Abelha, Fernando J; Castro, Maria A; Neves, Aida M; Landeiro, Nuno M; Santos, Cristina C
Inadvertent hypothermia is not uncommon in the immediate postoperative period and it is associated with impairment and abnormalities in various organs and systems that can lead to adverse outcomes. The aim of this study was to estimate the prevalence, the predictive factors and outcome of core hypothermia on admission to a surgical ICU. All consecutive 185 adult patients who underwent scheduled or emergency noncardiac surgery admitted to a surgical ICU between April and July 2004 were admitted to the study. Tympanic membrane core temperature (Tc) was measured before surgery, on arrival at ICU and every two hours until 6 hours after admission. The following variables were also recorded: age, sex, body weight and height, ASA physical status, type of surgery, magnitude of surgical procedure, anesthesia technique, amount of intravenous fluids administered during anesthesia, use of temperature monitoring and warming techniques, duration of the anesthesia, ICU length of stay, hospital length of stay and SAPS II score. Patients were classified as either hypothermic (Tc 35 degrees C). Univariate analysis and multiple regression binary logistic with an odds ratio (OR) and its 95% Confidence Interval (95%CI) were used to compare the two groups of patients and assess the relationship between each clinical predictor and hypothermia. Outcome measured as ICU length of stay and mortality was also assessed. Prevalence of hypothermia on ICU admission was 57.8%. In univariate analysis temperature monitoring, use of warming techniques and higher previous body temperature were significant protective factors against core hypothermia. In this analysis independent predictors of hypothermia on admission to ICU were: magnitude of surgery, use of general anesthesia or combined epidural and general anesthesia, total intravenous crystalloids administrated and total packed erythrocytes administrated, anesthesia longer than 3 hours and SAPS II scores. In multiple logistic regression analysis
Landeiro Nuno M
Full Text Available Abstract Background Inadvertent hypothermia is not uncommon in the immediate postoperative period and it is associated with impairment and abnormalities in various organs and systems that can lead to adverse outcomes. The aim of this study was to estimate the prevalence, the predictive factors and outcome of core hypothermia on admission to a surgical ICU. Methods All consecutive 185 adult patients who underwent scheduled or emergency noncardiac surgery admitted to a surgical ICU between April and July 2004 were admitted to the study. Tympanic membrane core temperature (Tc was measured before surgery, on arrival at ICU and every two hours until 6 hours after admission. The following variables were also recorded: age, sex, body weight and height, ASA physical status, type of surgery, magnitude of surgical procedure, anesthesia technique, amount of intravenous fluids administered during anesthesia, use of temperature monitoring and warming techniques, duration of the anesthesia, ICU length of stay, hospital length of stay and SAPS II score. Patients were classified as either hypothermic (Tc ≤ 35°C or normothermic (Tc> 35°C. Univariate analysis and multiple regression binary logistic with an odds ratio (OR and its 95% Confidence Interval (95%CI were used to compare the two groups of patients and assess the relationship between each clinical predictor and hypothermia. Outcome measured as ICU length of stay and mortality was also assessed. Results Prevalence of hypothermia on ICU admission was 57.8%. In univariate analysis temperature monitoring, use of warming techniques and higher previous body temperature were significant protective factors against core hypothermia. In this analysis independent predictors of hypothermia on admission to ICU were: magnitude of surgery, use of general anesthesia or combined epidural and general anesthesia, total intravenous crystalloids administrated and total packed erythrocytes administrated, anesthesia longer
Objectives:The Intensive Care Unit (ICU) has improved patient outcome in complex surgeries while the costs of maintaining services are high. ICU services in developing countries are often inadequate due to lack of funds. This study reviews the pattern and outcomes of General Surgical patients admitted to the ICU of our ...
Ertugrul, Bulent M; Yildirim, Ayse; Ay, Pinar; Oncu, Serkan; Cagatay, Atahan; Cakar, Nahit; Ertekin, Cemalettin; Ozsut, Halit; Eraksoy, Haluk; Calangu, Semra
To investigate the incidence, risk factors and the etiology of ventilator-associated pneumonia (VAP) in surgical emergency intensive care unit (ICU) patients. We conducted this prospective cohort study in the surgical emergency ICU of Istanbul Medical Faculty between December 1999 and May 2001. We included 100 mechanically ventilated patients in this study. We diagnosed VAP according to the current diagnostic criteria. We identified the etiology of VAP cases by both quantitative cultures of endotracheal aspiration and blood cultures. To analyze the predisposing factors for the development of VAP, we recorded the following variables: age, gender, acute physiology and chronic health evaluation (APACHE) II score, Glasgow coma scale (GCS), sequential organ failure assessment (SOFA) score, serum albumin level, duration of mechanical ventilation (MV) prior to the development of VAP, and underlying diseases. We determined the VAP incidence rate as 28%. We found the APACHE II score and the duration of MV to be statistically significant variables for the development of VAP. There were no significant differences regarding age, gender, GCS, SOFA score, albumin level, or underlying diseases for the development of VAP. The isolated bacteria among VAP cases were as follows: Staphylococcus aureus (n=12, 43%), Acinetobacter spp. (n=6, 21%), coagulase-negative Staphylococci (n=4, 15%), Pseudomonas aeruginosa (n=3, 10.7%) and Klebsiella pneumoniae (n=3, 10.7%). Ventilator-associated pneumonia is a common infection, and certain interventions might affect the incidence of VAP. The ICU clinicians should be aware of the risk factors for VAP, which could prove useful in identifying patients at high risk for VAP, and modifying patient care to minimize the risk of VAP.
Abelha, Fernando J; Santos, Cristina C; Maia, Paula C; Castro, Maria A; Barros, Henrique
In addition to mortality, Health Related Quality of Life (HRQOL) has increasingly been claimed as an important outcome variable. The aim of this study was to assess HRQOL and independence in activities of daily living (ADL) six months after discharge from an Intensive Care Unit (ICU), and to study its determinants. All post-operative adult patients admitted to a surgical ICU between October 2004 and July 2005, were eligible for the study. The following variables were recorded on admission: age, gender, American Society of Anesthesiologists physical status (ASA-PS), type and magnitude of surgical procedure, ICU and hospital length of stay (LOS), mortality and Simplified Acute Physiology Score II (SAPS II). Six months after discharge, a Short Form-36 questionnaire (SF-36) and a questionnaire to assess dependency in ADL were sent to all survivors. Descriptive statistics was used to summarize data. Patient groups were compared using non-parametric tests. A logistic regression analysis was performed to identify covariate effects of each variable on dependency in personal and instrumental ADL, and for the change-in-health question of SF-36. Out of 333 hospital survivors, 226 completed the questionnaires. Fifty-nine percent reported that their general level of health was better on the day they answered the questionnaire than 12 months earlier. Patients with greater co-morbidities (ASA-PS III/IV), had lower SF-36 scores in all domains and were more frequently dependent in instrumental and personal ADL. Logistic regression showed that SAPS II was associated with changes in general level of health (OR 1.06, 95%CI, 1.01-1.11, p = 0,016). Six months after ICU discharge, 60% and 34% of patients, respectively, were dependent in at least one activity in instrumental ADL (ADLI) and personal ADL (ADLP). ASA-PS (OR 3.00, 95%CI 1.31-6.87, p = 0.009) and age (OR 2.36, 95%CI, 1.04-5.34, p = 0.04) were associated with dependency in ADLI. For ADLP, only ASA-PS (OR 4.58, 95%CI, 1
Full Text Available Rostislav Horacek,1 Barbora Krnacova,2 Jan Prasko,2 Klara Latalova2 1Department of Central Intensive Care Unit for Surgery, 2Department of Psychiatry, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University Olomouc, Czech Republic Background: The aim of this study was to examine the impact of somatic illnesses, electrolyte imbalance, red blood cell count, hypotension, and antipsychotic and opioid treatment on the duration of delirium in Central Intensive Care Unit for Surgery.Patients and methods: Patients who were admitted to the Department of Central Intensive Care Unit for Surgery in the University Hospital Olomouc from February 2004 to November 2008 were evaluated using Riker sedation–agitation scale. Their blood pressure, heart rate, respiratory rate, and peripheral blood oxygen saturation were measured continually, and body temperature was monitored once in an hour. The laboratory blood tests including sodium, potassium, chlorides, phosphorus, urea and creatinine, hemoglobin, hematocrit, red and white blood cell count, and C-reactive protein, albumin levels and laboratory markers of renal and liver dysfunction were done every day. All measurements were made at least for ten consecutive days or longer until the delirium resolved.Results: The sample consisted of 140 consecutive delirious patients with a mean age of 68.21±12.07 years. Delirium was diagnosed in 140 of 5,642 patients (2.48% admitted in CICUS in the last 5 years. The median duration of delirium was 48 hours with a range of 12–240 hours. Statistical analysis showed that hyperactive subtype of delirium and treatment with antipsychotics were associated with prolonged delirium duration (hyperactive 76.15±40.53 hours, hypoactive 54.46±28.44 hours, mixed 61.22±37.86 hours; Kruskal–Wallis test: 8.022; P<0.05. The duration of delirium was significantly correlated also with blood potassium levels (Pearson’s r=0.2189, P<0.05, hypotension
Niederbichler, A D; Ipaktchi, K; Jokuszies, A; Hirsch, T; Altintas, M A; Handschin, A E; Busch, K H; Gellert, M; Steinau, H-U; Vogt, P M; Steinsträsser, L
The clinical appearance of septic disorders is characterized by an enormous dynamic. The sepsis-induced dysbalance of the immune system necessitates immediate and aggressive therapeutic interventions to prevent further damage progression of the disease to septic shock and multiple organ failure. This includes supportive therapy to normalize and maintain organ and tissue perfusion as well as the identification of the infection focus. In cases where an infectious focus is identified, surgical source control frequently is a key element of the treatment strategy besides pharmacologic and supportive measures. The integrative approach of the management of septic patients requires rapid communication between the involved medical disciplines and the nursing personnel. Therefore, this article outlines current therapeutic concepts of septic diseases as well as central nursing aspects.
Golob, Joseph F; Fadlalla, Adam M A; Kan, Justin A; Patel, Nilam P; Yowler, Charles J; Claridge, Jeffrey A
We developed a prototype electronic clinical information system called the Surgical Intensive Care-Infection Registry (SIC-IR) to prospectively study infectious complications and monitor quality of care improvement programs in the surgical and trauma intensive care unit. The objective of this study was to validate SIC-IR as a successful health information technology with an accurate clinical data repository. Using the DeLone and McLean Model of Information Systems Success as a framework, we evaluated SIC-IR in a 3-month prospective crossover study of physician use in one of our two surgical and trauma intensive care units (SIC-IR unit versus non SIC-IR unit). Three simultaneous research methodologies were used: a user survey study, a pair of time-motion studies, and an accuracy study of SIC-IR's clinical data repository. The SIC-IR user survey results were positive for system reliability, graphic user interface, efficiency, and overall benefit to patient care. There was a significant decrease in prerounding time of nearly 4 minutes per patient on the SIC-IR unit compared with the non SIC-IR unit. The SIC-IR documentation and data archiving was accurate 74% to 100% of the time depending on the data entry method used. This accuracy was significantly improved compared with normal hand-written documentation on the non SIC-IR unit. SIC-IR proved to be a useful application both at individual user and organizational levels and will serve as an accurate tool to conduct prospective research and monitor quality of care improvement programs.
Lusignani, Maura; Giannì, Maria Lorella; Re, Luca Giuseppe; Buffon, Maria Luisa
To assess the frequency, intensity and level of moral distress perceived by nurses working in medical, surgical and intensive care units. Moral distress among nurses compromises their ability to provide optimal patient care and may cause them to leave their job. A cross-sectional questionnaire survey of 283 registered nurses was conducted to evaluate the frequency, intensity and levels of moral distress. A revised version of the Moral Distress Scale (MDS-R) was used. The highest level of moral distress was associated with the provision of treatments and aggressive care that were not expected to benefit the patients and the competency of the health-care providers. Multivariate regression showed that nurses working in medical settings, nurses with lower levels of experience working in medical, surgical or intensive care settings, and nurses who intend to leave their job experienced the highest levels of moral distress. The present study indicates that nurses experience an overall moderate level of moral distress. Gaining further insight into the issue of moral distress among nurses and the clinical situations that most frequently cause this distress will enable development of strategies to reduce moral distress and to improve nurse satisfaction and, consequently, patient care. © 2016 John Wiley & Sons Ltd.
Gershengorn, Hayley B; Garland, Allan; Gong, Michelle N
Published studies suggest hospital costs on Day 1 in the intensive care unit (ICU) far exceed those of subsequent days, when costs are relatively stable. Yet, no study stratified patients by ICU type. To determine whether daily cost patterns differ by ICU type. We performed a retrospective study of adults admitted to five ICUs (two surgical: quaternary surgical ICU [SICU quat] and quaternary cardiac surgical ICU [CSICU quat]; two medical: tertiary medical ICU [MICU tertiary] and quaternary medical ICU [MICU quat]; one general: community medical surgical ICU [MSICU comm]) at Montefiore Medical Center in the Bronx, New York during 2013. After excluding costs clearly accrued outside the ICU, daily hospital costs were merged with clinical data. Patterns of daily unadjusted costs were evaluated in each ICU using median regression. Generalized estimating equations with first-order autocorrelation were used to identify factors independently associated with daily costs. Unadjusted daily costs were higher on Day 1 than on subsequent days only for surgical ICUs-SICU quat (median [interquartile range], $2,636 [$1,834-$4,282] on Day 1 vs. $1,840 [$1,501-$2,332] on Day 2; P cost from Days 1 to 2. After multivariate adjustment, there remained a significant decrease in cost from ICU Day 1 to 2 in surgical units with statistically similar Day 1 and 2 costs for other ICUs. Higher Day 1 costs are not seen in patients admitted to medical/nonsurgical ICUs.
Conn, Lesley Gotlib; Haas, Barbara; Cuthbertson, Brian H; Amaral, Andre C; Coburn, Natalie; Nathens, Avery B
This ethnography explores communication around critically ill surgical patients in three surgical intensive care units (ICUs) in Canada. A boundary framework is used to articulate how surgeons', intensivists', and nurses' communication practices shape and are shaped by their respective disciplinary perspectives and experiences. Through 50 hours of observations and 43 interviews, these health care providers are found to engage in seven communication behaviors that either mitigate or magnify three contested symbolic boundaries: expertise, patient ownership, and decisional authority. Where these boundaries are successfully mitigated, experiences of collaborative, high-quality patient care are produced; by contrast, boundary magnification produces conflict and perceptions of unsafe patient care. Findings reveal that high quality and safe patient care are produced through complex social and cultural interactions among surgeons, intensivists, and nurses that are also expressions of knowledge and power. This enhances our understanding of why current quality improvement efforts targeting communication may be ineffective. © The Author(s) 2015.
Hobson, Deborah B; Chang, Tracy Y; Aboagye, Jonathan K; Lau, Brandyn D; Shihab, Hasan M; Fisher, Betsy; Young, Samantha; Sujeta, Nancy; Shaffer, Dauryne L; Popoola, Victor O; Kraus, Peggy S; Knorr, Gina; Farrow, Norma E; Streiff, Michael B; Haut, Elliott R
This study aimed to determine the prevalence of static graduated compression stocking (sGCS)-associated pressure injury among patients in surgical intensive care units (ICUs). We retrospectively reviewed data from wound care rounds between April 2011 and June 2012 at 3 surgical ICUs at an urban, tertiary care hospital. Patients with sGCS-associated pressure injury were identified and descriptive analysis was performed on their demographic, perioperative, and postoperative characteristics. We examined 1787 individual patients during 2391 patient encounters. A total of 129 (7.2%) of patients developed pressure injuries. Forty patients (2.2%) developed sGCS-associated pressure injury. Static GCS-associated pressure injury accounted for 31% (40/129) of all pressure injuries and 74% (40/54) of all medical device-related pressure injury. Eighteen (45%) and 6 (15%) developed stage 1 and 2 pressure injury, respectively, and 16 (40%) developed deep tissue injuries. The mean age of our patients was 64.7 years, about half (47.5%) were male, and their mean Acute Physiology and Chronic Health Evaluation II score was 18.8. Many had comorbid conditions, including obesity (44.5%) and diabetes (42.5%), and required mechanical ventilation (45%). Pressure injuries are a notable complication of sGCS in surgical ICU patients. Appropriate measures are required to help avoid this potentially preventable harm. Copyright © 2017 Elsevier Inc. All rights reserved.
Ozdogan, Hatice Kaya; Karateke, Faruk; Ozdogan, Mehmet; Cetinalp, Sibel; Ozyazici, Sefa; Gezercan, Yurdal; Okten, Ali Ihsan; Celik, Muge; Satar, Salim
Since the civilian war in Syria began, thousands of seriously injured trauma patients from Syria were brought to Turkey for emergency operations and/or postoperative intensive care. The aim of this study was to present the demographics and clinical features of the wounded patients in Syrian civil war admitted to the surgical intensive care units in a tertiary care centre. The records of 80 trauma patients admitted to the Anaesthesia, General Surgery and Neurosurgery ICUs between June 1, 2012 and July 15, 2014 were included in the study. The data were reviewed regarding the demographics, time of presentation, place of reference, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Injury Severity Score (ISS), surgical procedures, complications, length of stay and mortality. A total of 80 wounded patients (70 males and 10 females) with a mean age of 28.7 years were admitted to surgical ICUs. The most frequent cause of injury was gunshot injury. The mean time interval between the occurrence of injury and time of admission was 2.87 days. Mean ISS score on admission was 21, and mean APACHE II score was 15.7. APACHE II scores of non-survivors were significantly increased compared with those of survivors (P=0.001). No significant differences was found in the age, ISS, time interval before admission, length of stay in ICU, rate of surgery before or after admission. The most important factor affecting mortality in this particular trauma-ICU patient population from Syrian civil war was the physiological condition of patients on admission. Rapid transport and effective initial and on-road resuscitation are critical in decreasing the mortality rate in civil wars and military conflicts.
Williams, Mallory; Alban, Rodrigo F; Hardy, James P; Oxman, David A; Garcia, Edward R; Hevelone, Nathanael; Frendl, Gyorgy; Rogers, Selwyn O
Staff coverage strategies of intensive care units (ICUs) impact clinical outcomes. High-intensity staff coverage strategies are associated with lower morbidity and mortality. Accessible clinical expertise, team work, and effective communication have all been attributed to the success of this coverage strategy. We evaluate the impact of in-hospital fellow coverage (IHFC) on improving communication of cardiorespiratory events. A prospective observational study performed in an academic tertiary care center with high-intensity staff coverage. The main outcome measure was resident to fellow communication of cardiorespiratory events during IHFC vs home coverage (HC) periods. Three hundred twelve cardiorespiratory events were collected in 114 surgical ICU patients in 134 study days. Complete data were available for 306 events. One hundred three communication errors occurred. IHFC was associated with significantly better communication of events compared to HC (Pcommunicated 89% of events during IHFC vs 51% of events during HC (PCommunication patterns of junior and midlevel residents were similar. Midlevel residents communicated 68% of all on-call events (87% IHFC vs 50% HC, Pcommunicated 66% of events (94% IHFC vs 52% HC, PCommunication errors were lower in all ICUs during IHFC (Pcommunication errors. Copyright © 2014 Elsevier Inc. All rights reserved.
Mallick, M.S.; Jado, A.M.; Al-Bassam, A.R.
