Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital

Objective: The present study aimed to describe the characteristics and outcomes of intubation occurring in the ICU and ED of an Australian tertiary teaching hospital. Methods: This was a prospective observational study of intubation practice across the Geelong Hospital over a 6 month period from 1 August 2012 to 31 January 2013. Data were entered by the intubating team through an online data collection form. Results: There were 119 patients intubated and 134 attempts at intubation in the ED and ICU over a 6 month period. The first-pass success rate was 104/119 (87.4%), and all but a single patient was intubated by the second attempt. Propofol, fentanyl, midazolam and suxamethonium were the most common drugs used in rapid sequence induction. AEs were reported in 44/134 (32.8%) of intubation attempts, with transient hypoxia and hypotension being the most common. A significant adverse outcome, namely aspiration pneumonitis, occurred in one patient. There were no peri-intubation deaths. Conclusion: The majority of airways are managed by ICU and ED consultants and trainees, with success rates and AE rates comparable with other published studies. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Findings of the first ANZICS conference on the role of intensive care in Rapid Response Teams.

Rapid Response Teams (RRTs) are specialised teams introduced into hospitals to improve the outcomes of deteriorating ward patients. Although Rapid Response Systems (RRSs) were developed by the intensive care unit (ICU) community, there is variability in their delivery, and consultant involvement, supervision and leadership appears to be relatively infrequent. In July 2014, the Australian and New Zealand Intensive Care Society (ANZICS) convened the first conference on the role of intensive care medicine in RRTs in Australia and New Zealand. The conference explored RRSs in the broader role of patient safety, resourcing and staffing of RRTs, effect on ICU workload, different RRT models, the outcomes of RRT patients and original research projects in the area of RRSs. Issues around education and training of both ICU registrars and nurses were examined, and the role of team training explored. Measures to assess the effectiveness of the RRS and RRT at the level of health system and hospital, team performance and team effectiveness were discussed, and the need to develop a bi-national ANZICS RRT patient database was presented. Strategies to prevent patient deterioration in the 'pre-RRT' period were discussed, including education of ward nurses and doctors, as well as an overarching governance structure. The role of the ICU in deteriorating ward patients was debated and an integrated model of acute care presented. This article summarises the findings of the conference and presents recommendations on the role of intensive care medicine in RRTs in Australia and New Zealand.

Protocol-directed sedation versus non-protocol-directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients (review)

Background : The sedation needs of critically ill patients have been recognized as a core component of critical care and meeting these is vital to assist recovery and ensure humane treatment. There is growing evidence to suggest that sedation requirements are not always optimally managed. Sub-optimal sedation incorporates both under- and over-sedation and has been linked to both short-term (e.g. length of stay) and long-term (e.g. psychological recovery) outcomes. Various strategies have been proposed to improve sedation management and address aspects of assessment as well as delivery of sedation.

Objectives : To assess the effects of protocol-directed sedation management on the duration of mechanical ventilation and other relevant patient outcomes in mechanically ventilated intensive care unit (ICU) patients. We looked at various outcomes and examined the role of bias in order to examine the level of evidence for this intervention.

Search methods : We searched the Cochrane Central Register of Controlled trials (CENTRAL) (2013; Issue 11), MEDLINE (OvidSP) (1990 to November 2013), EMBASE (OvidSP) (1990 to November 2013), CINAHL (BIREME host) (1990 to November 2013), Database of Abstracts of Reviews of Effects (DARE) (1990 to November 2013), LILACS (1990 to November 2013), Current Controlled Trials and US National Institutes of Health Clinical Research Studies (1990 to November 2013), and reference lists of articles. We re-ran the search in October 2014. We will deal with any studies of interest when we update the review.

Selection criteria : We included randomized controlled trials (RCTs) conducted in adult ICUs comparing management with and without protocol-directed sedation.

Data collection and analysis : Two authors screened the titles and abstracts and then the full-text reports identified from our electronic search. We assessed seven domains of potential risk of bias for the included studies. We examined the clinical, methodological and statistical heterogeneity and used the random-effects model for meta-analysis where we considered it appropriate. We calculated the mean difference (MD) for duration of mechanical ventilation and risk ratio (RR) for mortality across studies, with 95% confidence intervals (CI).

