Nursing Expertise Drives Early Detection of Patient Decline
The predictive tool is based on nurses’ expertise and real-life observation patterns.
The CONCERN Early Warning System (EWS) uses nursing surveillance patterns in acute and intensive care units to predict patient deterioration up to two days earlier than traditional systems, significantly improving outcomes and reducing mortality rates in hospitals, notes a Columbia University media release.
A study at Columbia, “Real-Time Surveillance System for Patient Deterioration: A Pragmatic Cluster-Randomized Controlled Trial,” in Nature Medicine, reveals that CONCERN EWS demonstrated a 35.6% reduction in mortality risk, and decreases in hospital length of stay (11.2%) and sepsis rates (7.5%) compared with usual care. Patients had a 24.9% higher risk of unexpected ICU transfers, underscoring the importance of early intervention to prevent complications.
To drive use across health systems, a Columbia team developed the CONCERN toolkit, including training and implementation materials. Ongoing research is focused on evaluating implementation strategies and adapting the predictive model for broader patient populations, including inpatient pediatrics and emergency department settings.
In an overview of the toolkit, the American Nurses Foundation encourages hospitals to join the CONCERN Initiative, noting that the predictive tool is based on nurses’ expertise and real-life observation patterns.
“Unlike many [other] AI-based healthcare tools, CONCERN has been successfully tested in real hospitals and proven to work across multiple locations,” the foundation adds.
A related article in News Medical Life Sciences explains that the CONCERN EWS uses machine learning to analyze data that nurses enter into electronic records, including subtle signs of patient deterioration — such as pallor change or shifts in mental status. The tool generates hourly, easy-to-read risk scores that support clinical decision-making.
“Nurses are particularly skilled and experienced in detecting when something is wrong with patients under their care,” Sarah Rossetti, associate professor of biomedical informatics and nursing at Columbia, says in the article. “When we can combine that expertise with AI, we can produce real-time, actionable insights that save lives.”
Sleep Spindles Signal Recovery After Brain Injury
The study proposes that sleep architecture could be an additional tool in prediction models.
For patients with acute brain injuries, well-formed sleep spindles (WFSS) are associated with faster recovery of consciousness and can predict return to functional independence – alongside cognitive motor dissociation (CMD) – regardless of differences in age, neurological status and injury type.
“Sleep Spindles as a Predictor of Cognitive Motor Dissociation and Recovery of Consciousness After Acute Brain Injury,” in Nature Medicine, shows that WFSS patterns on electroencephalography (EEG) appeared in about one-third of 226 patients who were behaviorally unresponsive, often emerging before CMD detection.
A related article in PulmCCM emphasizes that CMD, or covert consciousness, challenges the belief that unresponsive patients lack awareness, showing some can follow commands despite no outward reaction. But CMD detection is often limited to research centers using functional MRI or EEG protocols.
The sleep spindle study, conducted at Columbia University between 2014 and 2023, proposes that sleep architecture could become an additional tool in prediction models. The findings predicted both recovery of consciousness and one-year functional independence, even after controlling for established predictors.
A first-person article in a 2020 edition of AACN Bold Voices is a reminder that each patient with a brain injury heals differently, and patient care goes hand in hand with family support. (To view the article, enter page “18” in the toolbar after opening the PDF.)
Written by April Lackowski-Postel, the story begins the day her 20-year-old son, Dalton, sustained a traumatic brain injury in a motorcycle accident, resulting in a lengthy coma and a series of setbacks. Eventually, aided by coma stimulation and tracking, Dalton began to respond to his mother’s touch and gradually improved, returning home 10 months after the accident.
“The healthcare team educated me, and we worked together to find the best path for Dalton’s recovery,” April explained. “This journey showed me that nursing and medicine care for the body, and love heals and cares for the person.”
Family Participation Helps Prevent Delirium in ICU Patients
The review supports many potential ICU strategies, several of which involve family support.
Family participation can help prevent and reduce the duration of delirium for ICU patients.
“The Effectiveness of Family Participation Interventions for the Prevention of Delirium in Intensive Care Units: A Systematic Review,” in Intensive and Critical Care Nursing, notes that an assessment of 14 studies could not produce a viable meta-analysis due to “variability in study designs, interventions and patient populations,” but it highlights several successful interventions to manage delirium in the ICU.
Based on the results of the studies, published from 2017 to 2024 in Europe, America, Australia and Asia that included 33,232 patients, the review supports many potential ICU strategies, many of which involve family support and participation in nursing care.
“Despite the heterogeneity of interventions and results identified in this review, we conclude that non-pharmacological strategies, such as flexible family visitation, family presence and the development of family-mediated basic care activities, are effective in reducing delirium incidence in the ICU and offer multiple benefits for the patient and their family,” the review notes.
“Future research could standardize outcome measures and study designs to enhance data synthesis and improve the reliability of findings. Understanding whether elements such as education, engagement or emotional support have the greatest effect on delirium prevention could inform the development of more targeted and effective interventions.” Research should also focus on identifying specific components of family participation that are most effective in preventing delirium.
AACN offers many resources that address the prevention of ICU delirium, including “Awake and Walking ICU: Mastery of the ABCDEF Bundle,” a webinar on sedation and mobility practices. And a blog, “Delirium – What’s Old Is New Again,” reviews research on the effects of sedation choices and family visitation for treating patients with delirium.
New Clinical Practice Guideline on Transfusion Strategies
The guideline presents an opportunity for healthcare facilities to develop local policies.
New guidance from the American College of Chest Physicians advises a risk/benefit assessment before transfusions of platelet or fresh frozen plasma (FFP) in critically ill patients with thrombocytopenia or coagulopathy, recommending these transfusions only for patients at high risk of bleeding or facing potentially catastrophic outcomes.