Transferring unstable, ill neonates to and from the operating rooms carries significant risks and can lead to morbidity. We report on our experience in performing certain procedures in critically ill neonates in the neonatal intensive care unit (NICU). We examined the feasibility and safety for such an approach. All surgical procedures performed in the NICU between January 1999 and December 2005 were analyzed in terms of demographic data, diagnosis, preoperative stability of the patient, procedures performed, complications and outcome. Operations were performed at beside in the NICU in critically ill, unstable neonates who needed emergency surgery, in neonates of low birth weight (<1000 gm) and in neonates on special equipments like higher frequency ventilators and nitrous oxide. Thirty-seven surgical procedures were performed including 12 laparotomies, bowel resection and stomies, 7 repairs of congenital diaphragmatic hernias, 4 ligations of patent ductus arteriosus and various others. Birth weights ranged between 850 gm and 3500 gm (mean 2000 gm). Gestational age ranged between 25 to 42 weeks (mean, 33 weeks). Age at surgery was between 1 to 30 days (mean, 30 days). Preoperatively, 19 patients (51.3%) were on inotropic support and all were intubated and mechanically ventilated. There was no mortality related to surgical procedures. Postoperatively, one patient developed wound infection and disruption. Performing major surgical procedures in the NICU is both feasible and safe. It is useful in very low birth weight, critically ill neonates who have definite risk attached to transfer to the operating room. No special area is needed in the NICU to perform complication-free surgery, but designing an operating room within the NICU will be ideal. (author)
Hsu, Min-Hui; Yu, Ying E; Tsai, Yueh-Miao; Lee, Hui-Chen; Huang, Ying-Che; Hsu, Han-Shui
For intensive care unit (ICU) patients with gastrointestinal dysfunction and in need of total parenteral nutrition (TPN) support, the benefit of additional enteral feeding is not clear. This study aimed to investigate whether combined TPN with enteral feeding is associated with better outcomes in surgical intensive care unit (SICU) patients. Clinical data of 88 patients in SICU were retrospectively collected. Variables used for analysis included route and percentage of nutritional support, total caloric intake, age, gender, body weight, body mass index, admission diagnosis, surgical procedure, Acute Physiology and Chronic Health Evaluation (APACHE) II score, comorbidities, length of hospital stay, postoperative complications, blood glucose values and hospital mortality. Wound dehiscence and central catheter infection were observed more frequently in the group of patients receiving TPN calories less than 90% of total calorie intake (p = 0.004 and 0.043, respectively). APACHE II scores were higher in nonsurvivors than in survivors (p = 0.001). More nonsurvivors received TPN calories exceeding 90% of total calorie intake and were in need of dialysis during ICU admission (p = 0.005 and 0.013, respectively). Multivariate analysis revealed that the percentage of TPN calories over total calories and APACHE II scores were independent predictors of ICU mortality in patients receiving supplementary TPN after surgery. In SICU patients receiving TPN, patients who could be fed enterally more than 10% of total calories had better clinical outcomes than patients receiving less than 10% of total calorie intake from enteral feeding. Enteral feeding should be given whenever possible in severely ill patients. 2012 Published by Elsevier B.V
Full Text Available Objective: Multidrug resistant Acinetobacter baumannii (MRAB is an important cause of hospital acquired infection and leads to an increasing morbidity and mortality in intensive care units (ICU. The aim of this study was to investigate the predictors of MRAB infection in surgical ICU patients. Material and Method: The charts of the patients who were admitted to the ICU between January 2008 and August 2010 were reviewed to identify patients with MRAB infection. Recorded data were as follows: age, sex, medical history, underlying surgical pathology, Acute Physiology and Chronic Health Evaluation II score (APACHE II and Glasgow Coma Score on ICU admission,presence of invasive procedures (intubation, arterial, central venous lines, urinary catheters, and renal replacement therapy, days in ICU and white blood cells (WBC and lactate count on infection day, infection site, complications (such as organ/system failure, length of stay (LOS in the ICU and hospital, and final outcome. Results: During the study period 25 patients with MRAB infection were identified. When compared with their matched control group (n=25, patients with MRAB infection had a significantly higher mean APACHE II score (p=0.001 and more frequently had an open wound (p=0.002 or required mechanical ventilation (p=0.005, with respiratory system disease (p=0.03, arterial catheterization (p=0.006, and central venous catheterization (p=0.004. Multivariate logistic regression revealed that APACHE II score (OR,1.155; CI, 1.008-1.324; p= 0.038 and open wound (OR, 27.77; CI, 2.020-333.333; p=0.018 were predictors of MRAB infection in these patients. Compared to their controls, patients with MRAB infection hand a longer LOS in ICU (36.44±30.44 days vs 7.80±8.13 days, p<0.000 and hospital (55.12±40.81 days vs 19.04±13.44 days, p<0.000. In hospital mortality rates for patients with MRAB infection and their controls were 56% and 32%, respectively (p=0.154. Conclusion: Our results indicate
Morgan, David J R; Ho, Kwok Ming; Ong, Yang Jian; Kolybaba, Marlene L
The 'weekend' effect is a controversial theory that links reduced staffing levels, staffing seniority and supportive services at hospitals during 'out-of-office hours' time periods with worsening patient outcomes. It is uncertain whether admitting elective surgery patients to intensive care units (ICU) during 'out-of-office hours' time periods mitigates this affect through higher staffing ratios and seniority. Over a 3-year period in Western Australia's largest private hospital, this retrospective nested-cohort study compared all elective surgical patients admitted to the ICU based on whether their admission occurred 'in-office hours' (Monday-Friday 08.00-18.00 hours) or 'out-of-office hours' (all other times). The main outcomes were surgical complications using the Dindo-Clavien classification and length-of-stay data. Of the total 4363 ICU admissions, 3584 ICU admissions were planned following elective surgery resulting in 2515 (70.2%) in-office hours and 1069 (29.8%) out-of-office hours elective ICU surgical admissions. Out-of-office hours ICU admissions following elective surgery were associated with an increased risk of infection (P = 0.029), blood transfusion (P = 0.020), total parental nutrition (P office hours ICU admissions were also associated with an increased hospital length-of-stay, with (1.74 days longer, P office hours ICU admissions following elective surgery is common and associated with serious post-operative complications culminating in significantly longer hospital length-of-stays and greater transfers with important patient and health economic implications. © 2017 Royal Australasian College of Surgeons.
Abelha, Fernando José; Castro, Maria Ana; Landeiro, Nuno Miguel; Neves, Aida Maria; Santos, Cristina Costa
Outcome in intensive care can be categorized as mortality related or morbidity related. Mortality is an insufficient measure of ICU outcome when measured alone and length of stay may be seen as an indirect measure of morbidity related outcome. The aim of the present study was to estimate the incidence and predictive factors for intrahospitalar outcome measured by mortality and LOS in patients admitted to a surgical ICU. In this prospective study all 185 patients, who underwent scheduled or emergency surgery admitted to a surgical ICU in a large tertiary university medical center performed during April and July 2004, were eligible to the study. The following variables were recorded: age, sex, body weight and height, core temperature (Tc), ASA physical status, emergency or scheduled surgery, magnitude of surgical procedure, anesthesia technique, amount of fluids during anesthesia, use of temperature monitoring and warming techniques, duration of the anesthesia, length of stay in ICU and in the hospital and SAPS II score. The mean length of stay in the ICU was 4.09 +/- 10.23 days. Significant risk factors for staying longer in ICU were SAPS II, ASA physical status, amount of colloids, fresh frozen plasma units and packed erythrocytes units used during surgery. Fourteen (7.60%) patients died in ICU and 29 (15.70%) died during their hospitalization. Statistically significant independent risk factors for mortality were emergency surgery, major surgery, high SAPS II scores, longer stay in ICU and in the hospital. Statistically significant protective factors against the probability of dying in the hospital were low body weight and low BMI. In conclusion, prolonged ICU stay is more frequent in more severely ill patients at admission and it is associated with higher hospital mortality. Hospital mortality is also more frequent in patients submitted to emergent and major surgery.
Suzan Demir Pektas
Full Text Available Background: Intensive Care Units (ICUs are places where critically ill patients are managed. Aim: We aimed to investigate skin disorders that developed in critically ill surgical patients during their stay in the ICU. Methods: The prevalence of dermatological disorders and factors affecting their clinical features was prospectively analyzed in surgical ICU patients. We recorded age, sex, type of ICU, comorbidities, skin disorders, time to consultation, duration of ICU stay, and mortality rate. Results: Our study included 605 patients (mean age of 60.1 ± 20.2 years; 56.4% males. Seventy-three (12.1% patients were consulted with the Dermatology Department, among which 28.8% had infectious dermatological lesions, 26% dermatoses, and 45.2% drug reactions. The most common infectious dermatological disorder was wound infection (55.6%, the most common drug reaction was maculopapular drug eruption (75.8%, and the most common dermatosis was frictional blisters (47.4%. Multiple comorbidities, hypertension, diabetes mellitus, coronary artery disease, Parkinson disease, and stroke increased dermatological disorders (P < 0.05. The consulted patients had a median ICU stay of 7 days (range 2–53 days; consultation was significantly more common when it exceeded 10 days (74% vs. 26%, P < 0.05. The consulted patients died more commonly (P < 0.05. Infectious dermatological disorders and dermatoses were more common in patients older and younger than 50 years, respectively (P < 0.05. Dermatoses were more common among women (P < 0.05. The median time to consultation was 6 (2–30 days; it was longest for dermatological infections and shortest for dermatoses (P < 0.05. Infectious dermatological disorders were significantly more common among the deceased patients (P < 0.05. Conclusion: Multiple factors including multiple comorbidities, duration of ICU stay, time to consultation, and mortality increase dermatological disorders among surgical ICU patients.
Croft, Chasen A; Moore, Frederick A; Efron, Philip A; Marker, Peggy S; Gabrielli, Andrea; Westhoff, Lynn S; Lottenberg, Lawrence; Jordan, Janeen; Klink, Victoria; Sailors, R Matthew; McKinley, Bruce A
A system to provide surveillance, diagnosis, and protocolized management of surgical intensive care unit (SICU) sepsis was undertaken as a performance improvement project. A system for sepsis management was implemented for SICU patients using paper followed by a computerized system. The hypothesis was that the computerized system would be associated with improved process and outcomes. A system was designed to provide early recognition and guide patient-specific management of sepsis including (1) modified early warning signs-sepsis recognition score (MEWS-SRS; summative point score of ranges of vital signs, mental status, white blood cell count; after every 4 hours) by bedside nurse; (2) suspected site assessment (vascular access, lung, abdomen, urinary tract, soft tissue, other) at bedside by physician or extender; (3) sepsis management protocol (replicable, point-of-care decisions) at bedside by nurse, physician, and extender. The system was implemented first using paper and then a computerized system. Sepsis severity was defined using standard criteria. In January to May 2012, a paper system was used to manage 77 consecutive sepsis encounters (3.9 ± 0.5 cases per week) in 65 patients (77% male; age, 53 ± 2 years). In June to December 2012, a computerized system was used to manage 132 consecutive sepsis encounters (4.4 ± 0.4 cases per week) in 119 patients (63% male; age, 58 ± 2 years). MEWS-SRS elicited 683 site assessments, and 201 had sepsis diagnosis and protocol management. The predominant site of infection was abdomen (paper, 58%; computer, 53%). Recognition of early sepsis tended to occur more using the computerized system (paper, 23%; computer, 35%). Hospital mortality rate for surgical ICU sepsis (paper, 20%; computer, 14%) was less with the computerized system. A computerized sepsis management system improves care process and outcome. Early sepsis is recognized and managed with greater frequency compared with severe sepsis or septic shock. The system
Yi Lin Lee
Full Text Available Aim: Progress in medical care and technology has led to patients with more advanced illnesses being admitted to the Intensive Care Unit (ICU. The practice of approaching end-of-life (EOL care decisions and limiting care is well documented in Western literature but unknown in Singapore. We performed a retrospective cohort study to describe the practice of EOL care in patients dying in a Singapore surgical ICU (SICU. The surgical critical care population was chosen as it is unique because surgeons are frequently involved in the EOL process. Methods: All consecutive patients aged 21 and above admitted to the SICU from July 2011 to March 2012, and who passed away in the ICU or within 7 days of discharge from the ICU (to account for transferred patients out of the ICU after end-of life care decisions were made and subsequently passed away were included in the study. Results: There were 473 SICU admissions during this period, out of which 53 were included with a mean age of 67.2 ± 11.1 years. EOL discussions were held in 81.1% of patients with a median time from admission to first discussion at 1 day (IQR 0–2.75 and a median number of ICU discussion of 1 (IQR 1–2. As most patients lacked decision-making capacity (inability to retain and process information secondary to the underlying disease pathology or sedative use, a surrogate was involved: group decision in 27.9%, child in 25.6% and an unclear family nominated member in 20.9%. 28.3% of patients were managed as for full active with resuscitation, 39.6% nonescalation of care, and 32.1% for withdrawal. The main reasons for conservative management (nonescalation and withdrawal of care were certain death in 52.3%, medical futility with minimal response to maximal care (27.3%, and the presence of underlying malignancy (18.2%. There was no significant difference between race or religion among patients for active or conservative management. Conclusion: 71.7% of patients who passed away in the ICU or
Mohammad A. Abusedera
Conclusions: Bedside IVUS-guided filter placement in medical-surgical critically ill patient in intensive care unit is a feasible, safe and reliable technique for IVC interruption. IVUS may be the most appropriate tool to guide filter insertion in obese patient.
D. Talon; C. Rouget; V. Cailleaux; P. Bailly; M. Thouverez; F. Barale; Y. Michel-Briand
textabstractA six month prospective study was carried out in a surgical intensive care unit (SICU) of a university hospital to assess the incidence and routes of exogenous colonization by Staphylococcus aureus. A total of 157 patients were included in the study. One thousand one hundred and eleven
Bui, Lan N; Pham, Vy P; Shirkey, Beverly A; Swan, Joshua T
This study compares the proportions of surgical intensive care unit (ICU) patients with delirium detected using the Confusion Assessment Method for the ICU (CAM-ICU) who received administrative documentation for delirium using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, stratified by delirium motoric subtypes. This retrospective cohort study was conducted at a surgical ICU from 06/2012 to 05/2013. Delirium was assessed twice daily and was defined as having ≥1 positive CAM-ICU rating. Delirious patients were categorized into hyperactive/mixed and hypoactive subtypes using corresponding Richmond Agitation Sedation Scales. Administrative documentation of delirium was defined as having ≥1 of 32 unique ICD-9-CM codes. Proportions were compared using Pearson's Chi-square test. Of included patients, 40 % (423/1055) were diagnosed with delirium, and 17 % (183/1055) had an ICD-9-CM code for delirium. The sensitivity and specificity of ICD-9-CM codes for delirium were 36 and 95 %. ICD-9-CM codes for delirium were available for 42 % (95 % CI 35-48 %; 105/253) of patients with hyperactive/mixed delirium and 27 % (95 % CI 20-34 %; 46/170) of patients with hypoactive delirium (relative risk = 1.5; 95 % CI 1.2-2.0; p = 0.002). ICD-9-CM codes yielded a low sensitivity for identifying patients with CAM-ICU positive delirium and were more likely to identify hyperactive/mixed delirium compared with hypoactive delirium.
Wahl, Wendy L; Zalewski, Christy; Hemmila, Mark R
Pneumonia is a major complication for hospitalized patients and has come under the scrutiny of health care regulating bodies, which propose that hospital-acquired pneumonia should not be reimbursed and potentially be a "never event." We hypothesized that many of our acutely injured patients develop pneumonia at the time of their initial traumatic event despite aggressive measures to prevent pneumonia during hospitalization. This retrospective review included all mechanically ventilated patients admitted to a mixed surgical intensive care units (ICU; trauma, general surgery, and burns) who developed pneumonia from 2006 to 2008. All pneumonia diagnosed by culture were obtained from bronchoalveolar lavage (BAL) specimens with ≥ 10(4) colony forming united (CFU)/mL considered a positive result. Criteria for ventilator-associated pneumonia (VAP) applied only to those patients ventilated mechanically for >48 hours at the time of a positive BAL culture. Aspiration organisms included Streptococcus species, methicillin-sensitive Staphylococcus aureus, Haemophilus influenzae, and oral flora. This was an institutional review board-approved study. There were 208 mechanically ventilated who patients underwent BAL, half of which were performed in the first 48 hours after admission for fever, infiltrate on chest radiograph, or increasing white blood cell count (early BAL group). Of these patients, 58% had positive BAL cultures (pneumonia) but did not have VAP. Only 10% of patients studied with early BAL had no growth on culture. Although the predominant organisms in the early BAL group were aspiration-type organisms, 17% had resistant pathogens, and 16% had other Gram-negative rods (GNR). This percentage was compared with the VAP group in whom 33% of patients had resistant organisms (P = .04) and 8% other GNR (P = NS). Twenty-five patients with ≤ 10(4) CFU/mL on early BAL underwent repeat BAL, and 16 (64%) were later diagnosed with VAP. Many intubated patients in the surgical
Hendershot, Kimberly M; Bollins, John P; Armen, Scott B; Thomas, Yalaunda M; Steinberg, Steven M; Cook, Charles H
To efficiently capture evaluation and management (E&M) and procedural billing in our surgical intensive care unit (SICU), we have developed an electronic billing system that links to the electronic medical record (EMR). In this system, only notes electronically signed and coded by an attending generate billing charges. We hypothesized that capture of missed billing during nighttime and weekends might be sufficient to subsidize 24/7 in-house attending coverage. A retrospective chart EMR review was performed of the EMRs for all SICU patients during a 2-month period. Note type, date, time, attending signature, and coding were analyzed. Notes without attending signature, diagnosis, or current procedural terminology (CPT) code were considered incomplete and identified as "missed billing." Four hundred and forty-three patients had 465 admissions generating 2,896 notes. Overall, 76% of notes were signed and coded by an attending and billed. Incomplete (not billed) notes represented an overall missed billing opportunity of $159,138 for the 2-month time period (approximately $954,000 annually). Unbilled E&M encounters during weekdays totaled $54,758, whereas unbilled E&M and procedures from weeknights and weekends totaled $88,408 ($44,566 and $43,842, respectively). Missed billing after-hours thus represents approximately $530K annually, extrapolating to approximately $220K in collections from our payer mix. Surprisingly, missed E&M and procedural billing during weekdays totaled $70,730 (approximately $425K billing, approximately $170K collections annually), and typically represented patients seen, but transferred from the SICU before attending documentation was completed. Capture of nighttime and weekend ICU collections alone may be insufficient to add faculty or incentivize in-house coverage, but could certainly complement other in-house derived revenues to such ends. In addition, missed daytime billing in busy modern ICUs can be substantial, and use of an EMR to identify
Still, Mary D; Cross, Linda C; Dunlap, Martha; Rencher, Rugenia; Larkins, Elizabeth R; Carpenter, David L; Buchman, Timothy G; Coopersmith, Craig M
Pressure ulcers cause significant morbidity and mortality in the surgical intensive care unit (SICU). The purpose of this study was to determine if a dedicated team tasked with turning and repositioning all hemodynamically stable SICU patients could decrease the formation of pressure ulcers. A total of 507 patients in a 20-bed SICU in a university hospital were assessed for pressure ulcers using a point prevalence strategy, between December 2008 and September 2010, before and after implementation of a team tasked with turning and repositioning all hemodynamically stable patients every 2 hours around the clock. At baseline, when frequent turning was encouraged but not required, a total of 42 pressure ulcers were identified in 278 patients. After implementation of the turn team, a total of 12 pressure ulcers were identified in 229 patients (p < 0.0001). The preintervention group included 34 stage I and II ulcers and 8 higher stage ulcers. After implementation of the turn team, there were 7 stage I and II ulcers and 5 higher stage ulcers. The average Braden score was 16.5 in the preintervention group and 13.4 in the postintervention group (p = 0.04), suggesting that pressure ulcers were occurring in higher risk patients after implementation of the turn team. A team dedicated to turning SICU patients every 2 hours dramatically decreased the incidence of pressure ulcers. The majority of stage I and stage II ulcers appear to be preventable with an aggressive intervention aimed at pressure ulcer prevention. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Mayr, Andreas; Ritsch, Nicole; Knotzer, Hans; Dünser, Martin; Schobersberger, Wolfgang; Ulmer, Hanno; Mutz, Norbert; Hasibeder, Walter
To evaluate primary success rate and effectiveness of direct-current cardioversion in postoperative critically ill patients with new-onset supraventricular tachyarrhythmias. Prospective intervention study. Twelve-bed surgical intensive care unit in a university teaching hospital. Thirty-seven consecutive, adult surgical intensive care unit patients with new-onset supraventricular tachyarrhythmias without previous history of tachyarrhythmias. Direct-current cardioversion using a monophasic, damped sinus-wave defibrillator. Energy levels used were 50, 100, 200, and 300 J for regular supraventricular tachyarrhythmias (n = 6) and 100, 200, and 360 J for irregular supraventricular tachyarrhythmias (n = 31). None of the patients was hypoxic, hypokalemic, or hypomagnesemic at onset of supraventricular tachyarrhythmia. Direct-current cardioversion restored sinus rhythm in 13 of 37 patients (35% primary responders). Most patients responded to the first or second direct-current cardioversion shock. Only one of 25 patients requiring more than two direct-current cardioversion shocks converted into sinus rhythm. Primary responders were significantly younger and demonstrated significant differences in arterial Po2 values at onset of supraventricular tachyarrhythmias compared with nonresponders. At 24 and 48 hrs, only six (16%) and five (13.5%) patients remained in sinus rhythm, respectively. In contrast to recent literature, direct-current cardioversion proved to be an ineffective method for treatment of new-onset supraventricular tachyarrhythmias and, in particular, atrial fibrillation with a rapid ventricular response in surgical intensive care unit patients.
Khan, Anjum; Lampitoc, Marianita; Salaripour, Maryam; McKernan, Patricia; Devlin, Roslyn; Muller, Matthew P
Outbreaks of methicillin resistant Staphylococcus aureus in the intensive care unit setting can be prolonged and difficult to control. This report describes the rapid control of an outbreak of methicillin resistant Staphylococcus aureus in a 24-bed open-concept medical surgical intensive care unit with a baseline methicillin resistant Staphylococcus aureus acquisition rate of 1.5 cases per 1000 patient days. This institution's infection control policy mandates an outbreak investigation if two cases of hospital-acquired methicillin resistant Staphylococcus aureus colonization or infection are identified in an intensive care unit within a four-week period. In July 2007, methicillin resistant Staphylococcus aureus was identified in the sputum of two patients within a one-week period. Screening of all patients in the intensive care unit identified one additional case and a fourth case was identified from a clinical specimen before control measures were implemented. Initial control measures included healthcare worker education, enhanced surveillance, patient cohorting, and enhanced environmental cleaning. Despite these measures, three more cases occurred. All patients were then placed in contact isolation, healthcare workers were screened, and the nursing staff was cohorted. After two weeks without a case, two additional cases were identified. Decolonization of all positive patients was initiated. No further cases occurred over a five-week period and the outbreak was declared over. The outbreak resulted in nine cases of methicillin resistant Staphylococcus aureus colonization (n = 8) or infection (n = 1) over an 11-week period. Only one of 175 healthcare workers was colonized and it was not the outbreak strain. Early detection and the stepwise addition of infection control measures resulted in the rapid control of an outbreak of methicillin resistant Staphylococcus aureus in a medical surgical intensive care unit without unit closure. A low threshold of suspicion and
Full Text Available Konrad Jarosz,1 Bartosz Kubisa,2 Agata Andrzejewska,3 Katarzyna Mrówczyńska,3 Zbigniew Hamerlak,4 Alicja Bartkowska-Śniatkowska5 1Department of Clinical Nursing, Pomeranian Medical University, 2Thoracic Surgery and Transplantation Department, Pomeranian Medical University, 3Anaesthesiology and Intensive Care Department, Pomeranian Medical University, 4Stomatology Department, Pomeranian Medical University, 5Anaesthesiology and Pediatric Intensive Care Department, Poznan University of Medical Sciences, Szczecin, Poland Abstract: Tracheostomy is a routinely done procedure in the setting of intensive care unit (ICU in patients requiring prolonged mechanical ventilation. There are two ways of making a tracheostomy: an open surgical tracheostomy and percutaneous dilatational tracheostomy. Percutaneous dilatational tracheostomy is associated with fewer complications than open tracheostomy. In this study, we would like to compare both techniques of performing a tracheostomy in ICU patients and to present possible complications, methods of diagnosing and treating and minimizing their risk. Keywords: tracheostomy, percutaneous tracheostomy, percutaneous dilatational tracheostomy, bronchoscopy, surgical tracheostomy, tracheoesophageal fistula, tracheostomy complications
Özlü, Zeynep Karaman; Bilican, Pınar
Surgical pain is experienced by inpatients with clinical, disease-related concerns, unknown encounters after surgery, quality of sleep, restrictions in position after surgery is known to be serious. The study was conducted to determine the effect of aromatherapy massage on quality of sleep and physiological parameters in surgical intensive care patients. This is an experimental study. The sample of this study consisted of 60 patients who were divided into two groups as experimental group and control group including 30 patients in each one. The participants were postoperative patients, absent complications, who were unconscious and extubated. A data collection form on personal characteristics of the patients, a registration form on their physical parameters and the Richards-Campbell Sleep Scale (RCSQ) were used to collect the data of the study. The Richards-Campbell Sleep Scale indicated that while the experimental group had a mean score of 53.80 ± 13.20, the control group had a mean score of 29.08 ± 9.71 and there was a statistically significant difference between mean scores of the groups. In a comparison of physiologic parameters, only diastolic blood pressure measuring between parameters in favor of an assembly as a statistically significant difference was detected. Results of the study showed that aromatherapy massage enhanced the sleep quality of patients in a surgical intensive care unit and resulted in some positive changes in their physiological parameters.
