Use of a multidimensional assessment tool in a psychiatric adolescent care unit.

AIMS: Adolescent mental health problems require treatment and care that are adapted to their needs. To evaluate this issue, it was decided to implement a multidimensional instrument focused on a global approach to adolescent social and behavioural functioning, combined with the ICD-10 classification. METHODS: The combination of an assessment interview and a classification tool enabled the method to integrate the measurement of several domains of patient-based outcome rather than focus on the measurement of symptoms. A group of 68 adolescents from an inpatient unit were compared with 67 adolescents from the general population. RESULTS: Results suggest that adolescents from the care unit adopt significantly riskier behaviour compared with adolescents from the control group. As expected, the main problems identified refer to the psychological and familial areas. A cluster analysis was performed and provided three different profiles: a group with externalizing disorders and two groups with internalizing disorders. On the basis of a structured interview it was possible to obtain information in a systematic way about the adolescents' trajectory (delinquency, physical and sexual abuse, psychoactive substance use). CONCLUSION: It was shown that treatment and care should not focus exclusively on mental health symptoms, but also upon physical, psychological and social aspects of the adolescent. A global approach helps in the consideration of the multitude of factors which must be taken into account when working with people with serious mental health problems and may help to turn the care unit's activity more specifically towards the needs of these adolescents.

Mechanical ventilation and clinical practice heterogeneity in intensive care units: a multicenter case-vignette study.

BACKGROUND: Observational studies on mechanical ventilation (MV) show practice variations across ICUs. We sought to determine, with a case-vignette study, the heterogeneity of processes of care in ICUs focusing on mechanical ventilation procedures, and whether organizational patterns or physician characteristics influence practice variations. METHODS: We conducted a cross-sectional multicenter study using the case-vignette methodology. Descriptive analyses were calculated for each organizational pattern and respondent characteristics. An Index of Qualitative Variation (IQV, from 0, no heterogeneity, to a maximum of 1) was calculated. RESULTS: Forty ICUs from France (N = 33) and Switzerland (N = 7) participated; 396 physicians answered our case-vignettes. There was major heterogeneity of management processes related to MV within and across centers (mean IQV per center 0.51, SD 0.09). We observed the lowest variability (mean IQV per question < 0.4) for questions related to intubation procedure, ventilation of acute respiratory distress syndrome and the use of the semirecumbent position. We observed a high variability (mean IQV per question > 0.6) for questions related to management of endotracheal tube or suctioning, management of sedation and analgesia, and respect of autonomy. Heterogeneity was independent of respondent characteristics and of the presence of written procedures. There was a correlation between the processes associated with the highest variability (mean IQV per question > 0.6) and the annual volume of ICU admission (r = 0.32 (0.01 to 0.58)) and MV (r = 0.38 (0.07 to 0.63)). Within ICUs there was a large heterogeneity regarding knowledge of a local written procedure. CONCLUSIONS: Large clinical practice variations were found among ICUs. High volume centers were more likely to have heterogeneous practices. The presence of a local written procedure or respondent characteristics did not influence practice variation.

Hindsight judgement on ambiguous episodes of suspected infection in critically ill children: poor consensus amongst experts?

Few episodes of suspected infection observed in paediatric intensive care are classifiable without ambiguity by a priori defined criteria. Most require additional expert judgement. Recently, we observed a high variability in antibiotic prescription rates, not explained by the patients' clinical data or underlying diseases. We hypothesised that the disagreement of experts in adjudication of episodes of suspected infection could be one of the potential causes for this variability. During a 5-month period, we included all patients of a 19-bed multidisciplinary, tertiary, neonatal and paediatric intensive care unit, in whom infection was clinically suspected and antibiotics were prescribed ( n=183). Three experts (two senior ICU physicians and a specialist in infectious diseases) were provided with all patient data, laboratory and microbiological findings. All experts classified episodes according to a priori defined criteria into: proven sepsis, probable sepsis (negative cultures), localised infection and no infection. Episodes of proven viral infection and incomplete data sets were excluded. Of the remaining 167 episodes, 48 were classifiable by a priori criteria ( n=28 proven sepsis, n= 20 no infection). The three experts only achieved limited agreement beyond chance in the remaining 119 episodes (kappa = 0.32, and kappa = 0.19 amongst the ICU physicians). The kappa is a measure of the degree of agreement beyond what would be expected by chance alone, with 0 indicating the chance result and 1 indicating perfect agreement. CONCLUSION: agreement of specialists in hindsight adjudication of episodes of suspected infection is of questionable reliability.

