Something normal in a very, very abnormal environment – Nursing work to honour the life of dying infants and children in neonatal and paediatric intensive care in Australia

The majority of deaths of children and infants occur in paediatric and neonatal intensive care settings. For nurses, managing an infant/child's deterioration and death can be very challenging. Nurses play a vital role in how the death occurs, how families are supported leading up to and after the infant/child's death. This paper describes the nurses' endeavours to create normality amidst the sadness and grief of the death of a child in paediatric and neonatal ICU. Focus groups and individual interviews with registered nurses from NICU and PICU settings gathered data on how neonatal and paediatric intensive care nurses care for families when a child dies and how they perceived their ability and preparedness to provide family care. Four themes emerged from thematic analysis: (1) respecting the child as a person; (2) creating opportunities for family involvement/connection; (3) collecting mementos; and (4) planning for death. Many of the activities described in this study empowered parents to participate in the care of their child as death approached. Further work is required to ensure these principles are translated into practice.

Online mining abnormal period patterns from multiple medical sensor data streams

With the advanced technology of medical devices and sensors, an abundance of medical data streams are available. However, data analysis techniques are very limited, especially for processing massive multiple physiological streams that may only be understood by medical experts. The state-of-the-art techniques only allow multiple medical devices to independently monitor different physiological parameters for the patient's status, thus they signal too many false alarms, creating unnecessary noise, especially in the Intensive Care Unit (ICU). An effective solution which has been recently studied is to integrate information from multiple physiologic parameters to reduce alarms. But it is a challenge to detect abnormalities from high frequently changed physiological streams data, since abnormalities occur gradually due to the complex situation of patients. An analysis of ICU physiological data streams shows that many vital physiological parameters are changed periodically (such as heart rate, arterial pressure, and respiratory impedance) and thus abnormalities are generally abnormal period patterns. In this paper, we develop a Mining Abnormal Period Patterns from Multiple Physiological Streams (MAPPMPS) method to detect and rank abnormalities in medical sensor streams. The efficiency and effectiveness of the MAPPMPS method is demonstrated by a real-world massive database of multiple physiological streams sampled in ICU, comprising 250 patients' streams (each stream involving over 1.3 million data points) with a total size of 28 GB data.

Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting

BACKGROUND: Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated.

METHODS: Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated.

RESULTS: Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %.

CONCLUSIONS: Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.

Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to emergency departments

BACKGROUND: The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear.

METHODS: Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010.

RESULTS: Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% (n=163) patients who were older (p<0.001), with more comorbidities (p<0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly (p≤0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%).

CONCLUSIONS: Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality.

Sodium bicarbonate infusion in patients undergoing orthotopic liver transplantation: a single center randomized controlled pilot trial

BACKGROUND: Liver transplantation-associated acute kidney injury (AKI) carries significant morbidity and mortality. We hypothesized that sodium bicarbonate would reduce the incidence and/or severity of liver transplantation-associated AKI. METHODS: In this double-blinded pilot RCT, adult patients undergoing orthotopic liver transplantation were randomized to an infusion of either 8.4% sodium bicarbonate (0.5 mEq/kg/h for the first hour; 0.15 mEq/kg/h until completion of surgery); (n = 30) or 0.9% sodium chloride (n = 30). Primary outcome: AKI within the first 48 h post-operatively.RESULTS: There were no significant differences between the two treatment groups with regard to baseline characteristics, model for end-stage liver disease and acute physiology and chronic health evaluation (APACHE) II scores, and pre-transplantation renal function. Intra-operative factors were similar for duration of surgery, blood product requirements, crystalloid and colloid volumes infused and requirements for vasoactive therapy. Eleven patients (37%) in the bicarbonate group and 10 patients (33%) in the sodium chloride group developed a post-operative AKI (p = 0.79). Bicarbonate infusion attenuated the degree of immediate post-operative metabolic acidosis; however, this effect dissipated by 48 h. There were no significant differences in ventilation hours, ICU or hospital length of stay, or mortality. CONCLUSIONS: The intra-operative infusion of sodium bicarbonate did not decrease the incidence of AKI in patients following orthotopic liver transplantation.

