Assessing the reliability of the sedation-agitation scale between nurses and doctors in a New Zealand ICU

The aim of the study was to determine whether nurses and doctors rate “real world” intensive care unit (ICU) patients similarly using the Sedation–Agitation Scale (SAS) in a generalist ICU context outside USA

Organizational factors associated with decreased mortality among veterans affairs patients with an ICU stay

In-hospital mortality rates associated with an ICU stay are high and vary widely among units. This variation may be related to organizational factors such as staffing patterns, ICU structure, and care processes. We aimed to identify organizational factors associated with variation in in-hospital mortality for patients with an ICU stay. This was a retrospective observational cross-sectional study using administrative data from 34 093 patients from 171 ICUs in 119 Veterans Health Administration hospitals. Staffing and patient data came from Veterans Health Administration national databases. ICU characteristics came from a survey in 2004 of ICUs within the Veterans Health Administration. We conducted multilevel multivariable estimation with patient-, unit-, and hospital-level data. The primary outcome was in-hospital mortality. Of 34 093 patients, 2141 (6.3%)died in the hospital. At the patient level, risk of complications and having a medical diagnosis were significantly associated with a higher risk of mortality. At the unit level, having an interface with the electronic medical record was significantly associated with a lower risk of mortality. The finding that electronic medical records integrated with ICU information systems are associated with lower in-hospital mortality adds support to existing evidence on organizational characteristics associated with in-hospital mortality among ICU patients.

Families' experiences of their interactions with staff in an Australian intensive care unit (ICU): a qualitative study

Nursing is characterised as a profession that provides holistic, person-centred care. Due to the condition of the critically ill, a family-centred care model is more applicable in this context. Furthermore, families are at risk of emotional and psychological distress, as a result of the admission of their relative to intensive care. The families' experiences of their interactions in intensive care have the potential to enhance or minimise this risk. This paper presents a subset of findings from a broader study exploring families of critically ill patients' experiences of their interactions with staff, their environment, the patient and other families, when their relative is admitted to an Australian intensive care unit. By developing an understanding of their experience, nurses are able to implement interventions to minimise the families' distress, while providing more holistic, person- and family-centred care.

Emergency responses for clinical deterioration within and beyond 24 hours of emergency admission: Patient outcomes and ICU implications

Introduction: The National Emergency Access Target was implemented to ensure 90% of patients leave emergency departments (EDs) within 4h. The impact of time driven performance on the number of physiologically unstable ward-based patients is unknown. An increase in clinical deterioration episodes potentially leading to adverse events will have resource implications for intensive care units (ICUs).
Objectives: To compare the characteristics and outcomes of patients who required an emergency response for clinical deterioration (cardiac arrest team or rapid response system activation) within and beyond 24 h of emergency admission to general medical and surgical units.
Methods: A retrospective exploratory design was used. The study site was a 365 bed urban hospital in Melbourne. Emergency responses for clinical deterioration during 2012 were examined.
Results: Of 819 emergency responses for clinical deterioration, 587 patients were admitted via ED. The median time to first responsewas59h, 28.4% of patients required this <24 h after admission. One in eight patients required ICU admission. Comparison of patients requiring a response within and beyond 24h of admission showed no significant differences in age, gender, waiting times, ED length of stay or in-hospital mortality rates. Patients in whom first emergency response occurred <24h after admission were less likely to be admitted to ICU immediately following the emergency response (7.6% vs 13.9%, p-0.039), less likely to have recurrent emergency responses during their hospitalisation (9.7% vs 34.0%, p<0.001), and had shorter median hospital length of stay (7 vs 11 days, p<0.001).
Conclusions: Considerable ICU resources were utilised given one in eight patients required ICU admission following emergency response, and patients admitted via the ED constituted 55% of all rapid response system activations. Exploring potential antecedents to clinical deterioration in this cohort may assist in establishing risk management strategies to reduce utilisation of ICU resources.

Nursing handover from ICU to cardiac ward: standardised tools to reduce safety risks