Molecular epidemiology of pseudomonas aeruginosae in intensive care units (ICUs) over a 10-year period (1998-2007)

Pseudomonas aeruginosa, une bactérie environnementale ubiquitaire, est un des pathogènes nosocomiaux les plus fréquents aux soins intensifs. La source de ce microorganisme peut être soit endogène, 2,6 à 24 % des patients hospitalisés étant colonisés au niveau digestif, soit exogène. La proportion des cas d'infections à P. aeruginosa d'origine exogène, donc secondaires à une transmission par manuportage ou par l'eau du réseau utilisée pour la toilette ou d'autres soins, reste débattue. Or une meilleure évaluation du taux d'infections exogènes est importante pour la mise en place de mesures de contrôle appropriées. Le but de cette étude était de déterminer sur une période de 10 ans les rôles respectifs des sources exogènes (robinets, autres patients) et endogène dans la colonisation et/ou l'infection par P.aeruginosa chez les patients des Soins Intensifs, ainsi que de documenter les variations épidémiologiques au cours du temps. L'étude a été menée dans les unités de Soins Intensifs du Centre Hospitalier Universitaire Vaudois (CHUV). Les patients colonisés et/ou infectés par P. aeruginosa entre 1998 et 2007ont été identifiés via la base de données du laboratoire de microbiologie. Ils ont été inclus dans l'étude s'ils étaient hospitalisés dans une des unités de Soins Intensifs, Durant cette période, des prélèvements pour recherche de P. aeruginosa ont été effectués sur des robinets des soins intensifs. Un typage moléculaire a été effectué sur toutes les souches cliniques et environnementales isolées en 1998, 2000, 2003, 2004 et 2007. Les patients inclus dans l'étude ont été répartis en quatre catégories (A-D) selon le résultat du typage moléculaire leur souche de P. aeruginosa. La catégorie A inclut les cas pour lesquels le génotype de P. aeruginosa est identique à un des génotypes retrouvé dans l'environnement. La catégorie B comprend les cas pour lesquels le génotype est identique à celui d'au moins un autre patient. La catégorie C comprend les cas avec un génotype unique et la catégorie D comprend les cas pour lesquels la souche était non disponible pour le typage. Les cas des catégories A et B sont considérés comme ayant une origine exogène. Au cours des années de l'étude, le nombre d'admissions aux soins intensifs est resté stable. En moyenne, 86 patients par année ont été identifiés colonisés ou infectés par P. aeruginosa aux Soins Intensifs. Durant la première année d'investigation, un grand nombre de patients colonisés par une souche de P. aeruginosa identique à une de celles retrouvées dans l'environnement a été mis en évidence. Par la suite, possiblement suite à l'augmentation de la température du réseau d'eau chaude, le nombre de cas dans la catégorie A a diminué. Dans la catégorie B, le nombre de cas varie de 1,9 à 20 cas/1000 admissions selon les années. Ce nombre est supérieur à 10 cas/1000 admissions en 1998, 2003 et 2007 et correspond à des situations épidémiques transitoires. Tout au long des 10 ans de l'étude, le nombre de cas dans la catégorie C (source endogène) est demeuré stable et indépendant des variations du nombre de cas dans les catégories A et B. En conclusion, la contribution relative des réservoirs endogène et exogène dans la colonisation et/ou l'infection des patients de soins Intensifs varie au cours du temps. Les facteurs principaux qui contribuent à de telles variations sont probablement le degré de contamination de l'environnement, la compliance des soignants aux mesures de contrôle des infections et la génétique du pathogène lui-même. Etant donné que ce germe est ubiquitaire dans l'environnement aqueux et colonise jusqu'à 15% des patients hospitalisés, la disparition de son réservoir endogène semble difficile. Cependant, cette étude démontre que son contrôle est possible dans l'environnement, notamment dans les robinets en augmentant la température de l'eau. De plus, si une souche multi-résistante est retrouvée de manière répétée dans l'environnement, des efforts doivent être mis en place pour éliminer cette souche. Des efforts doivent être également entrepris afin de limiter la transmission entre les patients, qui est une cause importante et récurrente de contamination exogène. - Pseudomonas aeruginosa is one of the leading nosocomial pathogens in intensive care units (ICUs). The source of this microorganism can be either endogenous or exogenous. The proportion of cases as a result of transmission is still debated, and its elucidation is important for implementing appropriate control measures. To understand the relative importance of exogenous vs. endogenous sources of P. aeru¬ginosa, molecular typing was performed on all available P. aeruginosa isolated from ICU clinical and environmental specimens in 1998, 2000, 2003, 2004 and 2007. Patient samples were classified according to their P. aeruginosa genotypes into three categories: (A) identical to isolate from faucet; (B) identical to at least one other patient sample and not found in faucet; and (C) unique genotype. Cases in cat¬egories A and Β were considered as possibly exogenous, and cases in category C as possibly endogenous. A mean of 34 cases per 1000 admissions per year were found to be colonized or infected by P. aeruginosa. Higher levels of faucet contamination were correlated with a higher number of cases in category A. The number of cases in category Β varied from 1.9 to 20 cases per 1000 admissions. This num¬ber exceeded 10/1000 admissions on three occasions and was correlated with an outbreak on one occasion. The number of cases con¬sidered as endogenous (category C) was stable and independent of the number of cases in categories A and B. The present study shows that repeated molecular typing can help identify variations in the epidemiology of P. aeruginosa in ICU patients and guide infection control measures.

