ICU Teamwork Drives CLABSI Reduction
CLABSI reduction efforts were effective in a cardiac surgical ICU and improved patient safety.
A team-driven effort to combat central line-associated bloodstream infections (CLABSIs) in a cardiac surgical ICU produced notable improvements, highlighting the impact of shared accountability, ICU staff engagement and top-level executive support of patient safety outcomes.
“Interprofessional Approach to Reducing Central Line-Associated Bloodstream Infections in a Cardiac Surgical Intensive Care Unit,” in Critical Care Nurse, describes how a three-year initiative reduced the standardized infection ratio from 2.3 to 0.8 and decreased catheter use from 1.0 to 0.89.
A unit-based leadership team at University of Virginia Health in Charlottesville conducted case reviews of CLABSI events to identify common, modifiable risk factors. A targeted action plan incorporated the following interventions:
- Improved hand hygiene with mobile sanitizer stations, frequent performance checks and role modeling by unit leaders
- Standardized central venous catheter (CVC) insertion using a checklist, independent audits and proper chlorhexidine drying time
- Improved dressing adherence with topical hemostatic agents and gum mastic adhesive to reduce dressing changes
- Performed daily catheter removal assessments by nursing and physician teams to reduce unnecessary central line days
- Integrated electronic ICU checklist to alert clinicians to CVC duration and promote timely removal
- Reinforced blood culture stewardship by promoting evidence-based guidance and implementing team timeouts before ordering a new blood culture
“Although we were not able to achieve our goal of having 0 CLABSIs, we observed a reduction compared with baseline, with a standardized infection ratio of less than 1.0 at the end of 2 years,” the study reports, noting that the quality improvements may be applicable to other ICUs.
In addition to unit-based interventions, a separate study in Critical Care Medicine evaluated the effectiveness of medical liquid adhesive (MLA) to preserve jugular CVC dressings and reduce mechanical complications. MLA demonstrated an acceptable safety profile and was associated with longer dressing dwell times and fewer dressing failures, supporting its use in ICU settings.
Advancing Early Care in Cardiogenic Shock
The guidelines present a 24-hour road map for clinicians.
Recognizing an urgent need to improve outcomes in cardiogenic shock (CS), the American College of Cardiology (ACC) convened international experts to develop new clinical practice guidelines, addressing early diagnosis, hemodynamic monitoring and multidisciplinary management strategies.
The resulting ACC expert consensus statement, in Journal of the American College of Cardiology, highlights the complex clinical trajectory of CS, a leading cause of admission to cardiac ICUs. With short-term mortality at 30% to 40% and one-year mortality at 50% or more, a critical emphasis is placed on the first 24 hours of care.
This initial window requires hemodynamic reassessment and individualized intervention to stabilize patients, restore perfusion and prevent organ damage. A standardized, team-based approach guides clinical decisions and transitions to myocardial recovery, advanced therapies, or palliative care when appropriate.
The guidelines present a 24-hour road map, featuring the SUSPECT CS tool for evaluation across key clinical domains:
- Signs/symptoms – Watch for altered mental status, chest pain, cold extremities, rapid pulse, low pulse pressure, elevated jugular venous pressure and others.
- Urine output – Monitor for oliguria or anuria.
- Sustained hypotension – Identify SBP ›90 mm Hg, MAP ›65 mm Hg for >30 minutes, or a >30 mm Hg decrease from baseline.
- Perfusion – Look for signs of end-organ malperfusion, including elevated lactic acid, ALT, creatinine or severe acidosis without another known cause.
- ECG/echocardiogram – Assess for acute ischemia (e.g., STEMI), ventricular dysfunction or significant valvular pathology.
- Congestion – Evaluate for congestion using clinical and hemodynamic data; determine ventricular involvement.
- Triage – Activate the shock team, and determine the need for advanced support or a transfer to higher-level care.
“It is important to highlight that the initial suspicion and diagnosis of CS does not require invasive hemodynamics” the guidelines emphasize, noting that invasive assessment may still provide valuable insight into ventricular involvement and the patient’s congestive profile, which can inform early therapeutic decisions.