What did they expect? Exploring a link between students’ expectations, attendance and attrition on English language enhancement courses

This article reports on and discusses the findings of an investigationcarried out to explore the expectations of an English language enhancementcourse (ELEC) held by a group of undergraduate students at anAustralian university. For the study, a mixed-methods approach was utilised,with two instruments: a survey with a combination of closed- andopen-ended questions and semi-structured interviews. The research wasguided by the following three questions: (1) What do the students expectto learn on the course? (2) How are they developing their expectations?(3) Are the students’ expectations being met? The literature concerningstudent expectations foregrounds the complexity and multi-faceted natureof the concept, the satisfaction of which can impact on student engagement,satisfaction, performance, retention and attrition. Findings showthat the participants’ expectations of the course content and teachingstaff were largely met; nonetheless, a lack of class attendance was notedthroughout. Expectations were reported to have been developed largelythrough consultation with previous students of the course (43 per cent)and information materials provided by the university (42 per cent). Thearticle concludes with a discussion regarding the implications of thefindings for universities and education providers both in Australia andabroad.

Effectiveness of a care bundle to reduce central line-associated bloodstream infections

OBJECTIVE: To determine the effectiveness of a care bundle, with a novel line maintenance procedure, in reducing the rate of central line-associated bloodstream infection (CLABSI) in the intensive care unit (ICU).

DESIGN, PARTICIPANTS AND SETTING: Before-and-after study using CLABSI data reported to the Victorian Healthcare Associated Infection Surveillance System (VICNISS), in adult patients admitted to a tertiary adult ICU in regional Victoria between 1 July 2006 and 30 June 2014. VICNISS-reported CLABSI cases were reviewed for verification. An intervention was implemented in 2009.

INTERVENTION: The care bundle introduced in 2009 included a previously established line insertion procedure and a novel line maintenance procedure comprising Biopatch, daily 2% chlorhexidine body wash, daily ICU central line review, and liaison nurse follow-up of central lines.

MAIN OUTCOME MEASURES: CLABSI rate (cases per 1000 central line days). RESULTS: The average CLABSI rate fell from 2.2/1000 central line days (peak of 5.2/1000 central line days in quarter 4, 2008) during the pre-intervention period to 0.5/1000 central line days (0/1000 central line days from July 2012 to July 2014) during the post-intervention period.

CONCLUSION: Our study suggests that this care bundle, using a novel maintenance procedure, can effectively reduce the CLABSI rate and maintain it at zero out to 2 years.

Intensive care unit discharge policies prior to treatment completion

In this study we explore a model to optimize the Intensive Care Unit (ICU) discharging decisions prior to service completion as a result of capacity-constrained situation under uncertainty. Discharging prior to service completion, which is called demand-driven discharge or premature discharging, increases the chance that a patient to be readmitted to the ICU in the near future. Since readmission imposes an additional load on ICUs, the cost of demand-driven discharge is pertained to the surge of readmission chance and the length of stay (LOS) in the ICU after readmission. Hence, the problem is how to select a current patient in the ICU for demand-driven discharge to accommodate a new critically ill patient. In essence, the problem is formulated as a stochastic dynamic programming model. However, even in the deterministic form i.e. knowing the arrival and treatment times in advance, solving the dynamic programming model is almost unaffordable for a sizable problem. This is illustrated by formulating the problem by an integer programming model. The uncertainties and difficulties in the problem are convincing reasons to use the optimization-simulation approach. Thus, using simulations, we evaluate various scenarios by considering Weibull distribution for the LOS. While it is known that selecting a patient with the lowest readmission risk is optimum under certain conditions and supposing a memory-less distribution for LOS; we remark that when LOS is non-memory-less, considering readmission risk and remaining LOS rather than just readmission risk leads to better results.