Mason, Virginia M; Leslie, Gail; Clark, Kathleen; Lyons, Pat; Walke, Erica; Butler, Christina; Griffin, Martha
Preparation for replacing the large proportion of staff nurses reaching retirement age in the next few decades in the United States is essential to continue delivering high-quality nursing care and improving patient outcomes. Retaining experienced critical care nurses is imperative to successfully implementing the orientation of new inexperienced critical care nurses. It is important to understand factors that affect work engagement to develop strategies that enhance nurse retention and improve the quality of patient care. Nurses' experience of moral distress has been measured in medical intensive care units but not in surgical trauma care units, where nurses are exposed to patients and families faced with sudden life-threatening, life-changing patient consequences.This pilot study is a nonexperimental, descriptive, correlational design to examine the effect of compassion satisfaction, compassion fatigue, moral distress, and level of nursing education on critical care nurses' work engagement. This is a partial replication of Lawrence's dissertation. The study also asked nurses to describe sources of moral distress and self-care strategies for coping with stress. This was used to identify qualitative themes about the nurse experiences. Jean Watson's theory of human caring serves as a framework to bring meaning and focus to the nursing-patient caring relationship.A convenience sample of 26 of 34 eligible experienced surgical intensive care unit trauma nurses responded to this survey, indicating a 77% response rate. Twenty-seven percent of the nurses scored high, and 73% scored average on compassion satisfaction. On compassion fatigue, 58% scored average on burnout and 42% scored low. On the secondary traumatic stress subscale, 38% scored average, and 62% scored low. The mean moral distress situations subscale score was 3.4, which is elevated. The mean 9-item Utrecht Work Engagement Scale total score, measuring work engagement, was 3.8, which is considered low
Pecanac, Kristen E; Schwarze, Margaret L
Nurses and surgeons may experience intra-team conflict during decision making about the use of postoperative life-sustaining treatment in the intensive care unit due to their perceptions of professional roles and responsibilities. Nurses have a sense of advocacy-a responsibility to support the patient's best interest; surgeons have a sense of agency-a responsibility to keep the patient alive. The objectives were to (1) describe the discourse surrounding the responsibilities of nurses and surgeons, as "advocates" and "agents," and (2) apply these findings to determine how differences in role responsibilities could foster conflict during decision making about postoperative life-sustaining treatment in the intensive care unit. Articles, books, and professional documents were explored to obtain descriptions of nurses' and surgeons' responsibilities to their patients. Using discourse analysis, responsibilities were grouped into themes and then compared for potential for conflict. Ethical considerations: No data were collected from human participants and ethical review was not required. The texts were analyzed by a surgeon and a nurse to minimize profession-centric biases. Four themes in nursing discourse were identified: responsibility to support patient autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as an intermediary between the physician and the patient, and the responsibility to support the well-being of the patient. Three themes in surgery discourse were identified personal responsibility for the patient's outcome, commitment to patient survival, and the responsibility to prevent harm to the patient from surgery. These responsibilities may contribute to conflict because each profession is working toward different goals and each believes they know what is best for the patient. It is not clear from the existing literature that either profession understands each other's responsibilities
Jianhua, Yao; Xingxing, Shi; Fen, Wang; Xijing, Zhang
To summarize the causes of death and to analyze the risk factors in a surgical intensive care unit (SICU). The relevant information of patients died in the SICU of Xijing Hospital of Fourth Military Medical University in past 15 years (from December 1999 to February 2015) was retrospectively analyzed. The gender, age, reason and date of hospitalization, date of transfer SICU, past medical history, whether or not admitted directly from emergency department or transferred from other department, operated or not, date of death, the main cause of death, acute physiology and chronic health evaluation II (APACHE II) score, the history of undergoing mechanical ventilation, continuous renal replacement therapy (CRRT), or antifungal therapy, as well as the ratio of the patients with body temperature higher than 39 °C, white blood cell (WBC) count higher than 10 x 10⁹/L, platelet (PLT) count below 100 x 10⁹/L, albumin (Alb) below 35 g/L of two periods, namely from December 1999 to July 2007 (the first period), and from August 2007 to February 2015 (the second period) were compared. The above parameters were compared with those of 201 survivors in SICU, and the risk factors leading to death were analyzed by logistic regression. From December 1999 to February 2015, 4 317 patients were taken care of in the SICU. Among them, the number of death was 186, and the mortality rate was 4.3%. In the first time period (from December 1999 to July 2007), the total number of patients was 1 356, and the number of death were 109 (the mortality rate was 8.0%). In the second period, i.e. from August 2007 to February 2015, the number of SICU patients was 2,961, and 77 died (the mortality rate was 2.6%). The difference of mortality rate between the two periods was statistically significant (χ² = 66.707, P = 0.001 ). The death rate of patients transferred directly from emergency department in the first period was 79.8% (87/109), and it was lower in the second period (51.9%, 40/77, χ² = 16
Çelik, Sevim; Yildirim, Ismail; Arslan, Ibrahim; Yildirim, Sinan; Erdal, Fatih; Yandi, Yunus Emre
The purpose of this study was to determine the effects of fever and nursing interventions to lower fever on hemodynamic values and oxygenation in febrile (temperature greater than 38.3°C) surgical intensive care unit patients. This retrospective study was conducted in 53 febrile patients out of 519 patients admitted to the surgical intensive care unit at a university hospital. Data were obtained from the medical records, laboratory files and nursing notes. Statistical analysis of the data was analyzed by repeated measures analysis of variance and a paired sample t-test. The average hourly urine output (F = 5.46; P = 0.002) and systolic blood pressure (F = 2.87; P = 0.03) were significantly lower after fever onset. Heart rate, respiratory rate, positive end-expiratory pressure settings and FiO(2) settings were unchanged after the development of fever. Diastolic blood pressure and oxygen saturation had non-statistically significant decreases. Nursing interventions for febrile patients consisted of medication administration (69.8%), ice (62.3%) and sponging with tepid water (62.3%). The present results showed that fever was associated with an increase in heart rate, decreased systolic arterial pressure, mean arterial pressure, oxygen saturation and hourly urine output. © 2011 Blackwell Publishing Asia Pty Ltd.
Tatum, James M; White, Terris; Kang, Christopher; Ley, Eric J; Melo, Nicolas; Bloom, Matthew; Alban, Rodrigo F
The objective of the study was to characterize house staff time to response and intervention when notified of a patient care issue by pager vs. smartphone. We hypothesized that smartphones would reduce house staff time to response and intervention. Prospective study of all electronic communications was conducted between nurses and house staff between September 2015 and October 2015. The 4-week study period was randomly divided into two 2-week study periods where all electronic communications between intensive care unit nurses and intensive care unit house staff were exclusively by smartphone or by pager, respectively. Time of communication initiation, time of house staff response, and time from response to clinical intervention for each communication were recorded. Outcomes are time from nurse contact to house staff response and intervention. Single-center surgical intensive care unit of Cedars-Sinai Medical Center in Los Angeles, California, an academic tertiary care and level I trauma center. All electronic communications occurring between nurses and house staff in the study unit during the study period were considered. During the study period, 205 nurse-house staff electronic communications occurred, 100 in the phone group and 105 in the pager group. House staff response to communication time was significantly shorter in the phone group (0.5 [interquartile range = 1.7] vs. 2 min, p house staff intervention after response was also significantly more rapid in the phone group (0.8 [1.7] vs. 1 min, p = 0.003). Dedicated clinical smartphones significantly decrease time to house staff response after electronic nursing communications compared with pagers. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
T B Singh
Full Text Available Acute kidney injury (AKI is a common complication in hospitalized patients. There are few comparative studies on hospital-acquired AKI (HAAKI in medical, surgical, and ICU patients. This study was conducted to compare the epidemiological characteristics, clinical profiles, and outcomes of HAAKI among these three units. All adult patients (>18 years of either gender who developed AKI based on RIFLE criteria (using serum creatinine, 48 h after hospitalization were included in the study. Patients of acute on chronic renal failure and AKI in pregnancy were excluded. Incidence of HAAKI in medical, surgical, and ICU wards were 0.54%, 0.72%, and 2.2% respectively ( P < 0.0001. There was no difference in age distribution among the groups, but onset of HAAKI was earliest in the medical ward ( P = 0.001. RIFLE-R was the most common AKI in medical (39.2% and ICU (50% wards but in the surgical ward, it was RIFLE-F that was most common (52.6%. Acute tubular necrosis was more common in ICU ( P = 0.043. Most common etiology of HAAKI in medical unit was drug induced (39.2%, whereas in surgical and ICU, it was sepsis (34% and 35.2% respectively. Mortality in ICU, surgical and medical units were 73.5%, 43.42%, and 37.2%, respectively ( P = 0.003. Length of hospital stay in surgical, ICU and medical units were different ( P = 0.007. This study highlights that the characters of HAAKI are different in some aspects among different hospital settings.
Graat, Marleen E; Choi, Goda; Wolthuis, Esther K; Korevaar, Johanna C; Spronk, Peter E; Stoker, Jaap; Vroom, Margreeth B; Schultz, Marcus J
The clinical value of daily routine chest radiographs (CXRs) in critically ill patients is unknown. We conducted this study to evaluate how frequently unexpected predefined major abnormalities are identified with daily routine CXRs, and how often these findings lead to a change in care for intensive care unit (ICU) patients. This was a prospective observational study conducted in a 28-bed, mixed medical-surgical ICU of a university hospital. Over a 5-month period, 2,457 daily routine CXRs were done in 754 consecutive ICU patients. The majority of these CXRs did not reveal any new predefined major finding. In only 5.8% of daily routine CXRs (14.3% of patients) was one or more new and unexpected abnormality encountered, including large atelectases (24 times in 20 patients), large infiltrates (23 in 22), severe pulmonary congestion (29 in 25), severe pleural effusion (13 in 13), pneumothorax/pneumomediastinum (14 in 13), and malposition of the orotracheal tube (32 in 26). Fewer than half of the CXRs with a new and unexpected finding were ultimately clinically relevant; in only 2.2% of all daily routine CXRs (6.4% of patients) did these radiologic abnormalities result in a change to therapy. Subgroup analysis revealed no differences between medical and surgical patients with regard to the incidence of new and unexpected findings on daily routine CXRs and the effect of new and unexpected CXR findings on daily care. In the ICU, daily routine CXRs seldom reveal unexpected, clinically relevant abnormalities, and they rarely prompt action. We propose that this diagnostic examination be abandoned in ICU patients.
Full Text Available Objective: The most efficient and most cost effective method for preventing health care associated infections is hand hygiene. Although hand hygiene is the most effective and simple method, compliance rates are very low among health care workers. It was aimed to evaluate the rates of compliance of healthcare workers in a state hospital. Material and Method: In this study, totally 112 healthcare workers (31 doctors and 81 nurses were evaluated with the 5-indication observation method in a period between January and July 2013. Results: A total of 754 (65.9% out of 1.144 cases were resulted in accurate hand washing and hand-rubbing. When the intensive care unit and surgical clinics were evaluated together, it was found that hand hygiene compliance rates were 51.26% in 199 cases and 66.85% in 591 cases for doctors and nurses, respectively. Conclusion: Consequently, we think that pre-informed observations are important training instruments for hand hygiene compliance.
Full Text Available Aim: improving the results of the complex treatment of patients with surgical pathology of abdominal organs by improving prevention and treatment of motor-evacuation disorders of the gastrointestinal tract in the postoperative period. Results: the article presents data on the use of metoclopramide, L- ar¬ginine, simethicone for the prevention of postoperative dysmotility development. It is proved that L-arginine use reduces the effects of peripheral vasospasm by improving microcirculation of the intestinal wall and this leads to a more rapid recovery of motor-evacuation function of the gastrointestinal tract.
Federal Laboratory Consortium — The Surgical Critical Care Initiative (SC2i) is a USU research program established in October 2013 to develop, translate, and validate biology-driven critical care....
Full Text Available This study reported our experience of bedside patent ductus arteriosus (PDA ligation for prematurity in the neonatal intensive care unit (NICU. Between April 1992 and March 2006, 41 very-low-birth-weight premature infants underwent PDA ligation in the NICU. There were 18 male and 23 female infants. The mean gestational age and birth weight were 26.9 weeks and 900.9 g, respectively. Preoperatively, 25 infants were ventilator-dependent. After operation, there were five deaths caused by complications of prematurity. Surgical complications occurred in four and all recovered well after treatment. Twenty preoperatively intubated babies survived and were extubated at 21.6 ± 12.7 days postoperatively. In conclusion, bedside PDA ligation in the NICU is safe and effective. It can avoid transportation of critically ill, very small infants. We suggest surgical closure as the primary treatment in very-low-birth-weight infants who are ventilator-dependent to avoid the possible complications of indomethacin and prolonged intubation.
Kastrup, Marc; Seeling, Matthes; Barthel, Stefan; Bloch, Andy; le Claire, Marie; Spies, Claudia; Scheller, Matthias; Braun, Jan
There is an increasing demand for intensive care in hospitals, which can lead to capacity limitations in the intensive care unit (ICU). Due to postponement of elective surgery or delayed admission of emergency patients, outcome may be negatively influenced. To optimize the admission process to intensive care, the post-anaesthesia care unit (PACU) was staffed with intensivist coverage around the clock. The aim of this study is to demonstrate the impact of the PACU on the structure of ICU-patients and the contribution to overall hospital profit in terms of changes in the case mix index for all surgical patients. The administrative data of all surgical patients (n = 51,040) 20 months prior and 20 months after the introduction of a round-the-clock intensivist staffing of the PACU were evaluated and compared. The relative number of patients with longer length of stay (LOS) (more than seven days) in the ICU increased after the introduction of the PACU. The average monthly number of treatment days of patients staying less than 24 hours in the ICU decreased by about 50% (138.95 vs. 68.19 treatment days, P case mix index (CMI) per hospital day for all surgical patients was significantly higher after the introduction of a PACU: 0.286 (± 0.234) vs. 0.309 (± 0.272) P case mix index of the patients per hospital day, increased after the implementation of a PACU and more patients can be treated in the same time, due to a better use of resources.
Manoj Kumar Sahu
Full Text Available Background: Nosocomial infections (NIs in the postoperative period not only increase morbidity and mortality, but also impose a significant economic burden on the health care infrastructure. This retrospective study was undertaken to (a evaluate the incidence, characteristics, risk factors and outcomes of NIs and (b identify common microorganisms responsible for infection and their antibiotic resistance profile in our Cardiac Surgical Intensive Care Unit (CSICU. Patients and Methods: After ethics committee approval, the CSICU records of all patients who underwent cardiovascular surgery between January 2013 and December 2014 were reviewed retrospectively. The incidence of NI, distribution of NI sites, types of microorganisms and their antibiotic resistance, length of CSICU stay, and patient-outcome were determined. Results: Three hundred and nineteen of 6864 patients (4.6% developed NI after cardiac surgery. Lower respiratory tract infections (LRTIs accounted for most of the infections (44.2% followed by surgical-site infection (SSI, 11.6%, bloodstream infection (BSI, 7.5%, urinary tract infection (UTI, 6.9% and infections from combined sources (29.8%. Acinetobacter, Klebsiella, Escherichia coli, and Staphylococcus were the most frequent pathogens isolated in patients with LRTI, BSI, UTI, and SSI, respectively. The Gram-negative bacteria isolated from different sources were found to be highly resistant to commonly used antibiotics. Conclusion: The incidence of NI and sepsis-related mortality, in our CSICU, was 4.6% and 1.9%, respectively. Lower respiratory tract was the most common site of infection and Gram-negative bacilli, the most common pathogens after cardiac surgery. Antibiotic resistance was maximum with Acinetobacter spp.
Macleod Jana B
Full Text Available Abstract Background The hierarchical nature of medical education has been thought necessary for the safe care of patients. In this setting, medical students in particular have limited opportunities for experiential learning. We report on a student-faculty collaboration that has successfully operated an annual, short-term surgical intervention in Haiti for the last three years. Medical students were responsible for logistics and were overseen by faculty members for patient care. Substantial planning with local partners ensured that trip activities supplemented existing surgical services. A case review was performed hypothesizing that such trips could provide effective surgical care while also providing a suitable educational experience. Findings Over three week-long trips, 64 cases were performed without any reported complications, and no immediate perioperative morbidity or mortality. A plurality of cases were complex urological procedures that required surgical skills that were locally unavailable (43%. Surgical productivity was twice that of comparable peer institutions in the region. Student roles in patient care were greatly expanded in comparison to those at U.S. academic medical centers and appropriate supervision was maintained. Discussion This demonstration project suggests that a properly designed surgical trip model can effectively balance the surgical needs of the community with an opportunity to expose young trainees to a clinical and cross-cultural experience rarely provided at this early stage of medical education. Few formalized programs currently exist although the experience above suggests the rewarding potential for broad-based adoption.
Korošec Jagodič, Helena; Jagodič, Klemen; Podbregar, Matej
Introduction Our aim was to determine long-term survival and quality of life of patients admitted to a surgical intensive care unit (ICU) because of sepsis or trauma. Methods This was an observational study conducted in an 11-bed, closed surgical ICU at a 860-bed teaching general hospital over a 1-year period (January 2003 to December 2003). Patients were divided into two groups according to admission diagnoses: group 1 included patients with sepsis; and group 2 included patients with trauma ...
Isitt, Catherine E; McCloskey, Kayleigh A; Caballo, Alvaro; Sharma, Pranev; Williams, Andrew; Leon-Villapalos, Jorge; Vizcaychipi, Marcela P
Skin graft failure is a recognised complication in the treatment of major burns. Little research to date has analysed the impact of the complex physiological management of burns patients on the success of skin grafting. We analysed surgical and anaesthetic variables to identify factors contributing to graft failure. Inclusion criteria were admission to our Burns Intensive Care Unit (BICU) between January 2009 and October 2013 with a major burn. After exclusion for death before hospital discharge or prior skin graft at a different hospital, 35 patients remained and were divided into those with successful autografts (n=16) and those with a failed autograft (n=19). For the purposes of this study, we defined poor autograft viability as requiring at least one additional skin graft to the same site. Logistic regression of variables was performed using SPSS (Version 22.0 IBMTM). Age, Sex, %Total Burn Surface Area or Belgian Outcome Burns Injury score did not significantly differ between groups. No differences were found in any surgical factor at logistic regression (graft site, harvest site, infection etc.). When all operations were analysed, the use of colloids was found to be significantly associated with graft failure (p=0.035, CI 95%) and this remained significant when only split thickness skin grafts (STSGs) and debridement operations were included (p=0.034, CI 95%). No differences were found in crystalloid use, intraoperative temperature, pre-operative haemoglobin and blood products or vasopressor use. This analysis highlights an independent association between colloids and graft failure which has not been previously documented.
Benjamin E Szpila
Full Text Available Blood product transfusions are associated with increased morbidity and mortality. The purpose of this study was to determine if implementation of a restrictive protocol for packed red blood cell (PRBC and fresh frozen plasma (FFP transfusion safely reduces blood product utilization and costs in a surgical intensive care unit (SICU.We performed a retrospective, historical control analysis comparing before (PRE and after (POST implementation of a restrictive PRBC/FFP transfusion protocol for SICU patients. Univariate analysis was utilized to compare patient demographics and blood product transfusion totals between the PRE and POST cohorts. Multivariate logistic regression models were developed to determine if implementation of the restrictive transfusion protocol is an independent predictor of adverse outcomes after controlling for age, illness severity, and total blood products received.829 total patients were included in the analysis (PRE, n=372; POST, n=457. Despite higher mean age (56 vs. 52 years, p=0.01 and APACHE II scores (12.5 vs. 11.2, p=0.006, mean units transfused per patient were lower for both packed red blood cells (0.7 vs. 1.2, p=0.03 and fresh frozen plasma (0.3 vs. 1.2, p=0.007 in the POST compared to the PRE cohort, respectively. There was no difference in inpatient mortality between the PRE and POST cohorts (7.5% vs. 9.2%, p=0.39. There was a decreased risk of urinary tract infections (OR 0.47, 95%CI 0.28-0.80 in the POST cohort after controlling for age, illness severity and amount of blood products transfused.Implementation of a restrictive transfusion protocol can effectively reduce blood product utilization in critically ill surgical patients with no increase in morbidity or mortality.