“Transfusion of Fresh Frozen Plasma and Platelets in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline,” in Chest, emphasizes that evidence is limited to support transfusion’s benefits and associated risks. The guideline outlines platelet transfusion thresholds by bleeding risk, favoring a first-line no-transfusion approach for most procedures, except for lumbar puncture, where a less restrictive threshold is suggested to reduce the risk of catastrophic complications.
An expert panel evaluated 7,172 studies, narrowing the search to 100 articles for detailed assessment. After applying inclusion criteria, 16 studies — one randomized controlled trial and 15 observational studies — formed the basis for the recommendations, which apply to critically ill patients, excluding trauma and neuro-critical care populations due to their distinct treatment needs.
The panel developed seven clinical questions to systematically evaluate platelet and FFP transfusions in various scenarios, ranking outcomes to determine the most critical factors for decision-making. Initial recommendations apply to patients with thrombocytopenia, while later guidance addresses transfusions for invasive procedures such as central line or arterial line insertion, thoracic or abdominal procedures, lumbar puncture, endoscopy and bronchoscopy.
Standardizing transfusion practices through shared decision-making and institutional guidelines could optimize patient care, improve equity in accessing blood products and reduce costs, the guideline notes. It could result in about 500,000 fewer units of platelets and FFP transfused annually.
“These guidelines should be an opportunity for institutions to develop local policies, monitor their impact on transfusion practices, and provide a framework to longitudinally optimize platelet and FFP use,” the article adds.
Workplace Violence Frequent and Underreported in ICUs
The review included 12,614 ICU personnel in 18 specific studies.
Workplace violence, which frequently impacts healthcare workers worldwide, is underreported, with ICU and emergency department staff the most likely victims.
“Violence Against Healthcare Professionals in Intensive Care Units: A Systematic Review and Meta-Analysis of Frequency, Risk Factors, Interventions, and Preventive Measures,” in Critical Care, notes the median frequency of violence was 51% across a large population, with 31% of workers experiencing physical violence, 57% verbal violence and 12% sexual violence.
“Despite such severe consequences, we found up to 80% of incidents not being reported initially,” the review notes. “Workplace violence is frequent and underreported in intensive care units, with potential serious consequences for healthcare workers, calling for heightened awareness, screening, and preventive measures.”
Patients and visitors commit the most acts of violence against staff, with some studies showing that co-workers and superiors also are responsible for a significant number of incidents in ICUs. Younger and less experienced staff were more likely to be victims, and those exhibiting violence tended to be older and male with severe illness, delirium or dementia.
Based on data from 139,533 healthcare workers in 75 studies from 32 countries, the review included 12,614 ICU personnel in 18 specific studies. The most common results of violence on nurses, the studies show, are stress, burnout, anxiety and job dissatisfaction.
In interviews to track the failures to report incidents, the review finds medians of 39% to 85% based on the geographic continent, with the most common reasons a belief that reporting will not change anything and violence is part of the job. Multiple studies that focused on interventions found no reduction in frequency of events or inconclusive results.
“Further randomized prospective trials are urgently needed to improve reporting of these incidents and to gain a better understanding of the effectiveness of screening and preventive measures,” the review concludes. AACN offers extensive resources related to workplace violence across a range of media.
Communication Nudges Increase Discharge to Hospice, LOS Unaffected
The nudges may be a low-cost, effective approach to improve some end-of-life care.
A cluster randomized clinical trial that encouraged clinicians to document the prognosis of seriously chronically ill patients, potentially offering comfort-focused treatment, did not reduce hospital length of stay (LOS) and increased discharge to hospice.
“Nudging Clinicians to Promote Serious Illness Communication for Critically Ill Patients,” in JAMA Internal Medicine, notes that clinicians in the trial adhered to nudges built into electronic health records about 75% of the time, which reduced the time required to transition patients to comfort-focused care, with no significant impact on 20 secondary measures, including mortality. “The treatment alternative nudge, alone or in combination with the prognosis nudge, may be a low-cost and effective approach to improve some end-of-life care processes among critically ill patients who ultimately would not have survived,” the study notes.
Conducted at 10 North Carolina hospitals from February 2018 to October 2020, the trial started with a baseline of usual care, randomly added either prognosis or treatment alternative interventions and combined both interventions to produce four data groups. Using 3,500 encounters involving 3,250 patients, the trial noted an increase in discharge to hospice among the alternative care group (10.9%) and the combined group (8.9%) compared with usual care (7.3%) and earlier issuance of comfort-care orders in the alternative group (4.5 days vs. 3.6 days).
An accompanying editorial adds: “Although most patients and their caregivers prefer more time at home or outside the hospital setting, this goal is often counter-balanced by clinician-level, hospital-level and system-level factors in the setting of severe illness that tend to prolong aggressive treatment and delay the transition to comfort-focused care.”
“Palliative Care in the ICU: Communication Skills in Practice,” an AACN webinar, offers critical care nurses communication skills in different settings: “By applying specific strategies for eliciting another’s perspective, providing emotional support and giving information, nurses can navigate these conversations and facilitate clear communication about disease prognosis and patient goals of care.”
President’s Column: On Purpose
As AACN President Rebekah Marsh begins her term, she explores a purpose-filled life and intentional nursing practice despite detours and doubts. “It isn’t about having a superpower or being born to be a nurse. It isn’t about faking it until you make it. Practice it until you become it.”
Reimagining Medication Administration for Improved Workflow
In a busy med-surg/intermediate care unit in a Delaware hospital, nurses experienced a persistent time crunch after shift changes. After participating in an AACN Clinical Scene Investigator (CSI) Academy process improvement project, the team saw on-time medication administration improve from about 70% to over 90%. “Just that little change, changed everything … I have more time for my patients.”