Valoración del dolor en el paciente con trauma grave y ventilación mecánica no comunicativo

Pain is defined since 1979 by the International Association for the Study of Pain (IASP) as "unpleasant subjective, sensory and emotional experience associated with actual or potential damage of tissue", with the concept more acceptable in our days. The Intensive Care Unit (ICU) is a complex environment to assess pain, where the difficulty in communication with the patient is the biggest barrier to getting your "selfreport", which is considered the gold standard in pain assessment. Many factors alter communication with critically ill patients, as the low level of consciousness, mechanical ventilation, sedation, and the patient's own pathology, besides, there are other limitations such as excessive technology or devices that can divert professional attention to the patient's pain behavior, and lack of training and guidance for management. The multicenter study SUPPORT, it showed that 50-65% of critical patients included suffered pain, and 15% of them reported moderate to severe intensity for more than half the period of hospitalization. Critically ill patients experience pain due to high volume of potentially painful techniques applied to them during their ICU admission, emphasizing nursing care and tracheal suctioning, mobilization, wound healing and channeling of catheters and others. The underestimation of pain involves physiological and hemodynamic effects such as increased blood pressure and/or heart rate, altered breathing pattern, and psychological and anxiety. Also an increase of sedation and mechanical ventilation time and ICU stay of increasing the morbidity and mortality of critically ill patients...

Barriers, enablers and challenges to initiating end-of-life care in an Australian intensive care unit context.

BACKGROUND: Patients admitted to Australian intensive care units are often critically unwell, and present the challenge of increasing mortality due to an ageing population. Several of these patients have terminal conditions, requiring withdrawal of active treatment and commencement of end-of-life (EOL) care. OBJECTIVES: The aim of the study was to explore the perspectives and experiences of physicians and nurses providing EOL care in the ICU. In particular, perceived barriers, enablers and challenges to providing EOL care were examined. METHODS: An interpretative, qualitative inquiry was selected as the methodological approach, with focus groups as the method for data collection. The study was conducted in Melbourne, Australia in a 24-bed ICU. Following ethics approval intensive care physicians and nurses were recruited to participate. Focus group discussions were discipline specific. All focus groups were audio-recorded then transcribed for thematic data analysis. RESULTS: Five focus groups were conducted with 11 physicians and 17 nurses participating. The themes identified are presented as barriers, enablers and challenges. Barriers include conflict between the ICU physicians and external medical teams, the availability of education and training, and environmental limitations. Enablers include collaboration and leadership during transitions of care. Challenges include communication and decision making, and expectations of the family. CONCLUSIONS: This study emphasised that positive communication, collaboration and culture are vital to achieving safe, high quality care at EOL. Greater use of collaborative discussions between ICU clinicians is important to facilitate improved decisions about EOL care. Such collaborative discussions can assist in preparing patients and their families when transitioning from active treatment to initiation of EOL care. Another major recommendation is to implement EOL care leaders of nursing and medical backgrounds, and patient support coordinators, to encourage clinicians to communicate with other clinicians, and with family members about plans for EOL care.

Desenlaces de la escala Omaha+ en los pacientes en cuidado intensivo en la fundación santa fe de Bogotá

Introducción La ventilación mecánica es fundamental en el manejo de la falla respiratoria aguda, actualmente no existe consenso sobre el momento exacto de extubación. Este estudio describe el comportamiento de la escala OMAHA+ en nuestra institución. Objetivo Principal Describir los desenlaces clínicos relacionados con la escala OMAHA+ durante la extubación de los pacientes de las unidades de cuidado intensivo del hospital universitario. Métodos Estudio descriptivo, retrospectivo, basado en el registro de la escala OMAHA+ de 68 pacientes durante el proceso de extubación en las Unidades de cuidado intensivo adulto de la Fundación Santa Fe de Bogotá durante Agosto de 2014 a Mayo de 2015. Resultados Se encontraron valores gasométricos cercanos a la normalidad, con una PaO2/FiO2 media de 261 (DS 60,6), SaO2 media de 96% (DS 2%), media de lactato sérico de 1.5 mmol/L (DS 1,2 mmol/L), con signos vitales normales. La causa más común de ingreso a UCI fue Neumonía, seguida por cirugía cardiaca y abdominal. Las medias de parámetros ventilatorios al momento de extubación fueron; PEEP de 6 (DS 0,8), volumen corriente de 8ml/Kg (DS 1,4 ml/Kg), índice de Tobín de 34 (DS 11,9), test de fuga positivo 94%, y sólo una extubación fallida. Conclusiones La escala OMAHA+ puede ser una herramienta útil, aplicable y fácilmente reproducible en los pacientes con soporte ventilatorio mecánico invasivo previo al proceso de extubación, con baja proporción de fallo. Estos resultados deben ser evaluados en estudios prospectivos.