Park, Sang-Won; Ko, Suhui; An, Hye-Sun; Bang, Ji Hwan; Chung, Woo-Young
Central line-associated bloodstream infections (CLABSIs) can be prevented through well-coordinated, multifaceted programs. However, implementation of CLABSI prevention programs requires individualized strategies for different institutional situations, and the best strategy in resource-limited settings is uncertain. Peer tutoring may be an efficient and effective method that is applicable in such settings. A prospective intervention was performed to reduce CLABSIs in a surgical intensive care unit (SICU) at a tertiary hospital. The core interventions consisted of implementation of insertion and maintenance bundles for CLABSI prevention. The overall interventions were guided and coordinated by active educational programs using peer tutoring. The CLABSI rates were compared for 9 months pre-intervention, 6 months during the intervention and 9 months post-intervention. The CLABSI rate was further observed for three years after the intervention. The rate of CLABSIs per 1000 catheter-days decreased from 6.9 infections in the pre-intervention period to 2.4 and 1.8 in the intervention (6 m; P = 0.102) and post-intervention (9 m; P = 0.036) periods, respectively. A regression model showed a significantly decreasing trend in the infection rate from the pre-intervention period ( P tutoring in a resource-limited setting was useful and effectively reduced CLABSIs. However, maintaining the reduced CLABSI rate will require further strategies.
Ahmed, Armin; Baronia, Arvind Kumar; Azim, Afzal; Marak, Rungmei S. K.; Yadav, Reema; Sharma, Preeti; Gurjar, Mohan; Poddar, Banani; Singh, Ratender Kumar
Background: The aim of this study was to conduct external validation of risk prediction scores for invasive candidiasis. Methods: We conducted a prospective observational study in a 12-bedded adult medical/surgical Intensive Care Unit (ICU) to evaluate Candida score >3, colonization index (CI) >0.5, corrected CI >0.4 (CCI), and Ostrosky's clinical prediction rule (CPR). Patients' characteristics and risk factors for invasive candidiasis were noted. Patients were divided into two groups; invasive candidiasis and no-invasive candidiasis. Results: Of 198 patients, 17 developed invasive candidiasis. Discriminatory power (area under receiver operator curve [AUROC]) for Candida score, CI, CCI, and CPR were 0.66, 0.67, 0.63, and 0.62, respectively. A large number of patients in the no-invasive candidiasis group (114 out of 181) were exposed to antifungal agents during their stay in ICU. Subgroup analysis was carried out after excluding such patients from no-invasive candidiasis group. AUROC of Candida score, CI, CCI, and CPR were 0.7, 0.7, 0.65, and 0.72, respectively, and positive predictive values (PPVs) were in the range of 25%–47%, along with negative predictive values (NPVs) in the range of 84%–96% in the subgroup analysis. Conclusion: Currently available risk prediction scores have good NPV but poor PPV. They are useful for selecting patients who are not likely to benefit from antifungal therapy. PMID:28904481
Sustic, A.; Miletic, D.; Cicvaric, T.
Background. The aim of this study was to establish the incidence of abnormal ultrasonographic (US) findings of gallbladder (GB) in surgical patients with the prolonged stay in the intensive care unit (ICU) and to correlate these findings with the severity of illness. Methods. In the prospective study fifty-seven (57) adult surgical patients (male 66%; age 49±18 yr.) with the prolonged stay in ICU (>14 days) were analyzed. In all patients the US examination was performed on the 15th day of their stay in ICU. The presence of the following US findings was analyzed: GB wall thickening (?4 mm), biliary sludge, GB hydrops, striated GB wall and pericholecystitic fluid. The severity of illness was also evaluated on the 15th day of the stay in ICU using Simplified Acute Physiology Score (SAPS II). Results. At least one abnormal US finding was found in 36 (63%), patients with GB wall thickening in 32 (56%), biliary sludge in 23 (40%), pericholecystitic fluid in 9 (16%), hydrops of GB in 7 (12%), and striated GB wall in 4 (7%) cases, respectively. Two to five US findings were found in 20 (35%) patients, three to five in 12 (21%), four to five in 10 (18%), while all five US findings were present in 4 (7%) cases. The patients with one and more US findings had significantly higher SAPS II than the patients who presented regular US findings of the GB (36±9 vs. 28±7; p < 0.01). The patients with two and more US findings had higher SAPS II than those with one or none US criteria (40±8 vs. 29±6; p < 0.001), while the patients with three and more had higher SAPS II than those with two, one or none (41±8 vs. 31±9; p < 0.001). The patients with four or five US findings had higher SAPS II than those with three or less (42±11 vs. 31±6; p < 0.001) while the patients with all five had higher SAPS II than all others (45±10 vs. 32±9; p < 0.001). A significant positive correlation between the number of US findings and SAPS II was present (r 0.57; p < 0.001). Conclusions. More than
van Houdenhoven, Mark; van Oostrum, Jeroen M.; Wullink, Gerhard; Hans, Elias W.; Hurink, Johann L.; Bakker, Jan; Kazemier, Geert
Purpose: Mounting health care costs force hospital managers to maximize utilization of scarce resources and simultaneously improve access to hospital services. This article assesses the benefits of a cyclic case scheduling approach that exploits a master surgical schedule (MSS). An MSS maximizes
Jarosz, Konrad; Kubisa, Bartosz; Andrzejewska, Agata; Mr?wczy?ska, Katarzyna; Hamerlak, Zbigniew; Bartkowska-?niatkowska, Alicja
Konrad Jarosz,1 Bartosz Kubisa,2 Agata Andrzejewska,3 Katarzyna MrówczyÅska,3 Zbigniew Hamerlak,4 Alicja Bartkowska-Åniatkowska5 1Department of Clinical Nursing, Pomeranian Medical University, 2Thoracic Surgery and Transplantation Department, Pomeranian Medical University, 3Anaesthesiology and Intensive Care Department, Pomeranian Medical University, 4Stomatology Department, Pomeranian Medical University, 5Anaesthesiology and Pediatric Intensive Care Department, Poznan Universit...
Full Text Available Abstract Background Central line-associated bloodstream infections (CLABSIs can be prevented through well-coordinated, multifaceted programs. However, implementation of CLABSI prevention programs requires individualized strategies for different institutional situations, and the best strategy in resource-limited settings is uncertain. Peer tutoring may be an efficient and effective method that is applicable in such settings. Methods A prospective intervention was performed to reduce CLABSIs in a surgical intensive care unit (SICU at a tertiary hospital. The core interventions consisted of implementation of insertion and maintenance bundles for CLABSI prevention. The overall interventions were guided and coordinated by active educational programs using peer tutoring. The CLABSI rates were compared for 9 months pre-intervention, 6 months during the intervention and 9 months post-intervention. The CLABSI rate was further observed for three years after the intervention. Results The rate of CLABSIs per 1000 catheter-days decreased from 6.9 infections in the pre-intervention period to 2.4 and 1.8 in the intervention (6 m; P = 0.102 and post-intervention (9 m; P = 0.036 periods, respectively. A regression model showed a significantly decreasing trend in the infection rate from the pre-intervention period (P < 0.001, with incidence-rate ratios of 0.348 (95% confidence interval [CI], 0.98–1.23 in the intervention period and 0.257 (95% CI, 0.07–0.91 in the post-intervention period. However, after the 9-month post-intervention period, the yearly CLABSI rates reverted to 3.0–5.4 infections per 1000 catheter-days over 3 years. Conclusions Implementation of CLABSI prevention bundles using peer tutoring in a resource-limited setting was useful and effectively reduced CLABSIs. However, maintaining the reduced CLABSI rate will require further strategies.
Asghar, A.; Hashmi, M.; Rashid, S.; Khan, F.H.
Background: Sepsis is amongst the leading causes of admission to the intensive care units and is associated with a high mortality. However, data from developing countries is scarse. Aim of conducting this study was to determine the incidence, outcome and risk factors for sepsis on admission to surgical intensive care unit (SICU) of a teaching hospital in Pakistan. Methods: Two year retrospective observational study included all consecutive adult admissions to the surgical intensive care unit (SICU) of a University Hospital, from January 2012 to December 2013. Results: Two hundred and twenty-nine patients met the inclusion criteria. Average age of the patients was 46.35±18.23 years (16-85), mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 15.92±8.13 and males were 67.6 percentage. Median length of ICU stay was 4 [IQR 5]. 43 percentage patients fulfilled the criteria of sepsis at the time of admission to the SICU and incidence of severe sepsis/septic shock was 35 percentage. Abdominal sepsis was the most frequent source of infection (57.5 percentage). The overall intensive care unit mortality was 32.31 percentage but the mortality of sepsis-group was 51.15 percentage as compared to 17.7 percentage of the non-sepsis group. Stepwise logistic regression model showed that increasing age, female gender, non-operative admission, admission under general surgery and co-morbidities like ischaemic heart disease and chronic kidney disease were significant predictors of sepsis. Conclusion: The incidence of sepsis and severe sepsis/septic shock, on admission to SICU is high and mortality of the sepsis group is nearly three times the mortality of the non-sepsis group. (author)
Ohnuma, Tetsu; Shinjo, Daisuke; Brookhart, Alan M; Fushimi, Kiyohide
Reducing the 30-day unplanned hospital readmission rate is a goal for physicians and policymakers in order to improve quality of care. However, data on the readmission rate of critically ill patients in Japan and knowledge of the predictors associated with readmission are lacking. We investigated predictors associated with 30-day rehospitalization for medical and surgical adult patients separately. Patient data from 502 acute care hospitals with intensive care unit (ICU) facilities in Japan were retrospectively extracted from the Japanese Diagnosis Procedure Combination (DPC) database between April 2012 and February 2014. Factors associated with unplanned hospital readmission within 30 days of hospital discharge among medical and surgical ICU survivors were identified using multivariable logistic regression analysis. Of 486,651 ICU survivors, we identified 5583 unplanned hospital readmissions within 30 days of discharge following 147,423 medical hospitalizations (3.8% readmitted) and 11,142 unplanned readmissions after 339,228 surgical hospitalizations (3.3% readmitted). The majority of unplanned hospital readmissions, 60.9% of medical and 63.1% of surgical case readmissions, occurred within 15 days of discharge. For both medical and surgical patients, the Charlson comorbidity index score; category of primary diagnosis during the index admission (respiratory, gastrointestinal, and metabolic and renal); hospital length of stay; discharge to skilled nursing facilities; and having received a packed red blood cell transfusion, low-dose steroids, or renal replacement therapy were significantly associated with higher unplanned hospital readmission rates. From patient data extracted from a large Japanese national database, the 30-day unplanned hospital readmission rate after ICU stay was 3.4%. Further studies are required to improve readmission prediction models and to develop targeted interventions for high-risk patients.
Full Text Available Background: A cell injury from surgical stress in a trauma or a non-trauma case will induce a hyper metabolic response in which the protein degradation increases, the somatic protein synthesis decreases and the amino acid catabolism increases. Thus, the pyper metabolic response contributes to nitrogen loss in urine. This response, without an adequate nutrition, will lead an iatrogenic malnutrition and deterioration. A balance nitrogen formula through urinary urea nitrogen is one of many nutrition evaluation methods. This method aids in evaluating the daily nutrition status and it can be the baseline data for daily intake. Objective: To find a correlation between the protein intake and the nitrogen balance of the surgical patients in anesthesiology and intensive care installation, Sanglah General Hospital, Denpasar, Bali. Methods: Fifty-one surgical patients with trauma and non-trauma cases were observed for their protein intake for 2-3 days continuously. Moreover, they were evaluated for their nitrogen balance based on the urinary urea nitrogen per 24 hours for 2-3 days. For statistical analysis, we utilized Shapiro-Francia, Shapiro-Wilk, Spearman Frank correlation, two-sample t test, and multivariate regression analysis in Strata SE 12.1. Results: The correlation between the protein intake and the nitrogen balance on the first day was ra=0.50 (p<0.05, on the second day ra=0.70 (p<0,05, and on the third day ra=0.740 (p<0,05. Conclusions: There is a correlation between the protein intake and the nitrogen balance of surgical patients in Anesthesiology and Intensive Care Installation Sanglah General Hospital Denpasar.
Kelleher, Alyson Dare; Moorer, Amanda; Makic, MaryBeth Flynn
We conducted a quality improvement project in order to evaluate the effect of nurse-to-nurse bedside "rounding" as a strategy to decrease hospital-acquired pressure ulcers (HAPU) in a surgical intensive care unit. We instituted weekly peer-to-peer bedside skin rounds in a 17-bed surgical intensive care unit. Two nurses were identified as skin champions and trained by the hospital's certified WOC nurse to conduct skin rounds. The skin champion nurses conducted weekly peer-to-peer rounds that included discussions about key elements of our patients' skin status including current Braden Scale for Pressure Sore Risk score, and implementation of specific interventions related to subscale risk assessment. If a pressure ulcer was present, the current action plan was reevaluated for effectiveness. Quarterly HAPU prevalence studies were conducted from January 2008 to December 2010. Nineteen patients experienced a HAPU: 17 were located on the coccyx and 2 on the heel. Ten ulcers were classified as stage II, 3 PU were stage IV, 5 were deemed unstageable, and 1 was classified as a deep tissue injury. The frequency of preventive interventions rose during our quality improvement project. Specifically, the use of prevention surfaces increased 92%, repositioning increased 30%, nutrition interventions increased 77%, and moisture management increased 100%. Prior to focused nursing rounds, the highest HAPU prevalence rate was 27%. After implementing focused nursing rounds, HAPU rates trended down and were 0% for 3 consecutive quarters.
Antcliffe, D; Gordon, AC
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2016. Other selected articles can be found online at http://www.biomedcentral.com/collections/annualupdate2016. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
Walker, Sarah; Datta, Ankur; Massoumi, Roxanne L; Gross, Erica R; Uhing, Michael; Arca, Marjorie J
There is significant diversity in the utilization of antibiotics for neonates undergoing surgical procedures. Our institution standardized antibiotic administration for surgical neonates, in which no empiric antibiotics were given to infants with surgical conditions postnatally, and antibiotics are given no more than 72 hours perioperatively. We compared the time periods before and after implementation of antibiotic protocol in an institution review board-approved, retrospective review of neonates with congenital surgical conditions who underwent surgical correction within 30 days after birth. Surgical site infection at 30 days was the primary outcome, and development of hospital-acquired infections or multidrug-resistant organism were secondary outcomes. One hundred forty-eight infants underwent surgical procedures pre-protocol, and 127 underwent procedures post-protocol implementation. Surgical site infection rates were similar pre- and post-protocol, 14% and 9% respectively, (P = .21.) The incidence of hospital-acquired infections (13.7% vs 8.7%, P = .205) and multidrug-resistant organism (4.7% vs 1.6%, P = .143) was similar between the 2 periods. Elimination of empiric postnatal antibiotics did not statistically change rates of surgical site infection, hospital-acquired infections, or multidrug-resistant organisms. Limiting the duration of perioperative antibiotic prophylaxis to no more than 72 hours after surgery did not increase the rate of surgical site infection, hospital-acquired infections, or multidrug-resistant organism. Median antibiotic days were decreased with antibiotic standardization for surgical neonates. Copyright © 2017 Elsevier Inc. All rights reserved.
Lee, L; Liew, N C; Gee, T
This survey was conducted to determine the opinions and practices of peri-operative venous thromboembolism (VTE) prophylaxis among surgical and intensive care specialists in Asia. A set of questionnaire was distributed to surgeons and intensivists from different countries in Asia. The specialties included were general surgery and its sub-specialties, orthopaedic surgery, gynaecological surgery and intensive care unit. This survey involved teaching institutions, general hospitals and private hospitals. To gauge if the respondents were from hospitals that would likely encounter VTE cases, the hospital's bed-strength, intensive care facility and sub-specialty services were recorded. Over a period of six months, questionnaires and feedbacks were collected and analyzed. One hundred and ninety-one responses were received from 8 countries throughout Asia. Fifty-six percent of these were from large hospitals (800 bedded or more) and 62% of these hospitals have large intensive care facility (20 or more beds). Only half of the respondents practice routine thromboprophylaxis in moderate and high risk surgeries. Thirty six percent of them practices selective thromboprophylaxis and only 3% do not believe in any thromboprophylaxis. A third prescribed thromboprophylaxis for 3 to 5 days; another third extended it until patient is mobile. About 48.6% of the respondents do not have VTE guidelines in their institutions. Majority of the respondents agreed that more evidence is needed in the form of multi-centre randomized controlled trials to influence their decision on thromboprophylaxis. Despite the availability of strong epidemiological data, randomized controlled trials and multicentre case-controlled studies, perioperative VTE prophylactic practices are still suboptimal in Asia.
Lee, Seul; Oh, HyunSoo; Suh, YeonOk; Seo, WhaSook
To develop and examine a relocation stress intervention programme tailored for the family caregivers of patients scheduled for transfer from a surgical intensive care unit to a general ward. Family relocation stress syndrome has been reported to be similar to that exhibited by patients, and investigators have emphasised that nurses should make special efforts to relieve family relocation stress to maximise positive contributions to the well-being of patients by family caregivers. A nonequivalent control group, nonsynchronised pretest-post-test design was adopted. The study subjects were 60 family caregivers of patients with neurosurgical or general surgical conditions in the surgical intensive care unit of a university hospital located in Incheon, South Korea. Relocation stress and family burden were evaluated at three times, that is before intervention, immediately after transfer and four to five days after transfer. This relocation stress intervention programme was developed for the family caregivers based on disease characteristics and relocation-related needs. In the experimental group, relocation stress levels significantly and continuously decreased after intervention, whereas in the control group, a slight nonsignificant trend was observed. Family burden levels in the control group increased significantly after transfer, whereas burden levels in the experimental group increased only marginally and nonsignificantly. No significant between-group differences in relocation stress or family burden levels were observed after intervention. Relocation stress levels of family caregivers were significantly decreased after intervention in the experimental group, which indicates that the devised family relocation stress intervention programme effectively alleviated family relocation stress. The devised intervention programme, which was tailored to disease characteristics and relocation-related needs, may enhance the practicality and efficacy of relocation stress
Edmiston, Charles E; Krepel, Candace J; Leaper, David; Ledeboer, Nathan A; Mackey, Tami-Lea; Graham, Mary Beth; Lee, Cheong; Rossi, Peter J; Brown, Kellie R; Lewis, Brian D; Seabrook, Gary R
Ceftaroline is a new parenteral cephalosporin agent with excellent activity against methicillin-sensitive (MSSA) and resistant strains of Staphylococcus aureus (MRSA). Critically ill surgical patients are susceptible to infection, often by multi-drug-resistant pathogens. The activity of ceftaroline against such pathogens has not been described. Three hundred thirty-five consecutive microbial isolates were collected from surgical wounds or abscesses, respiratory, urine, and blood cultures from patients in the surgical intensive care unit (SICU) of a major tertiary medical center. Using Clinical and Laboratory Standards Institute (CLSI) standard methodology and published breakpoints, all aerobic, facultative anaerobic isolates were tested against ceftaroline and selected comparative antimicrobial agents. All staphylococcal isolates were susceptible to ceftaroline at a breakpoint of ≤1.0 mcg/mL. In addition, ceftaroline exhibited excellent activity against all streptococcal clinical isolates and non-ESBL-producing strains of Enterobacteriaceae (93.5%) recovered from SICU patients. Ceftaroline was inactive against ESBL-producing Enterobacteriaceae, Pseudomonas aeruginosa, vancomycin-resistant enterococci, and selective gram-negative anaerobic bacteria. At present, ceftaroline is the only cephalosporin agent that is active against community and healthcare-associated MRSA. Further studies are needed to validate the benefit of this novel broad-spectrum anti-infective agent for the treatment of susceptible serious infections in the SICU patient population.
Korosec Jagodic, Helena; Jagodic, Klemen; Podbregar, Matej
Our aim was to determine long-term survival and quality of life of patients admitted to a surgical intensive care unit (ICU) because of sepsis or trauma. This was an observational study conducted in an 11-bed, closed surgical ICU at a 860-bed teaching general hospital over a 1-year period (January 2003 to December 2003). Patients were divided into two groups according to admission diagnoses: group 1 included patients with sepsis; and group 2 included patients with trauma (polytrauma, multiple trauma, head injury, or spinal injury). Quality of life was assessed after 2 years following ICU admission using the EuroQol 5D questionnaire. A total of 164 patients (98 trauma patients and 66 patients with sepsis) were included in the study. Trauma patients were younger than patients with sepsis (53 +/- 21 years versus 64 +/- 13 years; P Trauma patients stayed longer on the general ward (35 +/- 44 days versus 17 +/- 24 days; P trauma group (surgical ICU survival: 60% versus 74%; in-hospital survival: 42% versus 62%; post-hospital survival: 78% versus 92%; cumulative 2-year survival: 33% versus 57%; P quality of life in all five dimensions of the EuroQol 5D between groups: 60% of patients had signs of depression, almost 60% had problems in usual activities and 56% had pain. Patients with sepsis treated in a surgical ICU have higher short-term and long-term mortality than do trauma patients. However, quality of life is reduced to the same level in both groups.