Improving patient safety: how and why incidences occur in nursing care

The present investigation was a cross-sectional, quantitative research study analyzing incidents associated with nursing care using a root-cause methodological analysis. The study was conducted in a public hospital intensive care unit (ICU) in Santiago de Chile and investigated 18 incidents related to nursing care that occurred from January to March of 2012. The sample was composed of six cases involving medications and the self-removal of therapeutic devices. The contributing factors were related to the tasks and technology, the professional work team, the patients, and the environment. The analysis confirmed that the cases presented with similar contributing factors, thereby indicating that the vulnerable aspects of the system are primarily responsible for the incidence occurrence. We conclude that root-cause analysis facilitates the identification of these vulnerable points. Proactive management in system-error prevention is made possible by recommendations.

L'hémodialyse intermittente aux soins intensifs = [Intermittent hemodialysis in the intensive care setting]

Acute renal failure is a frequent and potentially lethal disease in intensive care units. Renal replacement therapy (RRT) is often required. Either intermittent or continuous methods of RRT can be used. When to start a RRT and which method to use is not always clearly defined and a global evaluation of the clinical situation is required. The choice of the modality of RRT will be up to the general clinical context, hemodynamic stability, the type of molecules to be cleared and the haemorrhagic risk as much as habits and available resources. No study currently showed a superiority of either continuous or intermittent renal replacement therapy. The collaboration between intensive care specialists and nephrologists allows an optimized choice for a given patient and allow better move from one technic to another if required.

Warning systems in a computerized nursing process for Intensive Care Units

A hybrid study combining technological production and methodological research aiming to establish associations between the data and information that are part of a Computerized Nursing Process according to the ICNP® Version 1.0, indicators of patient safety and quality of care. Based on the guidelines of the Agency for Healthcare Research and Quality and the American Association of Critical Care Nurses for the expansion of warning systems, five warning systems were developed: potential for iatrogenic pneumothorax, potential for care-related infections, potential for suture dehiscence in patients after abdominal or pelvic surgery, potential for loss of vascular access, and potential for endotracheal extubation. The warning systems are a continuous computerized resource of essential situations that promote patient safety and enable the construction of a way to stimulate clinical reasoning and support clinical decision making of nurses in intensive care.