Main results : We identified two eligible studies with 633 participants. Both included studies compared the use of protocol-directed sedation, specifically protocols delivered by nurses, with usual care. We rated the risk of selection bias due to random sequence generation low for one study and unclear for one study. The risk of selection bias related to allocation concealment was low for both studies. We also assessed detection and attrition bias as low for both studies while we considered performance bias high due to the inability to blind participants and clinicians in both studies. Risk due to other sources of bias, such as potential for contamination between groups and reporting bias, was considered unclear. There was no clear evidence of differences in duration of mechanical ventilation (MD -5.74 hours, 95% CI -62.01 to 50.53, low quality evidence), ICU length of stay (MD -0.62 days, 95% CI -2.97 to 1.73) and hospital length of stay (MD -3.78 days, 95% CI -8.54 to 0.97) between people being managed with protocol-directed sedation versus usual care. Similarly, there was no clear evidence of difference in hospital mortality between the two groups (RR 0.96, 95% CI 0.71 to 1.31, low quality evidence). ICU mortality was only reported in one study preventing pooling of data. There was no clear evidence of difference in the incidence of tracheostomy (RR 0.77, 95% CI 0.31 to 1.89). The studies reported few adverse event outcomes; one study reported self extubation while the other study reported re-intubation; given this difference in outcomes, pooling of data was not possible. There was significant heterogeneity between studies for duration of mechanical ventilation (I2 = 86%, P value = 0.008), ICU length of stay (I2 = 82%, P value = 0.02) and incidence of tracheostomy (I2 = 76%, P value = 0.04), with one study finding a reduction in duration of mechanical ventilation and incidence of tracheostomy and the other study finding no difference.

Authors' conclusions : There is currently insufficient evidence to evaluate the effectiveness of protocol-directed sedation. Results from the two RCTs were conflicting, resulting in the quality of the body of evidence as a whole being assessed as low. Further studies, taking into account contextual and clinician characteristics in different ICU environments, are necessary to inform future practice. Methodological strategies to reduce the risk of bias need to be considered in future studies.

Intensive care nurses' perceptions of brain death

Research during the last 2 decades has revealed significant confusion or lack of acceptance and inconsistent application of the brain death concept within the medical and nursing professions. The aim of this naturalistic and descriptive study was to investigate the extent to which a sample of 40 Australian intensive care nurses regarded brain death as a meaningful conception of death. In contrast with the majority of the literature pertaining to health care professionals' perceptions of brain death which has focused upon clinical knowledge, the study elicited the expression of personal beliefs. The study utilised a structured interview method with nurses from seven metropolitan intensive care units (ICUs). Transcript analysis revealed five categories of perception constituting a spectrum ranging from complete acceptance to complete rejection, with almost half (48%, n=19) the sample regarding the brain dead patient as less than completely meaningfully dead.

Rather than supporting the literature's suggestion that non-acceptance of the medico-legally recognised brain death notion is, necessarily, evidence of professional ignorance, the findings suggest the participants holding these perceptions were generally well-informed about brain stem function and brain death diagnosis. The study affirms the importance of supportive workplace environments which facilitate the expression of dissonant perceptions and proposes that educators and managers must acknowledge these dissonances.

Hemodynamic team decision making in the cardiac surgical intensive care context

Purpose
The purpose of this study was to explore the extent and sources of variability of critical care nurses’ hemodynamic decision making as a function of contextual factors in the immediate 2-hour period after cardiac surgery.

Methods
A qualitative exploratory design with observation and interview was used. Eight critical care nurses were observed on different occasions in clinical practice for a 2-hour period. A brief interview immediately followed each observation to clarify observation data.

Findings
Analysis of the data revealed that patient management decisions were made both by individual nurses and by a team of nurses and health professionals. Team decision making (TDM) is described in this study as integrated or non-integrated and refers to an intra-professional nursing team. During displays of integrated TDM, the primary nurse, who was assigned to care for the patient, made most hemodynamic decisions and nurses who assisted the primary nurse deferred decisions. During displays of non-integrated TDM, nurses assisting the primary nurse assumed responsibilities for most patient-related decisions. Non-integrated TDM occurred more frequently when inexperienced cardiac surgical intensive care nurses were in the role of primary nurse, whereas integrated TDM was more common among experienced cardiac surgical intensive care nurses.

Conclusions
This observed variability can occur in multiple ways and in hemodynamic decision making has implications for patient outcomes as behaviors of non-integrated TDM led to nurses sensing a loss of control of patient management.