Livingston, David H; Tripp, Tovah; Biggs, Carina; Lavery, Robert F
Trauma centers successfully save lives of severely injured patients who would have formerly died. However, survivors often have multiple complications and morbidities associated with prolonged intensive care unit (ICU) stays. Because the reintegration of patients into the society to lead an active and a productive life is the ultimate goal of trauma center care, we questioned whether our "success" may condemn these patients to a fate worse than death? Charts on all patients > or =18 years with ICU stay > or =10 days, discharged alive between June 1, 2002, and May 31, 2005, were reviewed. Patients with complete spinal cord injuries were excluded. Demographics, Injury Severity Score (ISS), presence of severe traumatic brain injury (TBI; Head Abbreviated Injury Scale [AIS] score = 4 or 5), presence of extremity fractures, need for operative procedures, ventilator days, complications, and discharge disposition were collected. Glasgow Outcome Scale score was calculated on discharge. Patients were contacted by phone to determine general health, work status, and using this data, Glasgow Outcome Scale score and a modified Functional Independence Measure (FIM) score were calculated. Two hundred and forty-one patients met inclusion criteria. Thirty-three patients died postdischarge from the hospital and 39 were known to be alive from the electronic medical records but were unable to be contacted. Sixty-nine patients could not be tracked down and were ultimately considered as lost to follow-up. The remaining 100 patients who were successfully contacted participated in the study. Eighty-one percent were men with a mean age of 42 years, mean and median ISS of 28. Severe TBI was present in 50 (50%) patients. Mean and median follow-up was 3.3 years from discharge. At the time of follow-up, 92 (92%) patients were living at home, 5 in nursing homes, and 3 in assisted living, a shelter, or halfway house. FIM scores ranged from 6 to 12 with 55% reached a maximal FIM score of 12. One
Haut, Elliott R; Sicoutris, Corinna P; Meredith, Denise M; Sonnad, Seema S; Reilly, Patrick M; Schwab, C William; Hanson, C William; Gracias, Vicente H
The change from a "mandatory consultation" to a "semiclosed" surgical intensive care unit (SICU) model will impact nurses considerably. We hypothesize that nurse job satisfaction, job turnover rates, and hospital costs for temporary agency nurses will improve and these improvements will be more dramatic in SICU sections with greater involvement of a dedicated surgical critical care service (SCCS). Prospective longitudinal survey. Tertiary-care university hospital. SICU staff nurses. Change from mandatory consultation to semiclosed SICU. We surveyed SICU nurses during the year-long transition to a semiclosed SICU service (five time points, 3-month intervals). The first four surveys included ten questions on nurse job satisfaction. The final survey included two additional questions. All questions were on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Nurse job turnover rates and money spent on agency nurses were compared over time; 503 of a possible 914 surveys were completed (55% overall return rate). Nurse job satisfaction scores significantly improved over time for all questions (p job turnover rate dropped from 25% to 16% (p = .15). The scores for both year-end statements ("I am more satisfied with my job now than 1 year ago" and "The SCCS management of all orders has improved my job satisfaction") were significantly higher in sections with greater SCCS involvement (p = .0070 and p job satisfaction improved significantly with the transition to a semiclosed SICU. This higher satisfaction was associated with a significant decrease in spending on temporary agency nurses and a trend toward increased staff nurse job retention. SICU sections with greater SCCS involvement had more dramatic improvements. This semiclosed SICU model may help retain SICU nurses in a competitive job market in which experienced nurses are in short supply.
The ANNALS of AFRICAN SURGERY. January 2016 Volume 13 Issue 1 1. EDITORIAL. Access to Specialized Surgical Care. Saidi H. University of Nairobi. Correspondence to: Prof Hassan Saidi, P.O Box 30196-00100, Nairobi. Email: email@example.com. Ann Afr Surg. 2016;13(1):1-2. The narrative of surgical disease in ...
Graat, Marleen E.; Choi, Goda; Wolthuis, Esther K.; Korevaar, Johanna C.; Spronk, Peter E.; Stoker, Jaap; Vroom, Margreeth B.; Schultz, Marcus J.
INTRODUCTION: The clinical value of daily routine chest radiographs (CXRs) in critically ill patients is unknown. We conducted this study to evaluate how frequently unexpected predefined major abnormalities are identified with daily routine CXRs, and how often these findings lead to a change in care
Kirton, Orlando C; Calabrese, Rebecca C; Staff, Ilene
Less-invasive hemodynamic monitoring (eg, esophageal doppler monitoring [EDM] and arterial pressure contour analysis, FloTrac) is increasingly used as an alternative to pulmonary artery catheters (PACs) in critically ill intensive care unit (ICU). The decrease in use of PACs is not associated with increased mortality. Five-year retrospective review of 1894 hemodynamically monitored patients admitted to 3 surgical ICUs in a university-affiliate, tertiary care urban hospital. Data included the number of admissions, diagnosis-related group discharge case mix, length of stay, insertion of monitoring devices (PAC, EDM, and FloTrac probes), administered intravenous vasoactive agents (β-predominant agonists--dobutamine, epinephrine, and dopamine; vasopressors--norepinephrine and phenylephrine), and mortality. Data from hospital administrative databases were compiled to create patient characteristic and monitoring variables across a 5-year time period, 2005 to 2009 inclusive. Chi-square for independent proportions, 1-way analysis of variance, and Kruskal-Wallis tests were used; tests for trend were conducted. An α level of .05 was considered significant. Statistical Package for the Social Sciences v14 was used for all statistical testing. There was a significant change in the type of hemodynamic monitors inserted in 2 of the 3 surgical ICUs (in the general surgery and neurointensive care but not in the cardiac ICU) from PACs to less-invasive devices (FloTrac or EDM) during the 5-year study period (P < .001). There was no change in mortality rate over the time period (P = .492). There was an overall increase in the proportion of monitored patients who received intravenous vasoactive agents (P < .001) with a progressive shift from β-agonists to vasopressors (P < .002). Multivariate analyses indicated that age, case mix, and use of vasoactive agents were all independent predictors of inhospital mortality (P = .001) but that type of monitoring was not (P = .638). In a 5
Full Text Available Delirium is described as a manifestation of acute brain injury and recognized as one of the most common complications in intensive care unit (ICU patients. Although the causes of delirium vary widely among patients, delirium increases the risk of longer ICU and hospital length of stay, death, cost of care, and post-ICU cognitive impairment. Prevention and early detection are therefore crucial. However, the clinical approach toward delirium is not sufficiently aggressive, despite the condition’s high incidence and prevalence in the ICU setting. While the underlying pathophysiology of delirium is not fully understood, many risk factors have been suggested. As a way to improve delirium-related clinical outcome, high-risk patients can be identified. A valid and reliable bedside screening tool is also needed to detect the symptoms of delirium early. Delirium is commonly treated with medications, and haloperidol and atypical antipsychotics are commonly used as standard treatment options for ICU patients although their efficacy and safety have not been established. The approaches for the treatment of delirium should focus on identifying the underlying causes and reducing modifiable risk factors to promote early mobilization.
Claerhout, Helena; De Prins, Martine; Mesotten, Dieter; Van den Berghe, Greet; Mathieu, Chantal; Van Eldere, Johan; Vanstapel, Florent
We verified the analytical performance of strip-based handheld glucose meters (GM) for prescription use, in a comparative split-sample protocol using blood gas samples from a surgical intensive care unit (ICU). Freestyle Precision Pro (Abbott), StatStrip Connectivity Meter (Nova), ACCU-CHEK Inform II (Roche) were evaluated for recovery/linearity, imprecision/repeatability. The GMs and the ABL90 (Radiometer) blood gas analyzer (BGA) were tested for relative accuracy vs. the comparator hexokinase glucose-6-phosphate-dehydrogenase (HK/G6PDH) assay on a Cobas c702 analyzer (Roche). Recovery of spiked glucose was linear up to 19.3 mmol/L (347 mg/dL) with a slope of 0.91-0.94 for all GMs. Repeatability estimated by pooling duplicate measurements on samples below (n=9), in (n=51) or above (n=80) the 4.2-5.9 mM (74-106 mg/dL) range were for Freestyle Precision Pro: 4.2%, 4.0%, 3.6%; StatStrip Connectivity Meter: 4.0%, 4.3%, 4.5%; and ACCU-CHEK Inform II: 1.4%, 2.5%, 3.5%. GMs were in agreement with the comparator method. The BGA outperformed the GMs, with a MARD of 3.9% compared to 6.5%, 5.8% and 4.4% for the FreeStyle, StatStrip and ACCU-CHEK, respectively. Zero % of the BGA results deviated more than the FDA 10% criterion as compared to 9.4%, 3.7% and 2.2% for the FreeStyle, StatStrip and ACCU-CHEK, respectively. For all GMs, icodextrin did not interfere. Variation in the putative influence factors hematocrit and O2 tension could not explain observed differences with the comparator method. GMs quantified blood glucose in whole blood at about the 10% total error criterion, proposed by the FDA for prescription use.
Chen, Yong; Zhao, Wei; Liu, Hui; Song, Qing; Wang, Yan; Zhao, Jingya; Zheng, Dongyu; Han, Xuelin; Hu, Xiaohua; Grundmann, Hajo; Han, Li
In 2008, an intensive care unit (ICU) in a large Chinese hospital was moved from a 6-bed old ward to a 20-bed new ward. After the move, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in patients and environmental sites decreased significantly, but the number of ICU-acquired
George, Katie L; Quatrara, Beth
The current state of health care encompasses highly acute, complex patients, managed with ever-changing technology. The ability to function proficiently in critical care relies on knowledge, technical skills, and interprofessional teamwork. Integration of these factors can improve patient outcomes. Simulation provides "hands-on" practice and allows for the integration of teamwork into knowledge/skill training. However, simulation can require a significant investment of time, effort, and financial resources. The Institute of Medicine recommendations from 2015 include "strengthening the evidence base for interprofessional education (IPE)" and "linking IPE with changes in collaborative behavior." In one surgical-trauma-burn intensive care unit (STBICU), no IPE existed. The highly acute and diverse nature of the patients served by the unit highlights the importance of appropriate training. This is heightened during critical event situations where patients deteriorate rapidly and the team intervenes swiftly. The aims of this study were to (1) evaluate knowledge retention and analyze changes in perceptions of teamwork among nurses and resident physicians in a STBICU setting after completion of an interprofessional critical event simulation and (2) provide insight for future interprofessional simulations (IPSs), including the ideal frequency of such training, associated cost, and potential effect on nursing turnover. A comparison-cohort pilot study was developed to evaluate knowledge retention and analyze changes in perceptions of teamwork. A 1-hour critical event IPS was held for nurses and resident physicians in a STBICU setting. A traumatic brain injury patient with elevated intracranial pressure, rapid deterioration, and cardiac arrest was utilized for the simulation scenario. The simulation required the team to use interventions to reduce elevated intracranial pressure and then perform cardiac resuscitation according to Advanced Cardiac Life Support guidelines. A
Luciana Moraes dos Santos
increase of life expectancy, older patients with more co-morbidity are being submitted to high risk surgical procedures, what make clinical practice related to organ protection possible modifier of short and long term survival. This review about renal protection in surgical intensive care unit points risk factors and discusses scientific evidence related to reduction of renal dysfunction in perioperative. CONTENTS: Although low extraction and adequate renal reserve of oxygen, the kidney is extremely sensible to hypoperfusion being renal acute insufficiency a frequent complication of hemodynamic instability. This apparent paradox, high oxygen content and reduced extraction with high incidence of renal damage to hypotension reflects the intra-renal gradient of oxygen, what makes renal medulla highly susceptible to ischemia. Factors associated with renal lesion are observed in all fases of perioperative period: fasting, contrast use, hypovolemia, hypotension, catecholamine and cytokine release, extracorporeal circulation, trauma, rabdomiolisys and aortic clamp. CONCLUSIONS: Management of renal damage is based in principals of perioperative renal physiology and glomerular hemodynamic. Clinical practice directed to organic protection should be implemented to minimize the impact this dysfunction.
Christiansen, Christian Fynbo; Møller, Morten Hylander; Nielsen, Henrik
AIM OF DATABASE: The aim of this database is to improve the quality of care in Danish intensive care units (ICUs) by monitoring key domains of intensive care and to compare these with predefined standards. STUDY POPULATION: The Danish Intensive Care Database (DID) was established in 2007...... and standardized mortality ratios for death within 30 days after admission using case-mix adjustment (initially using age, sex, and comorbidity level, and, since 2013, using SAPS II) for all patients and for patients with septic shock. DESCRIPTIVE DATA: The DID currently includes 335,564 ICU admissions during 2005...
Glaubitt, D.; Drechsler, H.J.; Staedtische Krankenanstalten Krefeld
In 119 patients aged 16-86 who, within the framwork of surgical intensive care because of infections dangerous to life, had been treated with the aminoglucoside antibiotics gentamycin or tobramycin and who partly had renal dysfunction, gentamycin or tobramycin in plasma or in serum were determined radioimmunologically, either daily or at intervals of several days. Efforts were made to keep the concentration of the aminoglycoside antibiotic within the therapeutic range. This control of the therapy was particularly useful in short-term changes of the renal function because it facilitates the quick adaptation of the dosage of gentamycin or tobramycin to the assumed requirements. (orig.) [de
Boo, Yoon Jung; Lee, Eun Hee; Lee, Ji Sung
This study compared the outcomes of infants who underwent surgery in neonatal intensive care units by pediatric surgeons and by general surgeons. This was a retrospective study of infants who underwent surgery in neonatal intensive care units between 2010 and 2014. A total of 227 patients were included. Of these patients, 116 were operated on by pediatric surgeons (PS) and 111 were operated on by general surgeons (GS). The outcome measures were the overall rate of operative complications, unplanned reoperation, mortality rate, length of stay, operative time, and number of total number of operative procedures. The overall operative complication rate was higher in the GS group compared with the PS group (18.7% vs. 7.0%, p=0.0091). The rate of unplanned reoperations was also higher in the GS group (10.8% vs. 3.5%, p=0.0331). The median operation time (90min vs. 75min, p=0.0474) and median length of stay (24days vs. 18days, p=0.0075) were significantly longer in the GS group. The adjusted odd ratios of postoperative complications for GS were 2.9 times higher than that of PS (OR 2.90, p=0.0352). The operative quality and patient outcomes of the PS group were superior to those of the GS group. III. Copyright © 2017 Elsevier Inc. All rights reserved.
Full Text Available Christian Fynbo Christiansen,1 Morten Hylander Møller,2 Henrik Nielsen,1 Steffen Christensen3 1Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, 2Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, 3Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark Aim of database: The aim of this database is to improve the quality of care in Danish intensive care units (ICUs by monitoring key domains of intensive care and to compare these with predefined standards. Study population: The Danish Intensive Care Database (DID was established in 2007 and includes virtually all ICU admissions in Denmark since 2005. The DID obtains data from the Danish National Registry of Patients, with complete follow-up through the Danish Civil Registration System. Main variables: For each ICU admission, the DID includes data on the date and time of ICU admission, type of admission, organ supportive treatments, date and time of discharge, status at discharge, and mortality up to 90 days after admission. Descriptive variables include age, sex, Charlson comorbidity index score, and, since 2010, the Simplified Acute Physiology Score (SAPS II. The variables are recorded with 90%–100% completeness in the recent years, except for SAPS II score, which is 73%–76% complete. The DID currently includes five quality indicators. Process indicators include out-of-hour discharge and transfer to other ICUs for capacity reasons. Outcome indicators include ICU readmission within 48 hours and standardized mortality ratios for death within 30 days after admission using case-mix adjustment (initially using age, sex, and comorbidity level, and, since 2013, using SAPS II for all patients and for patients with septic shock. Descriptive data: The DID currently includes 335,564 ICU admissions during 2005–2015 (average 31,958 ICU admissions per year. Conclusion: The DID provides a
Thomsen, Thordis; Vester-Andersen, Morten; Nielsen, Martin Vedel
AIMS AND OBJECTIVES: To elicit knowledge of patient experiences of postoperative intermediate care in an intensive care unit and standard postoperative care in a surgical ward after emergency abdominal surgery. BACKGROUND: Emergency abdominal surgery is common, but little is known about how patie......, intermediate care patients felt hindered in doing so by continuous monitoring of vital signs. RELEVANCE TO CLINICAL PRACTICE: Intermediate care may increase patient perceptions of quality and safety of care.......AIMS AND OBJECTIVES: To elicit knowledge of patient experiences of postoperative intermediate care in an intensive care unit and standard postoperative care in a surgical ward after emergency abdominal surgery. BACKGROUND: Emergency abdominal surgery is common, but little is known about how...... patients experience postoperative care. The patient population is generally older with multiple comorbidities, and the short-term postoperative mortality rate is 15-20%. Thus, vigilant surgeon and nursing attention is essential. The present study is a qualitative sub-study of a randomised trial evaluating...
Optimisation of surgical care means weighing the risk of treatment related morbidity against the patients’ potential benefits of a surgical intervention. The first part of this thesis focusses on the anaemic patient undergoing colorectal surgery. Hypothesizing that a more profound haemoglobin
Lukish, J R; Gill, G G; McCoy, T R
To maintain the health of service members and their families throughout the world, the Department of Defense has established several isolated military hospitals (IHs). The operational environment of IHs is such that illness and traumatic injury requiring surgical intervention is common. This study sought to examine the general and orthopedic surgical experience at an IH to determine whether surgical care could be provided in an effective and safe manner. All patients evaluated by the general and orthopedic surgeon at Guantanamo Bay Naval Hospital from October 1, 1998, to April 1, 1999, were included in this study. The following data were retrospectively reviewed: patient demographic data, diagnosis, initial and follow-up care, medical evacuation data, operative procedures, and complications. There were 336 patients who presented for surgical evaluation, resulting in 660 follow-up appointments during the study period. There were 31 medical evacuations (3 emergent). The surgical services performed 122 major operative procedures. There were 58 inpatient admissions. There was 1 death, and surgical complications occurred in 2 patients, for an overall morbidity and mortality of 1.4% and 0.7%, respectively. Our data show that an IH is capable of providing surgical care, including care for traumatic injuries, in a safe manner. This is the first study that provides objective evidence that general and orthopedic surgery at an IH can be provided within the standard of care.
Bittner, Martin-Immanuel; Donnelly, Maria; van Zanten, Arthur Rh
Reimbursement schemes in intensive care are more complex than in other areas of healthcare, due to special procedures and high care needs. Knowledge regarding the principles of functioning in other countries can lead to increased understanding and awareness of potential for improvement. This can...... be achieved through mutual exchange of solutions found in other countries. In this review, experts from eight European countries explain their respective intensive care unit reimbursement schemes. Important conclusions include the apparent differences in the countries' reimbursement schemes---despite all...... of them originating from a DRG system, the high degree of complexity found, and the difficulties faced in several countries when collecting the data for this collaborative work. This review has been designed to help the intensivist clinician and researcher to understanding neighbouring countries...
Borel, M; Veber, B; Villette-Baron, K; Hariri, S; Dureuil, B; Hervé, C
Decision-making bringing to an admission or not in intensive care is complex. The aim of this study is to analyze with an ethical point of view the making decision process leading to the refusal and its consequences. It is proposed a setting in prospect through the principles of beneficence, non-maleficience, respect for autonomy, justice, and the Leonetti law. Prospective study in surgical reanimation at the University Hospital of Rouen over 9 months (November 2007-September 2008). Systematic collection for each non-admitted patient of the general characters, the methods of decision making, immediate becoming and within 48 h Constitution of two groups: patients for whom an admission in intensive care could be an unreasonable situation of obstinacy, and patients for whom an admission in reanimation would not be about unreasonable if it occurred. One hundred and fifty situations were analyzed. The potentially unreasonable character of an admission does not involve necessarily a refusal of care in intensive care. The question of the lack of place and equity in the access to the care is real but relative according to the typology of the patients. The research of the respect of the autonomy of the patient is difficult but could be facilitated. The Leonetti law does not appear to be able to be a framework with the situation of refusal of care in intensive care. It is not a question of going towards a systematic admission in intensive care of any patient proposed, but to make sure that so if there is a refusal, it is carried out according to a step ethically acceptable.
to various surgical and critical care disciplines, the usefulness of a paediatric intensive care unit (PICU) rotation was investigated. A brief overview of the experiences of anaesthetic registrars at a. South African teaching hospital rotating through a PICU is pre- sented, as well as the potential advantages for both trainees and.
Intensive care units (ICUs) provides intensive treatment medicine to avoid complications such as malnutrition, infection and even death. As very little is currently known about the nutritional practices in Iranian ICUs, this study attempted to assess the various aspects of current nutrition support practices in Iranian ICUs. We conducted a cross-sectional study on 150 critically ill patients at 18 ICUs in 12 hospitals located in 2 provinces of Iran from February 2015 to March 2016. Data were collected through interview with supervisors of ICUs, medical record reviews and direct observation of patients during feeding. Our study showed that hospital-prepared enteral tube feeding formulas are the main formulas used in Iranian hospitals. None of the dietitians worked exclusively an ICU and only 30% of patients received diet counselling. Regular monitoring of nutritional status, daily energy and protein intake were not recorded in any of the participating ICUs. Patients were not monitored for anthropometric measurements such as mid-arm circumference (MAC) and electrolyte status. The nasogastric tube was not switched to percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEGJ) in approximately 85% of patients receiving long-term enteral nutrition (EN) support. Our findings demonstrated that the quality of nutritional care was inappropriate in Iranian ICUs and improvement of nutritional care services within Iranian ICUs is necessary. PMID:29713622
Aochi, Osamu; Amaha, Keisuke; Takeshita, Hiroshi
Eight papers in this volume are in INIS scope, respectively dealing with the scientific use of the chest radiograph in intensive care unit, xenon computed tomography cerebral blood flow in diagnosis and management of symptomatic vasospasm and severe head injury, therapeutic relevance of MRI in acute head trauma, computerized tomography in the diagnosis of cerebral air embolism, thallium 201 myocardial perfusion during weaning from mechanical ventilation, thoracic computed tomography for ICU patients, and the effect of xenon inhalation upon internal carotid artery blood flow in awake monkeys. (H.W.). refs.; figs.; tabs
Boyko, Yuliya; Jennum, Poul; Nikolic, Miki
PURPOSE: To determine if improving intensive care unit (ICU) environment would enhance sleep quality, assessed by polysomnography (PSG), in critically ill mechanically ventilated patients. MATERIALS AND METHODS: Randomized controlled trial, crossover design. The night intervention "quiet routine...... Medicine) sleep scoring criteria were insufficient for the assessment of polysomnograms. Modified classification for sleep scoring in critically ill patients, suggested by Watson et al. (Crit Care Med 2013;41:1958-1967), was used. RESULTS: Sound level analysis showed insignificant effect...... patients. We were not able to further reduce the already existing low noise levels in the ICU and did not find any association between the environmental intervention and the presence of normal sleep characteristics in the PSG....