Usability of computerized nursing process from the ICNP® in intensive care units

OBJECTIVE To analyze the usability of Computerized Nursing Process (CNP) from the ICNP® 1.0 in Intensive Care Units in accordance with the criteria established by the standards of the International Organization for Standardization and the Brazilian Association of Technical Standards of systems. METHOD This is a before-and-after semi-experimental quantitative study, with a sample of 34 participants (nurses, professors and systems programmers), carried out in three Intensive Care Units. RESULTS The evaluated criteria (use, content and interface) showed that CNP has usability criteria, as it integrates a logical data structure, clinical assessment, diagnostics and nursing interventions. CONCLUSION The CNP is a source of information and knowledge that provide nurses with new ways of learning in intensive care, for it is a place that provides complete, comprehensive, and detailed content, supported by current and relevant data and scientific research information for Nursing practices.

Measuring professional satisfaction and nursing workload among nursing staff at a Greek Coronary Care Unit

ABSTRACT Objective To explore potential associations between nursing workload and professional satisfaction among nursing personnel (NP) in Greek Coronary Care Units (CCUs). Method A cross-sectional study was performed involving 66 members of the NP employed in 6 randomly selected Greek CCUs. Job satisfaction was assessed by the IWS and nursing workload by NAS, CNIS and TISS-28. Results The response rate was 77.6%. The reliability of the IWS was α=0.78 and the mean score 10.7 (±2.1, scale range: 0.5-39.7). The most highly valued component of satisfaction was “Pay”, followed by “Task requirements”, “Interaction”, “Professional status”, “Organizational policies” and “Autonomy”. NAS, CNIS and TISS-28 were negatively correlated (p≤0.04) with the following work components: “Autonomy”, “Professional status”, “Interaction” and “Task requirements”. Night shift work independently predicted the score of IWS. Conclusion The findings show low levels of job satisfaction, which are related with nursing workload and influenced by rotating shifts.

Nutrition parentérale compé- mentaire de la nutrition entérale aux soins intensifs: une association logique [Supplemental parenteral nutrition for intensive care patients: a logical combination with enteral nutrition]

Undernutrition is a widespread problem in the intensive care and is associated with a worse clinical outcome. Enteral nutrition is the recommended nutritional support in ICU patients. However, enteral nutrition is frequently insufficient to cover protein-energy needs. The initiation of supplemental parenteral nutrition, when enteral nutrition is insufficient, could optimize the nutritional therapy. Such a combination could allow reducing morbidity, length of stay and recovery, as well as improving quality of life and health care costs. Prospective studies are currently underway to test this hypothesis.

Prognostication in comatose survivors of cardiac arrest: An advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine.

OBJECTIVES: To review and update the evidence on predictors of poor outcome (death, persistent vegetative state or severe neurological disability) in adult comatose survivors of cardiac arrest, either treated or not treated with controlled temperature, to identify knowledge gaps and to suggest a reliable prognostication strategy. METHODS: GRADE-based systematic review followed by expert consensus achieved using Web-based Delphi methodology, conference calls and face-to-face meetings. Predictors based on clinical examination, electrophysiology, biomarkers and imaging were included. RESULTS AND CONCLUSIONS: Evidence from a total of 73 studies was reviewed. The quality of evidence was low or very low for almost all studies. In patients who are comatose with absent or extensor motor response at ≥72 h from arrest, either treated or not treated with controlled temperature, bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials were identified as the most robust predictors. Early status myoclonus, elevated values of neuron-specific enolase at 48-72 h from arrest, unreactive malignant EEG patterns after rewarming, and presence of diffuse signs of postanoxic injury on either computed tomography or magnetic resonance imaging were identified as useful but less robust predictors. Prolonged observation and repeated assessments should be considered when results of initial assessment are inconclusive. Although no specific combination of predictors is sufficiently supported by available evidence, a multimodal prognostication approach is recommended in all patients.