ACCCN national nursing workforce survey of intensive care units

A descriptive study was designed and implemented by the Australian College of Critical Care Nurses (ACCCN) Workforce Planning Advisory Committee to capture data pertaining to workforce issues of intensive care nurses. All intensive care units (ICUs) within Australia were mailed a self reporting survey. Despite a low response rate (52 per cent) and difficulty reported by respondents in gaining the appropriate data requested, the results revealed an interesting snapshot of the intensive care nursing workforce.
Types of services offered by units varied considerably; paid overtime hours were low (<2 per cent of total hours worked) and use of both part-time and agency staff was also low (10 per cent of total hours worked). Private hospitals utilised a greater proportion of part-time and agency nursing staff than public hospitals (20:10 per cent). The turnover rate for registered nursing staff was estimated at 18 per cent, with education, skill acquisition and improved communication reported as the major incentives used by managers to attract and retain staff. This study demonstrated that valuable data are currently uncaptured and recommends a more refined process of a national database to record and manage this important information for future workforce planning.

Staff perceptions on the use of a sedation protocol in the intensive care setting

Sedation protocols are increasingly being investigated as a method of achieving improved patient outcomes whilst guiding the decision making of both nursing and medical practitioners. However, only a limited number of studies have investigated the perceptions of staff towards a sedation protocol during its implementation. This study was designed to survey the perceptions of staff regarding the implementation of a sedation protocol in an Australian intensive care unit (ICU). Questionnaires were distributed to all multidisciplinary team members who had used the sedation protocol. The response rate was 50% (n=70). The questionnaire combined the use of visual analogue scales plus a comments section to obtain qualitative data.

The results revealed that staff perceived sedation management to be enhanced with the use of a protocol and therefore should be incorporated into routine clinical practice. Staff perceived that providing clear guidelines that facilitated decision making and assisted beginner practitioners enhanced sedation management. In addition, there was a perceived improvement in the patient outcomes, including a decrease in the frequency of over-sedation resulting in a reduced ICU stay.

Positive perceptions may assist in the introduction of other interventional protocols. Other protocols may target areas where variability in clinical decision making exists, despite research evidence that supports specific therapeutic interventions. Further studies addressing protocol implementation for clinical interventions are warranted in other ICU settings.

Nurses' critical event risk assessments : a judgement analysis

Aims. To explore and explain nurses' use of readily available clinical information when deciding whether a patient is at risk of a critical event.

Background. Half of inpatients who suffer a cardiac arrest have documented but unacted upon clinical signs of deterioration in the 24 hours prior to the event. Nurses appear to be both misinterpreting and mismanaging the nursing-knowledge 'basics' such as heart rate, respiratory rate and oxygenation. Whilst many medical interventions originate from nurses, up to 26% of nurses' responses to abnormal signs result in delays of between one and three hours.

Methods. A double system judgement analysis using Brunswik's lens model of cognition was undertaken with 245 Dutch, UK, Canadian and Australian acute care nurses. Nurses were asked to judge the likelihood of a critical event, 'at-risk' status, and whether they would intervene in response to 50 computer-presented clinical scenarios in which data on heart rate, systolic blood pressure, urine output, oxygen saturation, conscious level and oxygenation support were varied. Nurses were also presented with a protocol recommendation and also placed under time pressure for some of the scenarios. The ecological criterion was the predicted level of risk from the Modified Early Warning Score assessments of 232 UK acute care inpatients.

Results. Despite receiving identical information, nurses varied considerably in their risk assessments. The differences can be partly explained by variability in weightings given to information. Time and protocol recommendations were given more weighting than clinical information for key dichotomous choices such as classifying a patient as 'at risk' and deciding to intervene. Nurses' weighting of cues did not mirror the same information's contribution to risk in real patients. Nurses synthesized information in non-linear ways that contributed little to decisional accuracy. The low-moderate achievement (Ra) statistics suggests that nurses' assessments of risk were largely inaccurate; these assessments were applied consistently among 'patients' (scenarios). Critical care experience was statistically associated with estimates of risk, but not with the decision to intervene.

Conclusion. Nurses overestimated the risk and the need to intervene in simulated paper patients at risk of a critical event. This average response masked considerable variation in risk predictions, the need for action and the weighting afforded to the information they had available to them. Nurses did not make use of the linear reasoning required for accurate risk predictions in this task. They also failed to employ any unique knowledge that could be shown to make them more accurate. The influence of time pressure and protocol recommendations depended on the kind of judgement faced suggesting then that knowing more about the types of decisions nurses face may influence information use.