Kocjan, Marinka; Brunet, Fabrice P
Globally, critical care environments within health care organizations strive to provide optimal quality renal replacement therapy (RRT), an artificial replacement for lost kidney function. Examination of RRT delivery model literature and a case study review of the multidisciplinary-mixed RRT delivery model utilized within a closed medical surgical intensive care unit illustrates the organizational and clinical management of specialized resource and multidisciplinary roles. The successful utilization of a specific RRT delivery model is dependent upon resource availability.
Egerod, Ingrid; Bergbom, Ingegerd; Lindahl, Berit
: Nordic intensive care units. PARTICIPANTS: Patients in Nordic intensive care units. METHODS: We performed a literature search of qualitative studies of the patient experience of intensive care based on Nordic publications in 2000-2013. We searched the following databases: PubMed, CINAHL, Scopus, and Psyc...
V. V. Moroz
Full Text Available Objective: to enhance the efficiency of treatment of puerperas with eclampic coma, by substantiating, developing, and introducing new algorithms for correction of systemic hemodynamic, metabolic disturbances, and perfusion-metabolic changes in brain tissues. Subjects and methods. Studies were conducted in 18 puerperas with eclampic coma (Group 2 in whom the authors used a new treatment algorithm aimed at maintaining baseline cerebral perfusion pressure (CPP, restoring volemic levels at the expense of interstitial fluid. A control group (Group 1 included 30 patients who received conventional standard therapy. Regional cerebral circulation was measured by a non-invasive (inhalation radioisotopic method, by applying the tracer 131Xe, as described by V. D. Obrist et al., on a modified КПРДИ-1 apparatus (USSR. The rate of brain oxygen uptake was determined from the oxygen content between the artery and the internal jugular vein. Central hemodynamic parameters were studied by the direct method of right heart catheterization using a flow-directed Swan-Ganz catheter. The volumes of total and extracellular fluids were estimated using 20% urea and mannitol solutions, respectively, at 0.2 g/kg weight by the procedure of V. M. Mogen. Circulating blood volume (CBV was determined by a radioisotopic method using 131iodine albumin on an УPI-7 apparatus (USSR. Cerebral spinal fluid pressure was measured by an ИиНД apparatus. Studies were made in four steps: 1 on admission; 2 on days 2—3; 3 during emergence from coma; 4 before transition. Results. The use of the new algorithm for intensive care for eclampic coma, which is aimed at improving the perfusion metabolic provision of brain structures, with a reduction in mean blood pressure by 10—15% of the baseline level, by administering magnesium sulfate and nimodipine, and at compensating for CBV by high-molecular-weight hydroxyethylated starch (stabizol, ensured early emergence from a comatose state
Demir, Yurdanur; Korhan, Esra Akin; Eser, Ismet; Khorshid, Leyla
To determine the factors affecting a patient's intensive care experience. The descriptive study was conducted at an intensive care unit in the Aegean Region of Turkey, and comprised 158 patients who spent at least 48 hours at the unit between June and November 2009. A questionnaire form and the Intensive Care Experience Scale were used as data collection tools. SPSS 11.5 was used for statistical analysis of the data. Of the total, 86 (54.4%) patients related to the surgical unit, while 72 (45.5%) spent time at the intensive care unit. Most of the subjects (n=113; 71.5%) reported that they constantly experienced pain during hospitalisation. Patients receiving mechanical ventilation support and patients reporting no pain had significantly higher scores on the intensive care experience scale. Patients who reported pain remembered their experiences less than those having no pain. Interventions are needed to make the experiences of patients in intensive care more positive.
Pucher, Philip H; Darzi, Ara; Aggarwal, Rajesh
The role of simulation in surgical education, initially confined to technical skills and procedural tasks, increasingly includes training nontechnical skills including communication, crisis management, and teamwork. Research suggests that many preventable adverse events can be attributed to nontechnical error occurring within a ward context. Ward rounds represent the primary point of interaction between patient and physician but take place without formalized training or assessment. The simulated ward should provide an environment in which processes of perioperative care can be performed safely and realistically, allowing multidisciplinary assessment and training of full ward rounds. We review existing literature and describe our experience in setting up our ward simulator. We examine the facilities, equipment, cost, and personnel required for establishing a surgical ward simulator and consider the scenario development, assessment, and feedback tools necessary to integrate it into a surgical curriculum. Copyright © 2013 Elsevier Inc. All rights reserved.
Gurses, Ayse P; Carayon, Pascale
High nursing workload, poor patient safety, and poor nursing quality of working life (QWL) are major issues in intensive care units (ICUs). Characteristics of the ICU and performance obstacles may contribute to these issues. The goal of this study was to comprehensively identify the performance obstacles perceived by ICU nurses. We used a qualitative research design and conducted semi-structured interviews with 15 ICU nurses of a medical-surgical ICU. Based on this qualitative study and a previously reported quantitative study, we identified seven main types of performance obstacles experienced by ICU nurses. Obstacles related to the physical environment (e.g., noise, amount of space), family relations (e.g., distractions caused by family, lack of time to spend with family), and equipment (e.g., unavailability, misplacement) were the most frequently experienced performance obstacles. The qualitative interview data provided rich information regarding the factors contributing to the performance obstacles. Overall, ICU nurses experience a variety of performance obstacles in their work on a daily basis. Future research is needed to understand the impact of performance obstacles on nursing workload, nursing QWL, and quality and safety of care.
The purpose of the African Journal of Anaesthesia and Intensive Care is to provide a medium for the dissemination of original works in Africa and other parts of the world about anaesthesia and intensive care including the application of basic sciences ...
Inserra, Alessandro; Narciso, Alessandra; Paolantonio, Guglielmo; Messina, Raffaella; Crocoli, Alessandro
Survival rate for childhood cancer has increased in recent years, reaching as high as 70% in developed countries compared with 54% for all cancers diagnosed in the 1980s. In the remaining 30%, progression or metastatic disease leads to death and in this framework palliative care has an outstanding role though not well settled in all its facets. In this landscape, surgery has a supportive actor role integrated with other welfare aspects from which are not severable. The definition of surgical palliation has moved from the ancient definition of noncurative surgery to a group of practices performed not to cure but to alleviate an organ dysfunction offering the best quality of life possible in all the aspects of life (pain, dysfunctions, caregivers, psychosocial, etc.). To emphasize this aspect a more modern definition has been introduced: palliative therapy in whose context is comprised not only the care assistance but also the plans of care since the onset of illness, teaching the matter to surgeons in training and share paths. Literature is very poor regarding surgical aspects specifically dedicated and all researches (PubMed, Google Scholar, and Cochrane) with various meshing terms result in a more oncologic and psychosocial effort. Copyright © 2016 Elsevier Inc. All rights reserved.
Martin, J; Braun, J-P
Treatment of critical ill patients in the intensive care unit is tantamount to well-designed risk or quality management. Several tools of quality management and quality assurance have been developed in intensive care medicine. In addition to extern quality assurance by benchmarking with regard to the intensive care medicine, peer review procedures have been established for external quality assurance in recent years. In the process of peer review of an intensive care unit (ICU), external physicians and nurses visit the ICU, evaluate on-site proceedings, and discuss with the managing team of the ICU possibilities for optimization. Furthermore, internal quality management in the ICU is possible based on the 10 quality indicators of the German Interdisciplinary Society for Intensive Care Medicine (DIVI, "Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin"). Thereby every ICU has numerous possibilities to improve their quality management system.
da Silva, Rafael Celestino; Ferreira, Márcia de Assunção; Apostolidis, Thémistoklis; Brandão, Marcos Antônio Gomes
to propose a conceptual framework for clinical nursing care in intensive care. descriptive and qualitative field research, carried out with 21 nurses from an intensive care unit of a federal public hospital. We conducted semi-structured interviews and thematic and lexical content analysis, supported by Alceste software. the characteristics of clinical intensive care emerge from the specialized knowledge of the interaction, the work context, types of patients and nurses characteristic of the intensive care and care frameworks. the conceptual framework of the clinic's intensive care articulates elements characteristic of the dynamics of this scenario: objective elements regarding technology and attention to equipment and subjective elements related to human interaction, specific of nursing care, countering criticism based on dehumanization.
Brinkmann, A; Braun, J P; Riessen, R; Dubb, R; Kaltwasser, A; Bingold, T M
Intensive care medicine (ICM) is characterized by a high degree of complexity and requires intense communication and collaboration on interdisciplinary and multiprofessional levels. In order to achieve good quality of care in this environment and to prevent errors, a proactive quality and error management as well as a structured quality assurance system are essential. Since the early 1990s, German intensive care societies have developed concepts for quality management and assurance in ICM. In 2006, intensive care networks were founded in different states to support the implementation of evidence-based knowledge into clinical routine and to improve medical outcome, efficacy, and efficiency in ICM. Current instruments and concepts of quality assurance in German ICM include core intensive care data from the data registry DIVI REVERSI, quality indicators, peer review in intensive care, IQM peer review, and various certification processes. The first version of German ICM quality indicators was published in 2010 by an interdisciplinary and interprofessional expert commission. Key figures, indicators, and national benchmarks are intended to describe the quality of structures, processes, and outcomes in intensive care. Many of the quality assurance tools have proved to be useful in clinical practice, but nationwide implementation still can be improved.
Olson, Jody C
Cirrhosis is a major worldwide health problem which results in a high level of morbidity and mortality. Patients with cirrhosis who require intensive care support have high mortality rates of near 50%. The goal of this review is to address the management of common complications of cirrhosis in the ICU. Recent epidemiological studies have shown an increase in hospitalizations due to advanced liver disease with an associated increase in intensive care utilization. Given an increasing burden on the healthcare system, it is imperative that we strive to improve our management cirrhotic patients in the intensive care unit. Large studies evaluating the management of patients in the intensive care setting are lacking. To date, most recommendations are based on extrapolation of data from studies in cirrhosis outside of the ICU or by applying general critical care principles which may or may not be appropriate for the critically ill cirrhotic patient. Future research is required to answer important management questions.
Iglesias-Posadilla, D; Gómez-Marcos, V; Hernández-Tejedor, A
Technological advances have played a key role over the last century in the development of humankind. Critical Care Medicine is one of the greatest examples of this revolution. Smartphones with multiple sensors constitute another step forward, and have led to the development of apps for use by both professionals and patients. We discuss their main medical applications in the field of Critical Care Medicine. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.
Tisherman, Samuel A; Kaplan, Lewis; Gracias, Vicente H; Beilman, Gregory J; Toevs, Christine; Byrnes, Matthew C; Coopersmith, Craig M
Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few. Recommendations are made for broadening the multidisciplinary training and practice opportunities in surgical critical care for intensivists from all base specialties and for maintaining the intensivist model within acute care surgery practice. Support from academic and administrative leadership, as well as national organizations, will be needed.
Egerod, Ingrid; Storli, Sissel Lisa; Åkerman, Eva
Critical illness and intensive care therapy are often followed by psychological problems such as nightmares, hallucinations, delusions, anxiety, depression, and symptoms of posttraumatic stress. Intensive care patient diaries have been kept by nurses and the patients' family since the early 1990s...... in the Scandinavian countries to help critically ill patients come to terms with their illness after hospital discharge. The aim of the study was to describe and compare the emergence and evolution of intensive care patient diaries in Denmark, Norway, and Sweden. The study had a comparative international design using...... secondary analysis of qualitative data generated by key-informant telephone interviews with intensive care nurses (n=114). The study showed that diaries were introduced concurrently in the three Scandinavian countries as a grass-roots initiative by mutual cross-national inspiration. The concept has evolved...
Barbosa, Vanessa Maziero
Medical and technological advances in neonatology have prompted the initiation and expansion of developmentally supportive services for newborns and have incorporated rehabilitation professionals into the neonatal intensive care unit (NICU) multidisciplinary team. Availability of therapists specialized in the care of neonates, the roles of…
Blanch, L; Annane, D; Antonelli, M; Chiche, J D; Cuñat, J; Girard, T D; Jiménez, E J; Quintel, M; Ugarte, S; Mancebo, J
Intensive care medical training, whether as a primary specialty or as secondary add-on training, should include key competences to ensure a uniform standard of care, and the number of intensive care physicians needs to increase to keep pace with the growing and anticipated need. The organisation of intensive care in multiple specialty or central units is heterogeneous and evolving, but appropriate early treatment and access to a trained intensivist should be assured at all times, and intensivists should play a pivotal role in ensuring communication and high-quality care across hospital departments. Structures now exist to support clinical research in intensive care medicine, which should become part of routine patient management. However, more translational research is urgently needed to identify areas that show clinical promise and to apply research principles to the real-life clinical setting. Likewise, electronic networks can be used to share expertise and support research. Individuals, physicians and policy makers need to allow for individual choices and priorities in the management of critically ill patients while remaining within the limits of economic reality. Professional scientific societies play a pivotal role in supporting the establishment of a defined minimum level of intensive health care and in ensuring standardised levels of training and patient care by promoting interaction between physicians and policy makers. The perception of intensive care medicine among the general public could be improved by concerted efforts to increase awareness of the services provided and of the successes achieved. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.
ÖZCANLI, Derya; İLGÜN, Seda
Time is not like other resources, because it can not be bought, sold, stolen, borrowed, stored, saved, multiplied or changed. All it can be done is spent. Time management means the effective use of resources, including time, in such a way that indi- viduals are effective in achieving important personal goals. With the increasing emphasis on efficiency in health care, how a nurse manages her time is an important consideration. Since intensive care nurs- ing is focused on the care and tr...
Ho, Jim Q; Nguyen, Christopher D; Lopes, Richard; Ezeji-Okoye, Stephen C; Kuschner, Ware G
Spiritual care is an important component of high-quality health care, especially for critically ill patients and their families. Despite evidence of benefits from spiritual care, physicians and other health-care providers commonly fail to assess and address their patients' spiritual care needs in the intensive care unit (ICU). In addition, it is common that spiritual care resources that can improve both patient outcomes and family member experiences are underutilized. In this review, we provide an overview of spiritual care and its role in the ICU. We review evidence demonstrating the benefits of, and persistent unmet needs for, spiritual care services, as well as the current state of spiritual care delivery in the ICU setting. Furthermore, we outline tools and strategies intensivists and other critical care medicine health-care professionals can employ to support the spiritual well-being of patients and families, with a special focus on chaplaincy services.
Yaqub, K.M.; Usman, J.; Zaidi, S.B.H.; Khalil, A.; Noor, N.; Gill, M.M.
Objective: To determine the frequency of fungal infections in intensive care unit (ICU) of Military Hospital, Rawalpindi, a tertiary care health facility. Study Design: Cross sectional study. Place and Duration of Study: Intensive Care Department of Military Hospital Rawalpindi from 01 Jan 2012 to 30 Jun 2012. Methodology: A total of 89 patients were screened with stay of more than 5 days in intensive care unit. Thirty cases were enrolled in the study for investigation of fungal infections that had fever even after 05 days of being on broad spectrum antibiotics. Culture was done on blood, urine and catheter tip samples as per clinical condition of a patient. Results: Candida infection was found in 23.4% of study cases. The mean age of study patients was 41.2 +- 20.0 years while 63.4% were female patients as compared to 36.7% males. Conclusion: Fungal infections especially candidemias are quite frequent in the intensive care units. (author)
Capuzzo, M; Pinamonti, A; Cingolani, E; Grassi, L; Bianconi, M; Contu, P; Gritti, G; Alvisi, R
The purpose of this article was to investigate the relationship between analgesia, sedation, and memory of intensive care. One hundred fifty-two adult, cooperative intensive care unit (ICU) patients were interviewed 6 months after hospital discharge about their memory of intensive care. The patient was considered to be cooperative when he/she was aware of self and environment at the interview. The patients were grouped as follows: A (45 patients) substantially no sedation, B (85) morphine, and C (22) morphine and other sedatives. The patients having no memory of intensive care were 38%, 34%, and 23% respectively, in the three groups. They were less ill, according to SAPS II (P memories was not different among the three groups. Females reported at least one emotional memory more frequently than males (odds ratio 4.17; 95% CI 10.97-1.59). The patients receiving sedatives in the ICU are not comparable with those receiving only opiates or nothing, due to the different clinical condition. The lack of memory of intensive care is present in one third of patients and is influenced more by length of stay in ICU than by the sedation received. Sedation does not influence the incidence of factual, sensation, and emotional memories of ICU admitted patients. Females have higher incidences of emotional memories than males. Copyright 2001 by W.B. Saunders Company
DeKeyser Ganz, Freda; Berkovitz, Keren
To describe surgical nurses' perceived levels of ethical dilemmas, moral distress and perceived quality of care and the associations among them. Nurses are committed to providing quality care. They can experience ethical dilemmas and moral distress while providing patient care. Little research has focused on the effect of moral distress or ethical dilemmas on perceived quality of care. Descriptive, cross-sectional study. After administration and institutional Research Ethics Committee approval, a researcher requested 119 surgical nurses working in two Israeli hospitals to fill out three questionnaires (personal background characteristics; Ethical Dilemmas in Nursing and Quality of Nursing Care). Data collection took place from August 2007 to January 2008. Participant mean age was 39·7 years. The sample consisted mostly of women, Jewish and married staff nurses. The majority of nurses reported low to moderate levels of ethical dilemma frequency but intermediate levels of ethical dilemma intensity. Frequency of ethical dilemmas was negatively correlated with level of nursing skill, meeting patient's needs and total quality of care. No important correlations were found between intensity of ethical dilemmas and quality of care. Levels of ethical dilemma frequency were higher than intensity. Nurses tended to be satisfied with their level of quality of care. Increased frequency of ethical dilemmas was associated with some aspects of perceived quality of care. Quality of care is related to ethical dilemmas and moral distress among surgical nurses. Therefore, efforts should be made to decrease the frequency of these feelings to improve the quality of patient care. © 2011 Blackwell Publishing Ltd.
Veiga, Dalila; Luis, Clara; Parente, Daniela; Fernandes, Vera; Botelho, Miguela; Santos, Patricia; Abelha, Fernando
Postoperative delirium (POD) in Surgical Intensive Care patients is an important independent outcome determinant. The purpose of our study was to evaluate the incidence and determinants of POD. Prospective cohort study conducted during a period of 10 months in a Post-Anesthesia Care Unit (PACU) with five intensive care beds. All consecutive adult patients submitted to major surgery were enrolled. Demographic data, perioperative variables, length of stay (LOS) and the mortality at PACU, hospital and at 6-months follow-up were recorded. Postoperative delirium was evaluated using the Intensive Care Delirium Screening Checklist (ICDSC). Descriptive analyses were conducted and the Mann-Whitney test, Chi-square test or Fisher's exact test were used for comparisons. Logistic regression analysis evaluated the determinants of POD with calculation of odds ratio (OR) and its confidence interval 95% (95% CI). There were 775 adult PACU admissions and 95 patients had exclusion criteria. Of the remaining 680 patients, 128 (18.8%) developed POD. Independent determinants of POD identified were age, ASA-PS, emergency surgery and total amount of fresh frozen plasma administered during surgery. Patients with delirium had higher mortality rates, were more severely ill and stayed longer at the PACU and in the hospital. POD was an independent risk factor for hospital mortality There was a high incidence of delirium had a high incidence in intensive care surgical patients. POD was associated with worse severity of disease scores, longer LOS in hospital, and in PACU and higher mortality rates. The independent risk factors for POD were age, ASAPS, emergency surgery and the amount of plasma administered during surgery. Copyright © 2012 Elsevier Editora Ltda. All rights reserved.
Full Text Available Regulation of the Minister of Health dated 20/12/2012 on medical standards of conduct in the field of Anaesthesiology and intensive therapy, for carrying out the activities of healing in section § 2.2 intense therapy defines as: "any proceedings to maintain vital functions, and treatment of patients in life-threatening States, caused by potentially reversible renal failure one or more basic body systems, in particular the respiration, cardiovascular, central nervous system". However, in point § 12.1. We read that "Treatment of patients under intensive care in the hospital is an interdisciplinary". Annex 1 to this regulation refers to the work of physiotherapist in the ICU (INTENSIVE CARE UNITS and reads as follows: "the equivalent of at least 0.5 FTE-physical therapist-up to a range of benefits to be performed (the third reference level". [6
Intensive care medicine has achieved a significant increase in survival rates from critical illness. In addition to short-term outcomes like intensive care unit or hospital mortality, long-term prognosis and prospect of life of intensive care patients have recently become increasingly important. Pure survival is no longer a sole goal of intensive care medicine. The prediction of an intensive care patient's individual course should include the period after intensive care. A relevant proportion of all intensive care patients is affected by physical, psychological, cognitive, and social limitations after discharge from the intensive care unit. The prognosis of the status of the patient after discharge from the intensive care unit is an important part of the decision-making process with respect to the implementation or discontinuation of intensive care measures. The heavy burden of intensive care treatment should not solely be argued by pure survival but an anticipated sound prospect of life.
Nassar, Antonio Paulo; da Silva, Fernanda Maria Queiroz; de Cleva, Roberto
Although gastrointestinal motility disorders are common in critically ill patients, constipation and its implications have received very little attention. We aimed to determine the incidence of constipation to find risk factors and its implications in critically ill patients During a 6-month period, we enrolled all patients admitted to an intensive care unit from an universitary hospital who stayed 3 or more days. Patients submitted to bowel surgery were excluded. Constipation occurred in 69.9% of the patients. There was no difference between constipated and not constipated in terms of sex, age, Acute Physiology and Chronic Health Evaluation II, type of admission (surgical, clinical, or trauma), opiate use, antibiotic therapy, and mechanical ventilation. Early (constipation, a finding that persisted at multivariable analysis (P Constipation was not associated with greater intensive care unit or mortality, length of stay, or days free from mechanical ventilation. Constipation is very common among critically ill patients. Early enteral nutrition is associated with earlier return of bowel function.
