ventilatory support are able to
and maintain standards of practice in obtaining anthropo- participate in handgrip dynamometry, which can be used to monitor
metric measurements are essential to patient care. peripheral muscle strength
• Targeted, multidisciplinary education strategies using • Older female patients may be a greater risk for muscle weakness
evidence-based findings to create practice standards and • Prolonged periods of mechanical ventilatory support contribute
establish guidelines on how to obtain anthropometric mea- to peripheral muscle weakness
surements are necessary to dispel myths regarding barriers • Innovative, multidisciplinary interventions are needed to pre-
to obtaining these measurements in the PICU population. serve muscle strength and to minimize muscle weakness in critically
ill patients.

See Article, pp e99-e107 See Article, pp e91-e98
©2015 American Association of Critical-Care Nurses, doi: http://dx.doi.org/10.4037/ajcc2015261
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S C S S P
EMIQUANTITATIVE OUGH TRENGTH CORE FOR REDICTING
R A P E
EINTUBATION FTER LANNED XTUBATION
By Jun Duan, MD, Lintong Zhou, MD, Meiling Xiao, RN, Jinhua Liu, RN, and Xiangmei Yang, RN
Background Semiquantitative cough strength score (SCSS, graded 0-5) and cough peak flow (CPF) have been used to pre-
dict extubation outcome in patients in whom extubation is planned; however, the correlation of the 2 assessments is unclear.
Methods In the intensive care unit of a university- affiliated hospital, 186 patients who were ready for extubation after a
successful spontaneous breathing trial were enrolled in the study. Both SCSS and CPF were assessed before extuba-
tion. Reintubation was recorded 72 hours after extubation.
Results Reintubation rate was 15.1% within 72 hours after planned extubation. Patients in whom extubation was suc-
cessful had higher SCSSs than did reintubated patients (mean [SD], 3.2 [1.6] vs 2.2 [1.6], P = .002) and CPF (74.3 [40.0] vs
51.7 [29.4] L/min, P = .005). The SCSS showed a positive correlation with CPF (r = 0.69, P < .001). Mean CPFs were 38.36
L/min, 39.51 L/min, 44.67 L/min, 57.54 L/min, 78.96 L/min, and 113.69 L/min in patients with SCSSs of 0, 1, 2, 3, 4, and
5, respectively. The discriminatory power for reintubation, evidenced by area under the receiver operating characteris-
tic curve, was similar: 0.677 for SCSS and 0.678 for CPF (P = .97). As SCSS increased (from 0 to 1 to 2 to 3 to 4 to 5), the
reintubation rate decreased (from 29.4% to 25.0% to 19.4% to 16.1% to 13.2% to 4.1%).
Conclusions SCSS was convenient to measure at the bedside. It was positively correlated with CPF and had the same
accuracy for predicting reintubation after planned extubation. (American Journal of Critical Care. 2015;24:e86-e90)
©2015 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2015172
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P M S C M
ERIPHERAL USCLE TRENGTH AND ORRELATES OF USCLE
W P R M V
EAKNESS IN ATIENTS ECEIVING ECHANICAL ENTILATION
By Linda L. Chlan, RN, PhD, Mary Fran Tracy, RN, PhD, CCNS, Jill Guttormson, RN, PhD, and Kay Savik, MS
Background Intensive care unit–acquired weakness is a frequent complication of critical illness because of patients’
immobility and prolonged use of mechanical ventilation.
Objectives To describe daily measurements of peripheral muscle strength in patients receiving mechanical ventilation
and explore relationships among factors that influence intensive care unit–acquired weakness.
Methods Peripheral muscle strength of 120 critically ill patients receiving mechanical ventilation was measured daily
by using a standardized handgrip dynamometry protocol. Three grip measurements for each hand were recorded in
pounds-force; the mean of these 3 assessments was used in the analysis. Correlates of intensive care unit–acquired
weakness (age, sex, illness severity, duration of mechanical ventilation, medications) were analyzed by using mixed
models to explore the relationship to grip strength.
Results Median baseline grip strength was variable yet diminished (7.7 pounds-force), with either a pattern of dimin-
ishing grip strength or maintenance of the baseline low grip strength over time. With controls for days of measure-
ment, female sex ((cid:96) = -10.4; P < .001), age ((cid:96) = -0.24; P = .004), and days receiving mechanical ventilation ((cid:96) = -0.34;
P = .005) explained a significant amount of variance in grip strength over time.
Conclusions Patients receiving prolonged mechanical ventilation had marked decrements in grip strength, measured
by hand dynamometry, a marker for peripheral muscle strength. Hand dynamometry is a reliable method for measur-
ing muscle strength in cooperative critically ill patients and can be used to develop interventions to prevent intensive
care unit–acquired weakness. (American Journal of Critical Care. 2015;24:e91-e98)
©2015 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2015277
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