Staffing Standards Address Nurse Shortage, Systemic Issues
AACN’s staffing standards provide actions, tools and resources for nurses and teams.
Amid the ongoing nurse shortage and systemic issues in the workplace, AACN developed seven standards for adult progressive care staffing and also for adult critical care staffing, which are necessary for healthy work environments.
“AACN Standards for Appropriate Staffing in Adult Progressive Care” and “AACN Standards for Appropriate Staffing in Adult Critical Care” provide specific actions, tools and resources for nurses and units with the goals of improving patient assignments, minimizing burnout, considering moral distress and addressing staff shortages. The staffing standards align with and leverage AACN’s other Healthy Work Environment standards and emphasize real-world tactics.
Recent data from “The 2024 National Nursing Workforce Survey,” in Journal of Nursing Regulation, indicates about 40% of current RNs plan to exit the workforce within the next five years, either through retirement (21.9%) or leaving nursing (18.0%), which is an 11.2% increase over 2022, representing over 216,000 nurses. Besides retirement, the most common reasons for leaving include stress and burnout (41.3%), workload (32.8%) and understaffing (26.0%).
Concerns about staffing and workload remain significant even after the COVID-19 emergency, and the structural issues that existed previously remain a threat to nursing. “Continued efforts to retain more experienced nurses and otherwise address longstanding factors associated with nurses’ premature intent to leave, such as burnout, insufficient staffing and high workloads, are necessary to ensure sustainable workforce planning moving forward,” the survey adds.
Further concerns about the impact of staffing on patient care come from reliance on agency nurses and overtime shifts for staff nurses, according to, “Increased Utilization of Overtime and Agency Nurses and Patient Safety,” a report in JAMA Network Open. The quality improvement study involved 70 U.S. hospitals from 2019 to 2022, suggesting that “both nurse overtime and nurse agency hours are associated with increased rates of pressure ulcers, a measure that is one of the most sensitive to nursing care.”
Empower Nurses to Defuse Agitation Safely
Using a stepwise framework can reduce potential complications related to restraints.
Managing a patient’s agitation demands significant time and resources, and without appropriate de-escalation models and techniques, such episodes can contribute to staff burnout, compromise safety and undermine the therapeutic alliance between clinicians and patients.
“Avoid Restraints: De-escalation and Acute Agitation,” in American Nurse, outlines the reasons patients become agitated and suggests diagnostic tests to help determine the causes. The article advocates a four-step framework for de-escalation, emphasizing nonrestrictive interventions while reserving traditional methods such as chemical and physical restraints when primary efforts are ineffective.
- Step 1: De-escalation – Place patients in a calm, nonthreatening environment, while actively listening, adjusting surroundings for comfort and using nursing interventions such as assisted breathing or music therapy. Communicate calmly and regulate your emotions to help avoid escalation, maintain safety and limit the use of patient restraints or seclusion.
- Step 2: Physical restraint – Use this step only if step 1 is unsuccessful. Begin with the least-restrictive restraints, monitor the patient frequently, and escalate only if a patient’s behavior warrants it.
- Step 3: Pharmacotherapy – Initiate alone or with physical restraints as appropriate. Ideally, a clinician skilled in managing acute agitation should guide this step since patient cooperation may eliminate the need for restraints.
- Step 4: Manage acute agitation – Frequently reassess the effectiveness of interventions. Monitor vital signs and remain alert to decompensation.
The article lists a series of de-escalation techniques that all healthcare providers should know to recognize agitation early and respond with empathy, calm communication and nonconfrontational language. It also emphasizes environmental adjustments and personalized interventions to reduce anxiety, build trust and restore a sense of safety.
“Many models and programs, such as the Management of Aggressive Patient Situations and the Crisis Prevention Institute, offer resources aimed at educating healthcare workers and improving their de-escalation skills through proper training and the use of evidence-based techniques.”