Padar, Martin; Uusvel, Gerli; Starkopf, Liis
AIM: To determine the effects of implementing an enteral feeding protocol on the nutritional delivery and outcomes of intensive care patients. METHODS: An uncontrolled, observational before-and-after study was performed in a tertiary mixed medical-surgical intensive care unit (ICU). In 2013......, a nurse-driven enteral feeding protocol was developed and implemented in the ICU. Nutrition and outcome-related data from patients who were treated in the study unit from 2011-2012 (the Before group) and 2014-2015 (the After group) were obtained from a local electronic database, the national Population...... the groups. Patients in the After group had a lower 90-d (P = 0.026) and 120-d (P = 0.033) mortality. In the After group, enteral nutrition was prescribed less frequently (P = 0.039) on day 1 but significantly more frequently on all days from day 3. Implementation of the feeding protocol resulted in a higher...
van Rijsbergen, M.; Boucherie, Richardus J.; van Houdenhoven, M.; Litvak, Nelli
Many hospitals in the Netherlands are confronted with capacity problems at their Intensive Care Units (ICUs) resulting in cancelling operations, overloading the staff with extra patients, or rejecting emergency patients. In practice, the last option is a common choice because juridically, as well as
Egerod, Ingrid; Bagger, Christine
The aim of the study was to explore patients' experiences and perceptions of receiving intensive care diaries. A focus group and intensive care diaries for four former ICU patients were analysed to understand what works and what needs further development for patients who receive a diary. The stud......-ICU patients to gradually construct or reconstruct their own illness narrative, which is pieced together by their fragmented memory, the diary, the pictures, the hospital chart and the accounts from family and friends.......The aim of the study was to explore patients' experiences and perceptions of receiving intensive care diaries. A focus group and intensive care diaries for four former ICU patients were analysed to understand what works and what needs further development for patients who receive a diary. The study...... that the diary alone provided incomplete information and reading the diary did not necessarily bring back memories, but helped complete their story. The patients needed to know what they had gone through in ICU and wished to share their story with their family. We conclude that diaries might help post...
Keijsers, GJ; Schaufeli, WB; LeBlanc, P; Zwerts, C; Miranda, DR
The relationship between three different performance measures and burnout was explored in 20 Dutch Intensive Care Units (ICUs). Burnout (i.e. emotional exhaustion and depersonalization) proved to be significantly related to nurses' perceptions of performance as well as to objectively assessed unit
Merino, P; Martín, M C; Alonso, A; Gutiérrez, I; Alvarez, J; Becerril, F
To estimate the incidence of medication errors in Spanish intensive care units. Post hoc study of the SYREC trial. A longitudinal observational study carried out during 24 hours in patients admitted to the ICU. Spanish intensive care units. Patients admitted to the intensive care unit participating in the SYREC during the period of study. Risk, individual risk, and rate of medication errors. The final study sample consisted of 1017 patients from 79 intensive care units; 591 (58%) were affected by one or more incidents. Of these, 253 (43%) had at least one medication-related incident. The total number of incidents reported was 1424, of which 350 (25%) were medication errors. The risk of suffering at least one incident was 22% (IQR: 8-50%) while the individual risk was 21% (IQR: 8-42%). The medication error rate was 1.13 medication errors per 100 patient-days of stay. Most incidents occurred in the prescription (34%) and administration (28%) phases, 16% resulted in patient harm, and 82% were considered "totally avoidable". Medication errors are among the most frequent types of incidents in critically ill patients, and are more common in the prescription and administration stages. Although most such incidents have no clinical consequences, a significant percentage prove harmful for the patient, and a large proportion are avoidable. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.
Luana Loppi Goulart
Full Text Available Severely injured patients with multiple and conflicting injuries present themselves to nursing professionals at critical care units faced with care management challenges. The goal of the present study is to evaluate nursing workload and verify the correlation between workload and the APACHE II severity index. It is a descriptive study, conducted in the Trauma Intensive Care Unit of a teaching hospital. We used the Nursing Activities Score and APACHE II as instruments. The sample comprised 32 patients, of which most were male, young adults, presenting polytrauma, coming from the Reference Emergency Unit, in surgical treatment, and discharged from the ICU. The average obtained on the Nursing Activities Score instrument was 72% during hospitalization periods. The data displayed moderate correlation between workload and patient severity. In other words, the higher the score, the higher the patient’s mortality risk. doi: 10.5216/ree.v16i2.22922.
Kreckler, S; Catchpole, K; McCulloch, P; Handa, A
To evaluate the process of incident reporting in a surgical setting. In particular: the influence of event outcome on reporting behaviour; staff perception of surgical complications as reportable events. Anonymous web-based questionnaire survey. General Surgical Department in a UK teaching hospital. Of 203 eligible staff, 55 (76.4%) doctors and 82 (62.6%) nurses participated. Knowledge and use of local reporting system; propensity to report incidents which vary by outcome (harm, no harm, harm prevented); propensity to report surgical complications; practical and psychological barriers to reporting. Nurses were significantly more likely to know of the local reporting system and to have recently completed a report than doctors. The level of harm (F(1.8,246) = 254.2, pvs 53%, z = 4.633, psystems.
Boyd, Jennifer B; McGrath, Mary H; Maa, John
As total health care expenditures are expected to constitute an increasing portion of the US gross domestic product during the coming years, the US health care system is anticipating a historic spike in the need for care. Outsourcing medical and surgical care to other nations has expanded rapidly, and several ethical, legal, and financial considerations require careful evaluation. Ultimately, the balance between cost savings, quality, and patient satisfaction will be the key determinant in the future of medical outsourcing.
essential surgical staff, inadequate funding, poor state of ... individuals interested in surgical care in the developing world has been ... 5.69 per 100,000 in the United States . ... categorical variables e.g gender, the percentage of the ... lack of materials and supplies to be used, inability to pay ... Confirming a big gap in.
Full Text Available The antimicrobial management of patients in the Intensive Care Units are complex. Antimicrobial resistance is an increasing problem. Effective strategies for the prevention of antimicrobial resistance in ICUs have focused on limiting the unnecessary use of antibiotics and increasing compliance with infection control practices. Antibiotic policies have been implemented to modify antibiotic use, including national or regional formulary manipulations, antibiotic restriction forms, care plans, antibiotic cycling and computer assigned antimicrobial therapy. Moreover, infectious diseases consultation is a simple way to limit antibiotic use in ICU units. To improve rational antimicrobial using a multidisiplinary approach is suggested. [Archives Medical Review Journal 2003; 12(4.000: 299-309
Rogers, Eileen; Alderdice, Fiona; McCall, Emma; Jenkins, John; Craig, Stanley
Nosocomial infection is a common problem in neonatal intensive care. A pilot quality improvement initiative focussing on hand hygiene and aimed at reducing nosocomial infection in very low birth weight (VLBW) infants was introduced in five Neonatal Intensive Care Units. Line associated laboratory confirmed bloodstream infection (LCBSI) and ventilator associated pneumonia (VAP) were chosen as main outcome measures. In VLBW infants, the rate of line associated LCBSI per 1000 central venous catheter days fell by 24%. The rate of VAP per 1000 ventilator days in VLBW infants fell by 38%. Pre- and post-intervention questionnaires showed a statistically significant increase in use of alcohol-based gels and increased knowledge of hand hygiene.
Merlo, L.; Bighi, S.; Cervi, P.M.; Lupi, L.
The Authors report their experience in the employment of a computerized digital radiographic system in Neonatal Intensive Care. The analog screen-film system is replaced by photosensitive imaging plates, scanned after X-ray exposure by a laser that releases the digital image, which can then be manipulated on computer work-stations. In a period of twelve months about 200 chest-abdomen X-ray examinations in Neonatal Intensive Care have been performed using this method with good technical and diagnostic results. The use of digital radiography in the neonatal area is of high interest: this system produces good quality images, there is a reduction in radiation dose and 'retakes', the system allows selective enhancement of different structures and their magnification. (orig.)
Mikalauskas, Audrius; Benetis, Rimantas; Širvinskas, Edmundas; Andrejaitienė, Judita; Kinduris, Šarūnas; Macas, Andrius; Padaiga, Žilvinas
Burnout is a syndrome of depersonalization, emotional exhaustion, and low personal accomplishment. Little is known about burnout in physicians. Our objective was to determine the prevalence of burnout among anesthetists and intensive care physicians, and associations between burnout and personal, as well as professional, characteristics. In total, 220 anesthetists and intensive care physicians were contacted by email, asking them to participate in the study. For depression screening the PHQ-2 questionnaire, for problem drinking, CAGE items were used. Burnout was measured by the Maslach Burnout Inventory. Overall, 34% anesthetists and intensive care physicians indicated high levels of emotional exhaustion, 25% indicated high levels of depersonalization, and 38% showed low personal accomplishment. Burnout was found more frequent among subjects with problem drinking (OR 3.2, 95% CI 1.5-6.8), depressiveness (OR 10.2, 95% CI 4.6-22.6), cardiovascular disorders (OR 3.4, 95% CI 1.7-7.1), and digestive disorders (OR 2.2, 95% CI 1.2-4.0). Some favorite after-work activities positively correlated with burnout, such as sedative medications abuse (OR 4.8, 95% CI 1.8-12.5), alcohol abuse (OR 2.4, 95% CI 1.3-4.5), eating more than usual (OR 1.9, 95% CI 1.1-3.5), and transferring the accumulated stress to relatives (OR 2.8, 95% CI 1.4-5.5). In contrast, reading of non-medical literature seemed to have a protective effect (OR 0.5, 95% CI 0.2-0.9). Burnout was highly prevalent among anesthetists and intensive care physicians with two fifths of them meeting diagnostic criteria. It was strongly correlated with problem drinking, depressiveness, cardiovascular and digestive disorders, use of sedatives and overeating.
Happ, Mary Beth; Garrett, Kathryn; Thomas, Dana DiVirgilio; Tate, Judith; George, Elisabeth; Houze, Martin; Radtke, Jill; Sereika, Susan
Background The inability to speak during critical illness is a source of distress for patients, yet nurse-patient communication in the intensive care unit has not been systematically studied or measured. Objectives To describe communication interactions, methods, and assistive techniques between nurses and nonspeaking critically ill patients in the intensive care unit. Methods Descriptive observational study of the nonintervention/usual care cohort from a larger clinical trial of nurse-patient communication in a medical and a cardiothoracic surgical intensive care unit. Videorecorded interactions between 10 randomly selected nurses (5 per unit) and a convenience sample of 30 critically ill adults (15 per unit) who were awake, responsive, and unable to speak because of respiratory tract intubation were rated for frequency, success, quality, communication methods, and assistive communication techniques. Patients self-rated ease of communication. Results Nurses initiated most (86.2%) of the communication exchanges. Mean rate of completed communication exchange was 2.62 exchanges per minute. The most common positive nurse act was making eye contact with the patient. Although communication exchanges were generally (>70%) successful, more than one-third (37.7%) of communications about pain were unsuccessful. Patients rated 40% of the communication sessions with nurses as somewhat difficult to extremely difficult. Assistive communication strategies were uncommon, with little to no use of assistive communication materials (eg, writing supplies, alphabet or word boards). Conclusions Study results highlight specific areas for improvement in communication between nurses and nonspeaking patients in the intensive care unit, particularly in communication about pain and in the use of assistive communication strategies and communication materials. PMID:21362711
Tschudin-Sutter, Sarah; Pargger, Hans; Widmer, Andreas F
Healthcare-associated infections affect 1.4 million patients at any time worldwide, as estimated by the World Health Organization. In intensive care units, the burden of healthcare-associated infections is greatly increased, causing additional morbidity and mortality. Multidrug-resistant pathogens are commonly involved in such infections and render effective treatment challenging. Proper hand hygiene is the single most important, simplest, and least expensive means of preventing healthcare-associated infections. In addition, it is equally important to stop transmission of multidrug-resistant pathogens. According to the Centers for Disease Control and Prevention and World Health Organization guidelines on hand hygiene in health care, alcohol-based handrub should be used as the preferred means for routine hand antisepsis. Alcohols have excellent in vitro activity against Gram-positive and Gram-negative bacteria, including multidrug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, Mycobacterium tuberculosis, a variety of fungi, and most viruses. Some pathogens, however, such as Clostridium difficile, Bacillus anthracis, and noroviruses, may require special hand hygiene measures. Failure to provide user friendliness of hand hygiene equipment and shortage of staff are predictors for noncompliance, especially in the intensive care unit setting. Therefore, practical approaches to promote hand hygiene in the intensive care unit include provision of a minimal number of handrub dispensers per bed, monitoring of compliance, and choice of the most attractive product. Lack of knowledge of guidelines for hand hygiene, lack of recognition of hand hygiene opportunities during patient care, and lack of awareness of the risk of cross-transmission of pathogens are barriers to good hand hygiene practices. Multidisciplinary programs to promote increased use of alcoholic handrub lead to an increased compliance of healthcare
Afione, Cristina; Binda, Maria del C.
Purpose: To determine the role of imaging diagnostic methods in the location of infection causes of unknown origin in the critical care patient. Material and methods: A comprehensive medical literature search has been done. Recommendations for the diagnostic imaging of septic focus in intensive care patients are presented for each case, with analysis based on evidence. The degree of evidence utilized has been that of Oxford Center for Evidence-based Medicine. Results: Nosocomial infection is the most frequent complication in the intensive care unit (25 to 33%) with high sepsis incidence rate. In order to locate the infection focus, imaging methods play an important role, as a diagnostic tool and to guide therapeutic procedures. The most frequent causes of infection are: ventilation associated pneumonia, sinusitis, intra-abdominal infections and an acute acalculous cholecystitis. This paper analyses the diagnostic imaging of hospital infection, with the evaluation of choice methods for each one and proposes an algorithm to assess the septic patient. Conclusion: There are evidences, with different degrees of recommendation, for the use of diagnostic imaging methods for infectious focuses in critical care patients. The studies have been selected based on their diagnostic precision, on the capacity of the medical team and on the availability of resources, considering the risk-benefit balance for the best safety of the patient. (author)
Araki, Shunsuke; Saito, Tomoko; Ichikawa, Saori; Saito, Kaori; Takada, Tsuzumi; Noguchi, Satoko; Yamada, Miki; Nakagawa, Fumi
Advances in treatment in neonatal intensive care units (NICU) for preterm and sick newborns have improved the mortality rate of patients, but admission to the NICU may disrupt parent-infant interaction, with adverse consequences for infants and their families because of physical, psychological, and emotional separation. The concept of family centered care (FCC), in which family members are part of the care team and infants are close to the family, is important and has become popular in NICU. In 2013, we created a team called "Kodomo-Kazoku Mannaka" to promote FCC in Japan, and visited the NICU at Uppsala University Hospital in Sweden, which is internationally famous for FCC. Since this fruitful visit, we have been promoting FCC in Japan by exhibitions and presentations of the FCC ideas at academic conferences and using internet services. A questionnaire survey conducted in 2015 revealed that the importance and the benefits of FCC in NICU are recognized, although there are some barriers to FCC in each facility. It is hard to change facilities and social systems right away, but it is easier and more important to change people's minds. Our role is to spread the concept of FCC and to help each facility find its own way to adopt it. We will continue to make efforts encourage to promote FCC in Japan.
Osman, Mohamed F; Askari, Reza
It is critical for health care personnel to recognize and appreciate the detrimental impact of intensive care unit (ICU)-acquired infections. The economic, clinical, and social expenses to patients and hospitals are overwhelming. To limit the incidence of ICU-acquired infections, aggressive infection control measures must be implemented and enforced. Researchers and national committees have developed and continue to develop evidence-based guidelines to control ICU infections. A multifaceted approach, including infection prevention committees, antimicrobial stewardship programs, daily reassessments-intervention bundles, identifying and minimizing risk factors, and continuing staff education programs, is essential. Infection control in the ICU is an evolving area of critical care research. Copyright © 2014 Elsevier Inc. All rights reserved.
Tsai, Thomas C; Orav, E John; Jha, Ashish K
The relationship between patient satisfaction and surgical quality is unclear for US hospitals. Using national data, we examined if hospitals with high patient satisfaction have lower levels of performance on accepted measures of the quality and efficiency of surgical care. Federal policymakers have made patient satisfaction a core measure for the way hospitals are evaluated and paid through the value-based purchasing program. There is broad concern that performance on patient satisfaction may have little or even a negative correlation with the quality of surgical care, leading to potential trade-offs in efforts to improve patient experience with other surgical quality measures. We used the Hospital Consumer Assessment of Healthcare Providers and Systems survey data from 2010 and 2011 to assess performance on patient experience. We used national Medicare data on 6 common surgical procedures to calculate measures of surgical efficiency and quality: risk-adjusted length of stay, process score, risk-adjusted mortality rate, risk-adjusted readmission rate, and a composite z score across all 4 metrics. Multivariate models adjusting for hospital characteristics were used to assess the independent relationships between patient satisfaction and measures of surgical efficiency and quality. Of the 2953 US hospitals that perform one of these 6 procedures, the median patient satisfaction score was 69.5% (interquartile range, 63%-75.5%). Length of stay was shorter in hospitals with the highest levels of patient satisfaction (7.1 days vs 7.7 days, P patient satisfaction had the higher process of care performance (96.5 vs 95.5, P patient satisfaction also had a higher composite score for quality across all measures (P patient satisfaction provided more efficient care and were associated with higher surgical quality. Our findings suggest there need not be a trade-off between good quality of care for surgical patients and ensuring a positive patient experience.
Borel , Marie; Veber , Benoit; Villette-Baron , Karen; Hariri , S.; Dureuil , Bertrand; Hervé , Christian
International audience; It is not a question of going towards a systematic admission in intensive care of any patient proposed, but to make sure that so if there is a refusal, it is carried out according to a step ethically acceptable.
Coombs, Maureen; Mitchell, Marion; James, Stephen; Wetzig, Krista
End-of-life and bereavement care is an important consideration in intensive care. This study describes the type of bereavement care provided in intensive care units across Australia and New Zealand. Inductive qualitative content analysis was conducted on free-text responses to a web-based survey exploring unit-based bereavement practice distributed to nurse managers in 229 intensive care units in New Zealand and Australia. A total of 153 (67%) surveys were returned with 68 respondents making free-text responses. Respondents were mainly Australian (n = 54, 85·3%), from the public sector (n = 51, 75%) and holding Nurse Unit Managers/Charge Nurse roles (n = 39, 52·9%). From the 124 free-text responses, a total of 187 individual codes were identified focussing on bereavement care practices (n = 145, 77·5%), educational provision to support staff (n = 15, 8%) and organisational challenges (n = 27, 14·4%). Bereavement care practices described use of memory boxes, cultural specificity, annual memorial services and use of community support services. Educational provision identified local in-service programmes, and national bereavement courses for specialist bereavement nurse coordinators. Organisational challenges focussed on lack of funding, especially for provision of bereavement follow-up. This is the first Australasian-wide survey, and one of the few international studies, describing bereavement practices within intensive care, an important aspect of nursing practice. However, with funding for new bereavement services and education for staff lacking, there are continued challenges in developing bereavement care. Given knowledge about the impact of these areas of care on bereaved family members, this requires review. Nurses remain committed to supporting bereaved families during and following death in intensive care. With limited resource to support bereavement care, intensive care nurses undertake a range of bereavement care practices at time of death
Strandås, Maria; Fredriksen, Sven-Tore D
Neonatal nurses report a great deal of ethical challenges in their everyday work. Seemingly trivial everyday choices nurses make are no more value-neutral than life-and-death choices. Everyday ethical challenges should also be recognized as ethical dilemmas in clinical practice. The purpose of this study is to investigate which types of ethical challenges neonatal nurses experience in their day-to-day care for critically ill newborns. Data were collected through semi-structured qualitative in-depth interviews. Phenomenological-hermeneutic analysis was applied to interpret the data. Six nurses from neonatal intensive care units at two Norwegian hospitals were interviewed on-site. The study is designed to comply with Ethical Guidelines for Nursing Research in the Nordic Countries and the Helsinki declaration. Findings suggest that nurses experience a diverse range of everyday ethical challenges related to challenging interactions with parents and colleagues, emotional strain, protecting the vulnerable infant, finding the balance between sensitivity and authority, ensuring continuity of treatment, and miscommunication and professional disagreement. A major finding in this study is how different agents involved in caring for the newborn experience their realities differently. When these realities collide, ethical challenges arise. Findings suggest that acting in the best interests of the child becomes more difficult in situations involving many agents with different perceptions of reality. The study presents new aspects which increases knowledge and understanding of the reality of nursing in a neonatal intensive care unit, while also demanding increased research in this field of care. © The Author(s) 2014.
An evaluation of the diagnostic accuracy of the 1991 American College of Chest Physicians/Society of Critical Care Medicine and the 2001 Society of Critical Care Medicine/European Society of Intensive Care Medicine/American College of Chest Physicians/American Thoracic Society/Surgical Infection Society sepsis definition.
Zhao, Huifang; Heard, Stephen O; Mullen, Marie T; Crawford, Sybil; Goldberg, Robert J; Frendl, Gyorgy; Lilly, Craig M
Limited research has been conducted to compare the test characteristics of the 1991 and 2001 sepsis consensus definitions. This study assessed the accuracy of the two sepsis consensus definitions among adult critically ill patients compared to sepsis case adjudication by three senior clinicians. Observational study of patients admitted to intensive care units. Seven intensive care units of an academic medical center. A random sample of 960 patients from all adult intensive care unit patients between October 2007 and December 2008. None. Sensitivity, specificity, and the area under the receiver operating characteristic curve for the two consensus definitions were calculated by comparing the number of patients who met or did not meet consensus definitions vs. the number of patients who were or were not diagnosed with sepsis by adjudication. The 1991 sepsis definition had a high sensitivity of 94.6%, but a low specificity of 61.0%. The 2001 sepsis definition had a slightly increased sensitivity but a decreased specificity, which were 96.9% and 58.3%, respectively. The areas under the receiver operating characteristic curve for the two definitions were not statistically different (0.778 and 0.776, respectively). The sensitivities and areas under the receiver operating characteristic curve of both definitions were lower at the 24-hr time window level than those of the intensive care unit stay level, though their specificities increased slightly. Fever, high white blood cell count or immature forms, low Glasgow coma score, edema, positive fluid balance, high cardiac index, low PaO2/FIO2 ratio, and high levels of creatinine and lactate were significantly associated with sepsis by both definitions and adjudication. Both the 1991 and the 2001 sepsis definition have a high sensitivity but low specificity; the 2001 definition has a slightly increased sensitivity but a decreased specificity compared to the 1991 definition. The diagnostic performances of both definitions were
Rodiek, S.; Neu, I.