BACKGROUND: Standardising handover processes and content, and using context-specific checklists are proposed as solutions to mitigate risks for preventable errors and patient harm associated with clinical handovers. OBJECTIVES: Adapt existing tools to standardise nursing handover from the intensive care unit (ICU) to the cardiac ward and assess patient safety risks before and after pilot implementation. METHODS: A three-stage, pre-post interrupted time-series design was used. Data were collected using naturalistic observations and audio-recording of 40 handovers and focus groups with 11 nurses. In Stage 1, examination of existing practice using observation of 20 handovers and a focus group interview provided baseline data. In Stage 2, existing tools for high-risk handovers were adapted to create tools specific to ICU-to-ward handovers. The adapted tools were introduced to staff using principles from evidence-based frameworks for practice change. In Stage 3, observation of 20 handovers and a focus group with five nurses were used to verify the design of tools to standardise handover by ICU nurses transferring care of cardiac surgical patients to ward nurses. RESULTS: Stage 1 data revealed variable and unsafe ICU-to-ward handover practices: incomplete ward preparation; failure to check patient identity; handover located away from patients; and information gaps. Analyses informed adaptation of process, content and checklist tools to standardise handover in Stage 2. Compared with baseline data, Stage 3 observations revealed nurses used the tools consistently, ward readiness to receive patients (10% vs 95%), checking patient identity (0% vs 100%), delivery of handover at the bedside (25% vs 100%) and communication of complete information (40% vs 100%) improved. CONCLUSION: Clinician adoption of tools to standardise ICU-to-ward handover of cardiac surgical patients reduced handover variability and patient safety risks. The study outcomes provide context-specific tools to guide handover processes and delivery of verbal content, a safety checklist, and a risk recognition matrix.

Sedation protocols to reduce duration of mechanical ventilation in the ICU: a Cochrane Systematic Review

AIMS: 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 patients. BACKGROUND: Sedation is a core component of critical care. Sub-optimal sedation management incorporates both under- and over-sedation and has been linked to poorer patient outcomes. DESIGN: Cochrane systematic review of randomized controlled trials. DATA SOURCES: Cochrane Central Register of Controlled trials, MEDLINE, EMBASE, CINAHL, Database of Abstracts of Reviews of Effects, LILACS, Current Controlled Trials and US National Institutes of Health Clinical Research Studies (1990-November 2013) and reference lists of articles were used. REVIEW METHODS: Randomized controlled trials conducted in intensive care units comparing management with and without protocol-directed sedation were included. Two authors screened titles, abstracts and full-text reports. Potential risk of bias was assessed. Clinical, methodological and statistical heterogeneity were examined and the random-effects model used for meta-analysis where appropriate. Mean difference for duration of mechanical ventilation and risk ratio for mortality, with 95% confidence intervals, were calculated. RESULTS: Two eligible studies with 633 participants comparing protocol-directed sedation delivered by nurses vs. usual care were identified. There was no evidence of differences in duration of mechanical ventilation or hospital mortality. There was statistically significant heterogeneity between studies for duration of mechanical ventilation. CONCLUSIONS: There is insufficient evidence to evaluate the effectiveness of protocol-directed sedation as results from the two randomized controlled trials were conflicting.

Autopsy: quality assurance in the ICU

Objective: To examine the correlation between the clinical diagnosis and autopsy findings in adult patients who died in an intensive care unit (ICU). To determine the rate of agreement of the basic and terminal causes of death and the types of errors in order to improve quality control of future care,Design, Retrospective study.Setting: Adult ICU in a university hospital.Patients: 30 adult patients who died in the ICU. with the exclusion of medicolegal cases.Methods and main results: Anatomo-clinical meetings were held to analyze the pre- and postmortem correlations in 30 consecutive autopsies at the ICU of the University Hospital, School of Medicine of Botucatu/ UNESP, from January 1994 to January 1997. The rate of correct clinical diagnoses of the basic cause was 66.7 %; in 23.3 % of cases, if the correct diagnosis was made, management would have been different, as would have been the evolution of the patient's course (Class I error): in 10 % of the cases the error would not have led to a change in management (Class II error). The rate of correct clinical diagnoses of terminal cause was 80 %.Conclusions: the rate of recognition of the basic cause was 66.7 %, which is consistent with the literature, but the Class I error rate was higher than that reported in the literature.

Evolução temporal das definições de síndrome do desconforto respiratório agudo

OBJECTIVE: to review the evolution of acute respiratory distress syndrome (ARDS) definitions and present the current definition for the syndrome. DATA SOURCE: a literature review and selection of the most relevant articles on ARDS definitions was performed using the MEDLINE®/PubMed® Resource Guide database (last ten years), in addition to including the most important articles (classic articles) that described the disease evolution. DATA SYNTHESIS: the review included the following subjects: introduction; importance of definition; description of the first diagnostic criterion and subsequently used definitions, such as acute lung injury score; definition by the American-European Consensus Conference, and its limitations; description of the definition by Delphi, and its problems; accuracy of the aforementioned definitions; description of most recent definition (the Berlin definition), and its limitations; and practical importance of the new definition. CONCLUSIONS: ARDS is a serious disease that remains an ongoing diagnostic and therapeutic challenge. The evolution of definitions used to describe the disease shows that studies are needed to validate the current definition, especially in pediatrics, where the data are very scarce.