Spanish-Language Tool for Families May Improve Delirium Diagnosis
Larger studies are needed to further assess the tool’s accuracy.
A Spanish-language tool for family caregivers may help diagnose delirium in ICU patients more effectively than standard tools that do not account for language differences.
In “Achieving Health Equity in Delirium Detection in Spanish-speaking Latinx ICU Patients,” in American Journal of Respiratory and Clinical Care Medicine, the Spanish-language family-obtained Confusion Assessment Method (Spanish-FAM) aligned more closely with delirium detection tools than usual care. “In this patient population, Spanish-FAM may be an acceptable alternative to usual care, though larger scale studies are needed to assess further the accuracy of this tool,” the study notes.
The results of the single-center study at University of California, San Diego, involving 63 ICU patients, indicate that if a provider is unable to communicate directly with a patient it may lead to an inaccurate assessment of delirium. “These findings suggest that Spanish-speaking patients who experience patient-provider language discordance may be at high risk for developing ICU delirium,” notes study author Ana Lucia Fuentes Baldarrago in a related article in Medical Xpress.
“In some cases, patients were classified as not delirious but showed clear signs of delirium when engaged in Spanish. Conversely, she [Fuentes Baldarrago] also encountered patients labeled as delirious who were simply unable to communicate effectively because they were unable to communicate with providers in their own language,” the article notes.
Fuentes Baldarrago adds that Spanish-speaking patients had much higher odds of being restrained or receiving deep sedation, which may increase the risk of ICU delirium. They also had “lower odds of receiving evidence-based delirium-prevention interventions.”
The Spanish-language FAM was developed to test ways to improve diagnoses in this population. “These findings underscore the urgent need to evaluate commonly used clinical tools in diverse populations, particularly among non-English-speaking patients who are frequently excluded from clinical trials,” Fuentes Baldarrago adds.
ESICM Guidelines on Resuscitation Fluids
The guidelines include four conditional recommendations.
An international expert panel developing guidelines on volume of early resuscitation fluids for critically ill adults made four conditional recommendations and four ungraded best practice statements, and did not answer two questions.
In “European Society of Intensive Care Medicine (ESICM) 2025 Clinical Practice guideline on Fluid Therapy in Adult Critically Ill Patients: Part 2 – The Volume of Resuscitation Fluids,” in Intensive Care Medicine, the panel conditionally recommends up to 30 mL/kg of intravenous crystalloids for patients with sepsis and septic shock and an individualized approach during the optimization phase.
“Clinicians should assess their patients clinically and consider assessing fluid responsiveness (if possible) before administering more crystalloids in the initial phase of resuscitation, recognizing that some may require more or less,” the guidelines note.
The 19-person panel also issued conditional recommendations for a restrictive fluid strategy for patients with hemorrhagic shock after penetrating trauma and after blunt trauma. “The current evidence on low volume fluid resuscitation in trauma is limited, indicating a need for more large-scaled, well-designed RCTs [randomized clinical trials] to assess its effectiveness.”
In cases of obstructive shock, the panel offers best practice statements, suggesting cautious administration of fluids in patients with circulatory failure due to acute pulmonary embolism clots or cardiac tamponade. “Overall, there is insufficient evidence to support a systematic liberal or restrictive intravenous fluid strategy in patients with obstructive shock due to tamponade.”
For adults with left-sided cardiogenic shock causing circulatory failure, the guidelines include a best practice statement that fluid resuscitation should not be the primary treatment. “Standardized definitions and criteria for fluid status, responsiveness and overload in these patients are lacking.”
The panel made no recommendations on liberal vs. restrictive strategies for managing septic shock or acute respiratory distress syndrome. “RCTs are needed to determine the optimal fluid management strategy for patients with both circulatory failure and ARDS.”
Honoring the Black Angels
In the 1920s, facing nursing shortages, a Staten Island hospital began hiring 300 Black nurses to care for patients with tuberculosis. Virginia Allen, one of the last living Black Angels – as the nurses were known – tells the story of their frontline care for these patients and how their work helped advance a cure for the disease.