Relevance to clinical practice. Practice developers and educators need to pay attention to the quality of nurses' clinical experience as well as the quantity when developing judgement expertise in nurses. Intuitive unaided decision making in the assessment of risk may not be as accurate as supported decision making. Practice developers and educators should consider teaching nurses normative rules for revising probabilities (even subjective ones) such as Bayes' rule for diagnostic or assessment judgements and also that linear ways of thinking, in which decision support may help, may be useful for many choices that nurses face. Nursing needs to separate the rhetoric of 'holism' and 'expertise' from the science of predictive validity, accuracy and competence in judgement and decision making.

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.

Review : nurses can improve patient nutrition in intensive care

Aims and objectives. To review the literature and identify opportunities for nutritional practice improvement in the critically ill and opportunities to improve nurses’ knowledge relating to enteral feeding.

Background. The literature reports varying nutritional practices in intensive care.

Design. Systematic review.

Methods. A systematic search, selection, analysis and review of nursing, medical and dietetic primary research articles was undertaken. Fifteen studies met the selection criteria.

Results. Delivery of nutrition to the critically ill varied widely. Patients were frequently underfed and less frequently, overfed. Both under- and overfeeding have been linked with unacceptable consequences including infections, extended weaning from mechanical ventilation, increased length of stay and increased mortality. Underfeeding was related to slow initiation and advancement of nutrition support and avoidable feed interruptions. The most common reasons for interrupting feeds were gastrointestinal intolerance and fasting for procedures. Certain nursing practices contributed to underfeeding such as the management of gastric residual volumes.

Conclusions. Consistent and reliable nutrition support in intensive care units is hampered by a lack of evidence leading to varying nutrition practices. Factors impeding delivery of enteral nutrition were considered avoidable. A new concept of a therapeutic range of energy delivery in the critically ill has emerged implying the need for re-evaluation of energy recommendations and improved delivery of enteral nutrition.

Relevance to clinical practice. This review supports the multi-disciplinary development and implementation of an evidence-based enteral feeding protocol in intensive care units as a strategy to improve adequacy of nutritional intake. Critical care nurses are well placed to improve this process.

Assessment of variation in the alberta context tool : the contribution of unit level contextual factors and practice specialty in Canadian pediatric acute care settings

Background: There are few validated measures of organizational context and none that we located are parsimonious and address modifiable characteristics of context. The Alberta Context Tool (ACT) was developed to meet this need. The instrument assesses 8 dimensions of context, which comprise 10 concepts. The purpose of this paper is to report evidence to further the validity argument for ACT. The specific objectives of this paper are to: (1) examine the extent to which the 10 ACT concepts discriminate between patient care units and (2) identify variables that significantly contribute to between-unit variation for each of the 10 concepts.

Methods: 859 professional nurses (844 valid responses) working in medical, surgical and critical care units of 8 Canadian pediatric hospitals completed the ACT. A random intercept, fixed effects hierarchical linear modeling (HLM) strategy was used to quantify and explain variance in the 10 ACT concepts to establish the ACT’s ability to discriminate between units. We ran 40 models (a series of 4 models for each of the 10 concepts) in which we systematically assessed the unique contribution (i.e., error variance reduction) of different variables to between-unit variation. First, we constructed a null model in which we quantified the variance overall, in each of the concepts. Then we controlled for the contribution of individual level variables (Model 1). In Model 2, we assessed the contribution of practice specialty (medical, surgical, critical care) to variation since it was central to construction of the sampling frame for the study. Finally, we assessed the contribution of additional unit level variables (Model 3).

Results: The null model (unadjusted baseline HLM model) established that there was significant variation between units in each of the 10 ACT concepts (i.e., discrimination between units). When we controlled for individual characteristics, significant variation in the 10 concepts remained. Assessment of the contribution of specialty to between-unit variation enabled us to explain more variance (1.19% to 16.73%) in 6 of the 10 ACT concepts. Finally, when we assessed the unique contribution of the unit level variables available to us, we were able to explain additional variance (15.91% to 73.25%) in 7 of the 10 ACT concepts.

Conclusion: The findings reported here represent the third published argument for validity of the ACT and adds to the evidence supporting its use to discriminate patient care units by all 10 contextual factors. We found evidence of relationships between a variety of individual and unit-level variables that explained much of this between-unit variation for each of the 10 ACT concepts. Future research will include examination of the relationships between the ACT’s contextual factors and research utilization by nurses and ultimately the relationships between context, research utilization, and outcomes for patients.

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.