Descripción del análisis microbológico realizado mediante maldi-tof en muestras de la fundación santa fe de Bogotá.

Introducción: La rápida detección e identificación bacteriana es fundamental para el manejo de los pacientes críticos que presentan una patología infecciosa, esto requiere de métodos rápidos para el inicio de un correcto tratamiento. En Colombia se usan pruebas microbiología convencional. No hay estudios de espectrofotometría de masas en análisis de muestras de pacientes críticos en Colombia. Objetivo general: Describir la experiencia del análisis microbiológico mediante la tecnología MALDI-TOF MS en muestras tomadas en la Fundación Santa Fe de Bogotá. Materiales y Métodos: Entre junio y julio de 2013, se analizaron 147 aislamientos bacterianos de muestras clínicas, las cuales fueron procesadas previamente por medio del sistema VITEK II. Los aislamientos correspondieron a 88 hemocultivos (60%), 28 urocultivos (19%), y otros cultivos 31 (21%). Resultados: Se obtuvieron 147 aislamientos con identificación adecuada a nivel de género y/o especie así: en el 88.4% (130 muestras) a nivel de género y especie, con una concordancia del 100% comparado con el sistema VITEK II. El porcentaje de identificación fue de 66% en el grupo de bacilos gram negativos no fermentadores, 96% en enterobacterias, 100% en gérmenes fastidiosos, 92% en cocos gram positivos, 100% bacilos gram negativos móviles y 100% en levaduras. No se encontró ninguna concordancia en bacilos gram positivos y gérmenes del genero Aggregatibacter. Conclusiones: El MALDI-TOF es una prueba rápida para la identificación microbiológica de género y especie que concuerda con los resultados obtenidos de manera convencional. Faltan estudios para hacer del MALDI-TOF MS la prueba oro en identificación de gérmenes.

Uso de dexmedetomidina como tratamiento coadyuvante de síndrome de abstinencia alcohólica: revisión sistemática

El objetivo de este estudio es establecer si la dexmedetomidina (DEX) es segura y efectiva para el manejo coadyuvante de síndrome de abstinencia a alcohol (SAA) a través de la búsqueda de evidencia científica. Metodología: se realiza una revisión sistemática de literatura publicada y no publicada desde enero de 1989 hasta febrero 2016 en PubMed, Embase, Scopus, Bireme, Cochrane library y en otras bases de datos y portales. Los criterios de inclusión fueron ensayos clínicos aleatorizados y no aleatorizados, estudios cuasi-experimentales, estudios de cohorte, y estudios de casos y controles; que incluyeron pacientes mayores de 18 años hospitalizados con diagnóstico de SAA y donde se usó DEX como terapia coadyuvante. Resultados: 7 estudios, 477 pacientes, se incluyeron en el análisis final. Se encontraron dos ensayos clínicos aleatorizados, tres estudios de casos y controles y dos estudios de cohorte retrospectivo. Solo uno de los estudios fue doble ciego y utilizó placebo como comparador. Análisis y conclusiones: en los estudios experimentales se determinan que el uso de DEX como terapia coadyuvante en el manejo de SAA tiene significancia clínica y estadística para disminuir dosis de BZD en las primeras 24 horas de tratamiento; pero no demostraron tener otros beneficios clínicos. En los estudios no aleatorizados existe consenso que relaciona el uso de DEX con menores dosis de BZD de forma temprana. Recomendaciones: no se recomienda el uso de DEX en SAA de forma rutinaria. Se recomienda usar DEX solo en casos en el que exista evidencia fallo terapéutico a BZD.

