Predicting future intensive care demand in Australia

BACKGROUND: Predicting future demand for intensive care is vital to planning the allocation of resources.

METHOD: Mathematical modelling using the autoregressive integrated moving average (ARIMA) was applied to intensive care data from the Australian and New Zealand Intensive Care Society (ANZICS) Core Database and population projections from the Australian Bureau of Statistics to forecast future demand in Australian intensive care.

RESULTS: The model forecasts an increase in ICU demand of over 50% by 2020, with current total ICU bed-days (in 2007) of 471 358, predicted to increase to 643 160 by 2020. An increased rate of ICU use by patients older than 80 years was also noted, with the average bed-days per 10 000 population for this group increasing from 396 in 2006 to 741 in 2007.

CONCLUSION: An increase in demand of the forecast magnitude could not be accommodated within current ICU capacity. Significant action will be required.

Critical ethnographic study of an intensive care unit in Hong Kong

This critical ethnographic study was initiated to explore the ways in which the concepts of caring and caring practices were constructed by nurses working in an intensive care unit in a Hong Kong hospital using a broadly Habermasian critical framework. A reform of the health care system has disturbed both the nurses and the structure of nursing.

Medical error and decision making : learning from the past and present in intensive care

Background : Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments.

Purpose : The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care.

Data source : Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein.

Findings : Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events.

Conclusion : It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.

Early diagnosis and treatment of necrotizing fasciitis can improve survival : an observational intensive care unit cohort study

Background
The aim of this study was to describe the clinical characteristics, causative pathogens, clinical management and outcomes of patients presenting to a tertiary adult Australian intensive care unit (ICU) with a diagnosis of necrotizing fasciitis (NF).
Methods
This retrospective observational study was conducted in a 19-bed, level III, adult ICU in a 450-bed tertiary, regional hospital. Clinical databases were accessed for patients diagnosed with NF and admitted to The Geelong Hospital ICU between 1 February 2000 and 1 June 2011. Information on severity of sepsis, surgical procedures and microbiological results were collected.
Results
Twenty patients with NF were identified. The median age was 52.5 years and 38% were female. The overall mortality rate was 8.3%. Common co-morbidities were diabetes (21%) and heart failure (17%), although 50% of patients had no co-morbidities. Group A Streptococcus was the identified pathogen in 11 (46%) patients, and Streptococcus milleri group in 5 (21%) patients. Hyperbaric oxygen therapy was not used in the majority of patients. The initial antibiotics administered were active against subsequently cultured bacteria in 83% of patients. Median time to surgical debridement was 20 h. Diagnosis and management was delayed in the nosocomial group.
Conclusions
This study reports physiological data, aetiology and therapeutic interventions in NF for an adult tertiary hospital. We demonstrate one of the lowest reported mortality rates, with early surgical debridement being achieved in the majority of patients. The main delay was found to be in the diagnosis of NF.

Factors to drive clinical practice improvement in a Malaysian intensive care unit : assessment of organisational readiness using a mixed method approach

This study assessed organisational readiness and factors to drive clinical practice improvement for VAP, CRBSI and PU in a Malaysian intensive care unit (ICU). A mixed method study approach was undertaken in a 16-bed ICU in regional Malaysia using an environmental scan, key informant interviews, staff surveys, and patient audit to elucidate factors contributing to planning for clinical practice improvement. Measurements of sustainability of practice and regard for the practice environment were assessed using validated measures. An environmental scan demonstrated high patient occupancy and case load. Nineteen percent of ICU patients developed complications according to validated measures. Survey results indicated that the majority of nurses had a good knowledge of strategies to prevent ICU complications and a positive attitude toward change processes. Engaging executive leadership was identified as crucial in priming the clinical site for practice change. Providing nurses with tools to monitor their clinical practice and empowering them to change practices are important in improving clinical outcomes.

Examining adverse events after intensive care unit discharge : outcomes from a pilot questionnaire

Adverse events are common in acute clinical settings but little is known about these events occurring after Intensive Care discharge. This study aimed to develop a reliable and valid tool for exploring clinicians’ opinions of factors associated with post-Intensive Care adverse events. A convenience sample of Australian Intensive Care Liaison Nurses was invited to complete and appraise a questionnaire using structured guidelines. Content validity and internal consistency were assessed.

Twelve Intensive Care Liaison Nurses completed the questionnaire. Cronbach?s alpha coefficient showed high internal consistency for the questionnaire; all 24 items on the questionnaire had coefficients greater than 0.852. The content validity index of the questionnaire overall was 0.76.

The post-Intensive Care adverse events questionnaire demonstrated reliability and validity. It is a tool that can be used to explore clinicians? opinions of factors associated with these events. The tool is important as it facilitates further insight into the causes of post-Intensive Care adverse events.

Patient comfort in the intensive care unit : a multicentre, binational point prevalence study of analgesia, sedation and delirium management

Objective: To measure the prevalence of assessment and management practices for analgesia, sedation and delirium in patients in Australian and New Zealand intensive care units.
Materials and Methods: We developed survey items from a modified Delphi panel and included them in a binational, point prevalence study. We used a standard case report form to capture retrospective patient data on management of analgesia, sedation and delirium at the end of a 4-hour period on the study day. Other data were collected during independent assessment of patient status and medication requirements.
Results: Data were collected on 569 patients in 41 ICUs. Pain assessment was documented in the 4 hours before study observation in 46% of patients. Of 319 assessable patients, 16% had moderate pain and 6% had severe pain. Routine sedation assessment using a scale was recorded in 63% of intubated and ventilated patients. When assessed, 38% were alert and calm, or drowsy and rousable, 22% were lightly to moderately sedated, 31% were deeply sedated (66% of these had a documented indication), and 9% were agitated or restless. Sedatives were titrated to a target level in 42% of patients. Routine assessment of delirium occurred in 3%, and at study assessment 9% had delirium. Wrist or arm restraints were used for 7% of patients.
Conclusions: Only two-thirds of sedated patients had their sedation levels formally assessed, half had pain assessed and very few had formal assessment of delirium. Our description of current practices, and other observational data, may help in planning further research in this area.

Creating spaces in intensive care for safe communication : a video-reflexive ethnographic study

The built environment in acute care settings is a new focus in patient safety research, with few studies focusing primarily on the design of ward environments and the location and choice of material objects such as light fittings and hand-washing basins.