Delirium in elderly patients hospitalized in an acute care unit.

Introduction: Delirium is frequent in hospitalized older people, with incidence rate up to 40% in acute care. Delirium is associated with several adverse consequences, including increased mortality and institutionalization. This study aims to investigate the prevalence, incidence, and consequences of delirium in patients hospitalized in an acute care unit for elderly (ACE unit). Methods: Over a 3 months period, every patient (N = 93, mean age 84.1 ± 7.8 years, 66/93(71%) women) admitted to a 28-bed ACE unit were systematically assessed for delirium. Trained nurses used the Confusion Assessment Method (CAM) instrument to determine the presence of delirium at admission and on each subsequent day over patients' stay. Delirium prevalence rate was defined as the proportion of patients with a positive CAM within 24 hours of admission to the ACE unit. Delirium incidence rate was defined as the proportion of patients with a negative CAM at admission whose CAM became positive at least once during their stay. This evaluation was part of a functional assessment, including Basic Activities of Daily Life (Katz BADL, from 0 to 6, higher score indicating better function). Delirium prevention interventions and specific treatment was provided if needed. Results: Overall,25/93(27%)patients had delirium during their stay. Prevalence of delirium at admission was 10/93 (11%), with an incidence of 15/83(18%). Compared with non-delirious patients, those with delirium were more frequently men (10/25(40%) vs 17/68(25%), p <.001) and had reduced functional status at admission(BADL 2.0 ± 1.9 vs 3.6 ± 2.1, p = .004). They tended to be older (86.0 ± 6.7 vs 83.3 ± 8.1 years, p = .110). At discharge, delirium was associated with reduced functional status (BADL 2.0 ± 2.1 vs 4.3 ± 1.9, p <.001), lower rate of home discharge (6/20(30%) vs 28/65 (43%), p = .009) and increased mortality (5/25 (20%) vs 3/68 (5%), p <.001). On average, patients with delirium stayed 5.7 days longer (17.0 ± 9.8 vs 11.31 ± 6.3, p = .011). Conclusion: Delirium occurred in almost a third of these older patients, even though its incidence was relatively low in this frail population. Despite specific management, delirium remained associated with higher risk for adverse outcomes at discharge. These results suggest that early preventive interventions, implemented as soon as possible after hospital admission, might be needed in similar population to achieve better outcomes. Effectiveness of such interventions will be evaluated in future studies.

ESPEN Guidelines on Parenteral Nutrition: intensive care.

Nutritional support in the intensive care setting represents a challenge but it is fortunate that its delivery and monitoring can be followed closely. Enteral feeding guidelines have shown the evidence in favor of early delivery and the efficacy of use of the gastrointestinal tract. Parenteral nutrition (PN) represents an alternative or additional approach when other routes are not succeeding (not necessarily having failed completely) or when it is not possible or would be unsafe to use other routes. The main goal of PN is to deliver a nutrient mixture closely related to requirements safely and to avoid complications. This nutritional approach has been a subject of debate over the past decades. PN carries the considerable risk of overfeeding which can be as deleterious as underfeeding. Therefore the authors will present not only the evidence available regarding the indications for PN, its implementation, the energy required, its possible complementary use with enteral nutrition, but also the relative importance of the macro- and micronutrients in the formula proposed for the critically ill patient. Data on long-term survival (expressed as 6 month survival) will also be considered a relevant outcome measure. Since there is a wide range of interpretations regarding the content of PN and great diversity in its practice, our guidance will necessarily reflect these different views. The papers available are very heterogeneous in quality and methodology (amount of calories, nutrients, proportion of nutrients, patients, etc.) and the different meta-analyses have not always taken this into account. Use of exclusive PN or complementary PN can lead to confusion, calorie targets are rarely achieved, and different nutrients continue to be used in different proportions. The present guidelines are the result of the analysis of the available literature, and acknowledging these limitations, our recommendations are intentionally largely expressed as expert opinions.