This issue of Critical Care Nursing Quarterly includes articles that illustrate the importance of clinical studies and research aimed at validating intensive care unit (ICU) protocols and practice. The international list of authors represents bedside clinicians, nurse managers, physicians, pharmacologists, educators, and research associates who are passionate about improving the clinical outcomes for patients in critical care units.

Mohrien and colleagues' article, "Remifentanil, Ketamine, and Fospropofol: A Review of Alterative Continuous Infusion Agents for Sedation in the Critically Ill," indicates that these may be suitable alternatives for certain patient populations, especially when the usual options are unavailable or contraindicated. ICU staff members must be well versed about their actions and side effects prior to utilization to ensure safe administration and to attain the desired clinical outcomes.

The researchers from Turkey, Genc, Koca, and Gunerli, report their findings about the physiological impact of an exercise regimen in their article, "What Are the Hemodynamic and Respiratory Effects of Passive Limb Exercise for Mechanically Ventilated Patients Receiving Low-Dose Vasopressor/Inotropic Support." They conclude that further prospective research is indicated to validate their findings.

Mullin's article, "Transradial Approach Versus Transfemoral Approach for Coronary Angiography and Coronary Angioplasty," compares the clinical and procedural outcomes of these alternatives and provides evidence that the transradial approach for coronary angiography and angioplasty is associated with lower risks of adverse outcomes contrasted with the transfemoral approach. She highlights the role of the nurse practitioner to ensure proper assessment and management of patients.

The article, "Glycemic Control in a Medical Intensive Care Setting: Revision of an Intensive Care Unit Nurse-Driven Hyperglycemia Protocol," by Dodson, Simpson, and Feinstein explores the impact of a rapid-acting insulin bolus administered with enteral feedings. The study establishes groundwork for practice changes aimed at improving glycemic control among patients in a medical ICU. This work is followed by a complementary study, "Acute Ischemic Stroke and Hyperglycemia," by Clark, Payton, and Pittiglio. Their objective was to illustrate the importance of glucose control and to stress the vital role of nurses in controlling glucose levels efficiently and immediately during the first 48 hours poststroke.

Beachem and Litton's work, "Take a Deep Breath: Understanding Pulmonary Arterial Hypertension," encourages clinicians to achieve a better understanding of this condition and to appreciate why certain advancements in medical treatment options have been shown to significantly improve patient outcomes. In some cases, surgery has also demonstrated value. Despite these recent advancements, the authors admit that right ventricular failure remains a frequent complication of PAH and this often proves fatal.

Bing and her associates present their report, "Analysis of Bowel Sounds Application Status for Gastrointestinal Function Monitoring in the Intensive Care Unit." Although the findings associated with the assessment of bowel sounds have been a traditional indicator of gastrointestinal motility, standards need to be developed regarding both procedural techniques and interpretation of auscultatory findings. These authors representing important ICUs in China suggest that advent of digitizing techniques that support automated bowel sound monitoring will improve objectivity and utility of bowel sound monitoring.

The article, "The Six 'W's' of Rapid Response Systems: Best Practices for Improving Development, Implementation, and Evaluation," by Lazzara and colleagues illustrates how rapid response systems are used to promptly manage a deteriorating patient. Composed of experienced, highly skilled personnel, these teams have become a valid strategy for coping with several types of clinical emergencies. This article presents a review of the literature and offers insight in developing, implementing, and evaluating rapid response systems.

Turkish authors Korban, Yont, Endemir and Miller-Staub outline their perspectives on nurses' abilities to formulate precise diagnoses. "Nursing Diagnosis in Intensive Care Unit: The Turkey Experience" presents their study revealing that most nurses were able to diagnose physiological needs more consistently than psychosocial needs. They also stress the implications for nursing education as a key component of practice improvement.

Daniel and N-Wilfong provide a vital strategy for improving patient safety in their article, "Empowering Interprofessional Teams to Perform Effective Handoffs Through Online Hybrid Simulation Education." The authors outline the program and relate their successes in using this approach in one large health care system.

Finally, Stupak offers a case study, "Seven Steps to Success: Identifying Quality Indicators for Better Patient Care." Avoiding any acquired infections and zero patient injuries are basic elements in a quality patient care program. Visual reminders at the bedside have proven to be useful in keeping these objectives in the forefront for caregivers in her facility.

I trust that you will appreciate the clinical studies and research that authors have contributed to this issue. In addition, I urge you to refresh your approach to patient care by incorporating their insights into your protocols and practice.

-Carmen G. Warner, MSN, MDiv,

RN, FAAN

Issue Editor