Seguridad del monitoreo hemodinámico invasivo versus mínimamente invasivo en pacientes con choque cardiogénico en cuidado intensivo adultos. Revisión sistemática

Introducción: El monitoreo hemodinámico es una herramienta para diagnosticar el choque cardiogénico y monitorear la respuesta al tratamiento; puede ser invasivo, mínimamente invasivo o no invasivo. Se realiza rutinariamente con catéter de arteria pulmonar (CAP) o catéter de Swan Ganz; nuevas técnicas de monitoreo hemodinámico mínimamente invasivo tienen menor tasa de complicaciones. Actualmente se desconoce cuál técnica de monitoreo cuenta con mayor seguridad en el paciente con choque cardiogénico. Objetivo: Evaluar la seguridad del monitoreo hemodinámico invasivo comparado con el mínimamente invasivo en pacientes con choque cardiogénico en cuidado intensivo adultos. Diseño: Revisión sistemática de la literatura. Búsqueda en Pubmed, EMBASE, OVID - Cochrane Library, Lilacs, Scielo, registros de ensayos clínicos, actas de conferencias, repositorios, búsqueda de literatura gris en Google Scholar, Teseo y Open Grey hasta agosto de 2016, publicados en inglés y español. Resultados: Se identificó un único estudio con 331 pacientes críticamente enfermos que comparó el monitoreo hemodinámico con CAP versus PiCCO que concluyó que después de la corrección de los factores de confusión, la elección del tipo de monitoreo no influyó en los resultados clínicos más importantes en términos de complicaciones y mortalidad. Dado que se incluyeron otros diagnósticos, no es posible extrapolar los resultados sólo a choque cardiogénico. Conclusión: En la literatura disponible no hay evidencia de que el monitoreo hemodinámico invasivo comparado con el mínimamente invasivo, en pacientes adultos críticamente enfermos con choque cardiogénico, tenga diferencias en cuanto a complicaciones y mortalidad.

Evaluación del desempeño pronóstico de dos puntajes de predicción de mortalidad a siete días en pacientes adultos oncológicos críticamente enfermos admitidos a una unidad de cuidados intensivos en Bogotá

Introducción Los sistemas de puntuación para predicción se han desarrollado para medir la severidad de la enfermedad y el pronóstico de los pacientes en la unidad de cuidados intensivos. Estas medidas son útiles para la toma de decisiones clínicas, la estandarización de la investigación, y la comparación de la calidad de la atención al paciente crítico. Materiales y métodos Estudio de tipo observacional analítico de cohorte en el que reviso las historias clínicas de 283 pacientes oncológicos admitidos a la unidad de cuidados intensivos (UCI) durante enero de 2014 a enero de 2016 y a quienes se les estimo la probabilidad de mortalidad con los puntajes pronósticos APACHE IV y MPM II, se realizó regresión logística con las variables predictoras con las que se derivaron cada uno de los modelos es sus estudios originales y se determinó la calibración, la discriminación y se calcularon los criterios de información Akaike AIC y Bayesiano BIC. Resultados En la evaluación de desempeño de los puntajes pronósticos APACHE IV mostro mayor capacidad de predicción (AUC = 0,95) en comparación con MPM II (AUC = 0,78), los dos modelos mostraron calibración adecuada con estadístico de Hosmer y Lemeshow para APACHE IV (p = 0,39) y para MPM II (p = 0,99). El ∆ BIC es de 2,9 que muestra evidencia positiva en contra de APACHE IV. Se reporta el estadístico AIC siendo menor para APACHE IV lo que indica que es el modelo con mejor ajuste a los datos. Conclusiones APACHE IV tiene un buen desempeño en la predicción de mortalidad de pacientes críticamente enfermos, incluyendo pacientes oncológicos. Por lo tanto se trata de una herramienta útil para el clínico en su labor diaria, al permitirle distinguir los pacientes con alta probabilidad de mortalidad.