The first 100 computed tomographic (CT) examinations of the patients on the neurological intensive care ward are discussed and reported on the basis of selected typical findings. Characteristic patterns of the CT findings in determined cerebral diseases are explained. The possibility and necessity of CT observations of the development of inflammatory and cerebrovascular processes in particular are emphasized. A comparison of our experience with CT and other neuroradiological methods, is made. The clinical diagnoses, including the respective number of cases and the pertinent CT findings, are presented in a Table. (orig.) [de
Adam, G.; Wein, B.; Keulers, P.; Stargardt, A.; Guenther, R.W.
The authors have evaluated the image quality of a stimulable phosphorous plate system in intensive care chest radiography. Four radiologists examined 308 chest radiographs (200 conventional, 108 digital) according to the following criteria: visibility of catheters, tubes (artificial objects), bronchi, central and peripheral vessels, diaphragm, trachea, and retrocardial lung parenchyma. Detectability of these structures was classified as good, poor, or impossible to see. In addition, optical density was measured in the region of liver, heart, and lung. Results were evaluated by Student and υ test
David Lee Skinner
Full Text Available Background. Appropriate critical care admissions are an important component of surgical care. However, there are few data describing postoperative critical care admission in resource-limited low- and middle-income countries. Objective. To describe the demographics, organ failures, organ support and outcomes of non-cardiac surgical patients admitted to critical care units in South Africa (SA. Methods. The SA Surgical Outcomes Study (SASOS was a 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 government-funded hospitals. All patients admitted to critical care units during this study were included for analysis. Results. Of the 3 927 SASOS patients, 255 (6.5% were admitted to critical care units; of these admissions, 144 (56.5% were planned, and 111 (43.5% unplanned. The incidence of confirmed or strongly suspected infection at the time of admission was 35.4%, with a significantly higher incidence in unplanned admissions (49.1 v. 24.8%, p<0.001. Unplanned admission cases were more frequently hypovolaemic, had septic shock, and required significantly more inotropic, ventilatory and renal support in the first 48 hours after admission. Overall mortality was 22.4%, with unplanned admissions having a significantly longer critical care length of stay and overall mortality (33.3 v. 13.9%, p<0.001. Conclusion. The outcome of patients admitted to public sector critical care units in SA is strongly associated with unplanned admissions. Adequate ‘high care-dependency units’ for postoperative care of elective surgical patients could potentially decrease the burden on critical care resources in SA by 23%. This study was registered on ClinicalTrials.gov (NCT02141867.
Full Text Available Delirium is characterized by impaired cognition with nonspecific manifestations. In critically ill patients, it may develop secondary to multiple precipitating or predisposing causes. Although it can be a transient and reversible syndrome, its occurrence in Intensive Care Unit (ICU patients may be associated with long-term cognitive dysfunction. This condition is often under-recognized by treating physicians, leading to inappropriate management. For appropriate management of delirium, early identification and risk factor assessment are key factors. Multidisciplinary collaboration and standardized care can enhance the recognition of delirium. Interdisciplinary team working, together with updated guideline implementation, demonstrates proven success in minimizing delirium in the ICU. Moreover, should the use of physical restraint be necessary to prevent harm among mechanically ventilated patients, ethical clinical practice methodology must be employed. This traditional narrative review aims to address the presentation, risk factors, management, and ethical considerations in the management of delirium in ICU settings.
Mariama Amaral Michels
Full Text Available Rationale and objective: currently, Healthcare-associated Infections (HAIs constitute a serious public health problem. It is estimated that for every ten hospitalized patients, one will have infection after admission, generating high costs resulting from increased length of hospitalization, additional diagnostic and therapeutic interventions. The intensive care unit (ICU, due to its characteristics, is one of the most complex units of the hospital environment, a result of the equipment, the available technology, the severity of inpatients and the invasive procedures the latter are submitted to. The aim of the study was to evaluate the adherence to specifi c HAI prevention measures in invasive ICU procedures. Methods: This study had a quantitative, descriptive and exploratory approach. Among the risk factors for HAIs are the presence of central venous access, indwelling vesical catheter and mechanical ventilation, and, therefore, the indicators were calculated for patients undergoing these invasive procedures, through a questionnaire standardized by the Hospital Infection Control Commission (HICC. Results: For every 1,000 patients, 15 had catheter-related bloodstream infection, 6.85 had urinary tract infection associated with indwelling catheter in the fi rst half of 2010. Conclusion: most HAIs cannot be prevented, for reasons inherent to invasive procedures and the patients. However, their incidence can be reduced and controlled. The implementation of preventive measures based on scientifi c evidence can reduce HAIs signifi cantly and sustainably, resulting in safer health care services and reduced costs. The main means of prevention include the cleaning of hands, use of epidemiological block measures, when necessary, and specifi c care for each infection site. KEYWORDS Nosocomial infection. Intensive care units.
Silveira, Natyele Rippel; Nascimento, Eliane Regina Pereira do; Rosa, Luciana Martins da; Jung, Walnice; Martins, Sabrina Regina; Fontes, Moisés Dos Santos
to know the feelings of nurses regarding palliative care in adult intensive care units. qualitative study, which adopted the theoretical framework of Social Representations, carried out with 30 nurses of the state of Santa Catarina included by Snowball sampling. Data were collected through semi-structured interviews conducted from April to August 2015, organized and analyzed through the Collective Subject Discourse. the results showed how central ideas are related to feelings of comfort, frustration, insecurity and anguish, in addition to the feeling that the professional training and performance are focused on the cure. the social representations of nurses regarding the feelings related to palliative care are represented mainly by negative feelings, probably as consequence of the context in which care is provided.
Full Text Available Introduction: The intensive care unit (ICU represents a special environment for patients. We analyzed patients in the ICU/ high care unit (HCU with respect to dermatology counselling and skin problems.Setting: Academic Teaching Hospital over a 10 month period.Methods: The total number of patients of the ICU was 1,208 with a mean stay of 4.1 days. In the HCU the mean stay was 16 days. Diagnosis leading to admission were analyzed. All files of dermatological counselling were evaluated in detail.Results: Fifty-five patients with dermatologic problems were identified: 19 women and 26 males. The age ranged from 22 to 90 years of life (mean ± standard deviation: 67.2 ± 17.4 years. The total number of consultations were 85. The range of repeated dermatological consultation ranged from two to ten. The major reasons were skin and soft tissue infections, adverse drug reactions, chronic wounds including pressure sores and skin irritation or dermatitis. Pre-existing skin conditions may complicate the treatment and care during ICU/HCU stay.Conclusion: A tight collaboration between of the medical staff of ICU/HCU and dermatology department will ensure a rapid diagnosis and treatment of various skin conditions in the ICU, without increasing the costs significantly. Interdisciplinary education of nursing staff contributes to improved skin care in the ICU/HCU and helps to prevent acute skin failure.
Critical care admission of South African (SA) surgical patients: Results of the SA Surgical Outcomes Study. D.L. Skinner, K de Vasconcellos, R Wise, T.M. Esterhuizen, C Fourie, A Goolam Mahomed, P.D. Gopalan, I Joubert, H Kluyts, L.R. Mathivha, B Mrara, J.P. Pretorius, G Richards, O Smith, M.G.L. Spruyt, R.M. Pearse, ...
Luna, Jesus; Dikaiakos, Marios D; Kyprianou, Theodoros; Bilas, Angelos; Marazakis, Manolis
Novel eHealth systems are being designed to provide a citizen-centered health system, however the even demanding need for computing and data resources has required the adoption of Grid technologies. In most of the cases, this novel Health Grid requires not only conveying patient's personal data through public networks, but also storing it into shared resources out of the hospital premises. These features introduce new security concerns, in particular related with privacy. In this paper we survey current legal and technological approaches that have been taken to protect a patient's personal data into eHealth systems, with a particular focus in Intensive Care Grids. However, thanks to a security analysis applied over the Intensive Care Grid system (ICGrid) we show that these security mechanisms are not enough to provide a comprehensive solution, mainly because the data-at-rest is still vulnerable to attacks coming from untrusted Storage Elements where an attacker may directly access them. To cope with these issues, we propose a new privacy-oriented protocol which uses a combination of encryption and fragmentation to improve data's assurance while keeping compatibility with current legislations and Health Grid security mechanisms.
Madsen, Kristian Rørbaek; Lorentzen, Kristian; Clausen, Niels
Stress ulcer prophylaxis (SUP) is commonly used in the intensive care unit (ICU), and is recommended in the Surviving Sepsis Campaign guidelines 2012. The present guideline from the Danish Society of Intensive Care Medicine and the Danish Society of Anesthesiology and Intensive Care Medicine sums...
Williams, Amber L; van Drongelen, Wim; Lasky, Robert E
Weekly sound surveys (n = 63) were collected, using 5 s sampling intervals, for two modern neonatal intensive care units (NICUs). Median weekly equivalent sound pressure levels (LEQ) for NICU A ranged from 61 to 63 dB (A weighted), depending on the level of care. NICU B L(EQ) measurements ranged from 55 to 60 dB (A weighted). NICU B was recently built with a focus on sound abatement, explaining much of the difference between the two NICUs. Sound levels exceeded 45 dB (A weighted), recommended by the American Academy of Pediatrics, more than 70% of the time for all levels of care. Hourly L(EQ)s below 50 dB (A weighted) and hourly L10s below 55 dB (A weighted), recommended by the Sound Study Group (SSG) of the National Resource Center, were also exceeded in more than 70% of recorded samples. A third SSG recommendation, that the 1 s L(MAX), should not exceed 70 dB (A weighted), was exceeded relatively infrequently (< 11% of the time). Peak impulse measurements exceeded 90 dB for 6.3% of 5 s samples recorded from NICU A and 2.8% of NICU B samples. Twenty-four h periodicities in sound levels as a function of regular staff activities were apparent, but short-term variability was considerable.
Madsen, Matias Vested; Donatsky, Anders Meller; Jensen, Bente Rona
endotracheally intubated, mechanically ventilated, anesthetized with propofol and fentanyl, and randomized into two groups in a cross-over assessor-blinded design. Neuromuscular block was established with rocuronium. Artificial laparotomy for ileus was performed. We investigated the influence of intense...
Full Text Available The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform.
Efectividad de una intervención formativa en prevención de úlceras por presión en una unidad de cuidados intensivos quirúrgica: un estudio cuasi experimental Effectiveness of an educational intervention in pressure ulcer prevention in a surgical intensive care unit: a quasi experimental study
M.ª Jesús Wandosell Picatoste
Full Text Available Uno de los indicadores más relevantes para evaluar la seguridad del paciente es la incidencia de eventos adversos (EA. Las úlceras por presión (UPP son un EA con una incidencia muy elevada en las unidades de cuidados intensivos. El objetivo de este estudio es valorar la efectividad de una intervención formativa en prevención de UPP a través de la valoración de la incidencia y la gravedad de las lesiones en una unidad de cuidados intensivos quirúrgicos. Se llevó a cabo un estudio cuasi experimental de controles antes-después. Los resultados muestran que la incidencia de UPP disminuye tras la intervención formativa.One of the most relevant indicators to assess patient safety is the incidence of adverse events (AE. Pressure Ulcers (PU are an AE with a high incidence in intensive care units. The aim of this study is to evaluate the effectiveness of a formative intervention on prevention of PU through the assessment of the incidence and the severity of PU in the pre and the post intervention periods, in an intensive care surgical unit. We have carried out a quasi experimental study of pre and post controls. The results show that the incidence of PU is lower after the formative intervention.
Metabolic alkalosis is a commonly seen imbalance in the intensive care unit (ICU). Extreme metabolic alkalemia, however, is less common. A pH greater than 7.65 may carry a high risk of mortality (up to 80%). We discuss the entity of life threatening metabolic alkalemia by means of two illustrative cases - both with a pH greater than 7.65 on presentation. The cause, modalities of managing and complications of this condition is discussed from the point of view of both the traditional method of Henderson and Hasselbalch and the mathematical model based on physiochemical model described by Stewart. Special mention to the pitfalls in managing patients of metabolic alkalosis with concomitant renal compromise is made.
Chu, Kathryn M; Ford, Nathan P; Trelles, Miguel
Somalia is one of the most political unstable countries in the world. Ongoing insecurity has forced an inconsistent medical response by the international community, with little data collection. This paper describes the "remote" model of surgical care by Medecins Sans Frontieres, in Guri-El, Somalia. The challenges of providing the necessary prerequisites for safe surgery are discussed as well as the successes and limitations of task shifting in this resource-limited context. In January 2006, MSF opened a project in Guri-El located between Mogadishu and Galcayo. The objectives were to reduce mortality due to complications of pregnancy and childbirth and from violent and non-violent trauma. At the start of the program, expatriate surgeons and anesthesiologists established safe surgical practices and performed surgical procedures. After January 2008, expatriates were evacuated due to insecurity and surgical care has been provided by local Somalian doctors and nurses with periodic supervisory visits from expatriate staff. Between October 2006 and December 2009, 2086 operations were performed on 1602 patients. The majority (1049, 65%) were male and the median age was 22 (interquartile range, 17-30). 1460 (70%) of interventions were emergent. Trauma accounted for 76% (1585) of all surgical pathology; gunshot wounds accounted for 89% (584) of violent injuries. Operative mortality (0.5% of all surgical interventions) was not higher when Somalian staff provided care compared to when expatriate surgeons and anesthesiologists. The delivery of surgical care in any conflict-settings is difficult, but in situations where international support is limited, the challenges are more extreme. In this model, task shifting, or the provision of services by less trained cadres, was utilized and peri-operative mortality remained low demonstrating that safe surgical practices can be accomplished even without the presence of fully trained surgeon and anesthesiologists. If security improves
Smith, Francis Duval
Body piercing, a type of body modification that is practiced in many cultures, creates an unnatural tract through tissue that is then held open by artificial means. Today, professional body piercing is often performed in piercing establishments that are subject to dissimilar forms of regulation. The most frequently reported medical complication of body piercing and similar body modifications, such as dermal implantation, is infection. Patients with piercings who undergo surgery may have additional risks for infection, electrical burns, trauma, or airway obstruction. The published research literature on piercing prevalence, complications, regulations, education, and nursing care is outdated. The purpose of this article is to educate nurses on topics related to nursing care for patients with piercings and similar body modifications, including the history, prevalence, motivations for, and perceptions of body piercings as well as possible complications, devices used, locations, healing times, regulations, patient education, and other health concerns. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Zamoscik, Katarzyna; Godbold, Rosemary; Freeman, Pauline
To explore nurses' experiences and perceptions of delirium, managing delirious patients, and screening for delirium, five years after introduction of the Confusion Assessment Method for Intensive Care into standard practice. Twelve nurses from a medical-surgical intensive care unit in a large teaching hospital attended two focus group sessions. The collected qualitative data was thematically analysed using Braun and Clarke's framework (2006). The analysis identified seven themes: (1) Delirium as a Secondary Matter (2) Unpleasant Nature of Delirium (3) Scepticism About Delirium Assessment (4) Distrust in Delirium Management (5) Value of Communication (6) Non-pharmacological Therapy (7) Need for Reviewed Delirium Policy. Nurses described perceiving delirium as a low priority matter and linked it to work culture within the intensive care specialty. Simultaneously, they expressed their readiness to challenge this culture and to promote the notion of providing high-quality delirium care. Nurses discussed their frustrations related to lack of confidence in assessing delirium, as well as lack of effective therapies in managing this group of patients. They declared their appreciation for non-pharmacological interventions in treatment of delirium, suggested improvements to current delirium approach and proposed introducing psychological support for nurses dealing with delirious patients. Copyright © 2017 Elsevier Ltd. All rights reserved.
Background. Acute appendicitis in rural South Africa is associated with significant morbidity due to prolonged delays before definitive surgical care. Objective. This audit aimed to quantify the delay in our healthcare system. Methods. From September 2010 to September 2012, all patients with confirmed acute appendicitis ...
Understanding the reasons for delay to definitive surgical care of patients with acute appendicitis in rural South Africa. V Y Kong,1 MB ChB; C Aldous,2 PhD; D L Clarke,1 FCS ... Acute appendicitis in rural South Africa is associated with significant morbidity due to prolonged delays before definitive .... telemedicine support.
Dekimpe, Remi; Heldt, Thomas
High rates of false monitoring alarms in intensive care can desensitize staff and therefore pose a significant risk to patient safety. Like other critical arrhythmia alarms, asystole alarms require immediate attention by the care providers as a true asystole event can be acutely life threatening. Here, it is illustrated that most false asystole alarms can be attributed to poor signal quality, and we propose and evaluate an algorithm to identify data windows of poor signal quality and thereby help suppress false asystole alarms. The algorithm combines intuitive signal-quality features (degree of signal saturation and baseline wander) and information from other physiological signals that might be available. Algorithm training and testing was performed on the MIMIC II and 2015 PhysioNet/Computing in Cardiology Challenge databases, respectively. The algorithm achieved an alarm specificity of 81.0% and sensitivity of 95.4%, missing only one out of 22 true asystole alarms. On a separate neonatal data set, the algorithm was able to reject 89.7% (890 out of 992) of false asystole alarms while keeping all 22 true events. The results show that the false asystole alarm rate can be significantly reduced through basic signal quality evaluation.
Robinson, A.; Dellagrammaticas, H.D.
Radiological investigations have become accepted as an important part of the range of facilities required to support severely ill newborn babies. Since the infants are so small, many of the examinations are virtually ''whole-body'' irradiations and it was thought that the total doses received might be appreciable. A group of such babies admitted to the Neonatal Intensive Care Unit in Sheffield over a six-month period have been studied. X-ray exposure factors used for each examination have been noted and total skin, gonad and bone marrow doses calculated, supplemented by measurements on phantoms. It is concluded that in most cases doses received are of the same order as those received over the same period from natural background radiation and probably less than those received from prenatal obstetric radiography, so that the additional risks from the diagnostic exposure are small. The highest doses are received in CT scans and barium examinations and it is recommended that the need for these should be carefully considered. (author)
Allen, Jennifer; North, John B; Ware, Robert S
Objectives It is assumed that increased age signifies increased surgical care. Few surgical studies describe the differences in care provided to older patients compared with younger patients. We aimed to examine the relationships between increasing age, preoperative factors and markers of postoperative care in adults who died in-hospital after surgery in Australia. Design This retrospective cross-sectional study extracted data from a national surgical mortality audit—an independent, peer-reviewed process. Setting From January 2009 to December 2012, 111 public and 61 private Australian hospitals notified the audit of in-hospital deaths after general anaesthetic surgery or if the patient was admitted under a surgeon. Participants Notified deaths totalled 19 723. We excluded deaths if patients were brain dead, younger than 17 years or never had an operation (n=11 376). From this baseline population, we divided 11 201 deaths into three patient age groups: youngest (17–64 years), medium (65–79 years) and oldest (≥80 years). Outcome measures Univariable and multivariable logistic regression analyses determined the relationships between increasing age and the measured preoperative factors and postoperative variables. Results The baseline population's median age was 78 years (IQR 66–85), 43.7% (4892/11 201) were 80 years or older and 83.4% (9319/11 173) had emergency admissions. The oldest group had increased trauma and emergency admissions than the medium and youngest age groups. Seven of the eight measured markers of postoperative care demonstrate strong and significant relationships with increasing age. The oldest group compared with the medium group had decreased rates of: unplanned returns to theatre (11.2% (526/4709) vs 20.2% (726/3586)), unplanned intensive care admissions (16.3% (545/3350) vs 24.0% (601/2504)) and treatment in intensive care units (59.7% (2689/4507) vs 76.7% (2754/3590)). Conclusions The oldest patients received
Jensen, Hanne Irene; Gerritsen, Rik T; Koopmans, Matty
PURPOSE: The purpose of the study is to adapt and provide preliminary validation for questionnaires evaluating families' experiences of quality of care for critically ill patients in the intensive care unit (ICU). MATERIALS AND METHODS: This study took place in 2 European ICUs. Based on literature...... validity. RESULTS: A total of 110 family members participated. Response rate was 87%. For all questions, a median of 97% (94%-99%) was assessed as relevant, and a median of 98% (97%-100%), as understandable. Median ceiling effect was 41% (30%-47%). There was a median of 0% missing data (0%-1%). Test......-retest reliability showed a median weighted κ of 0.69 (0.53-0.83). Validation showed significant correlation between total scores and key questions. CONCLUSIONS: The questions were assessed as relevant and understandable, providing high face and content validity. Ceiling effects were comparable to similar...
Fraisse, Alain; Le Bel, Stéphane; Mas, Bertrand; Macrae, Duncan
Over recent decades, specialized paediatric cardiac intensive care has emerged as a central component in the management of critically ill, neonatal, paediatric and adult patients with congenital and acquired heart disease. The majority of high-volume centres (dealing with over 300 surgical cases per year) have dedicated paediatric cardiac intensive care units, with the smallest programmes more likely to care for paediatric cardiac patients in mixed paediatric or adult intensive care units. Specialized nursing staff are also a crucial presence at the patient's bedside for quality of care. A paediatric cardiac intensive care programme should have patients (preoperative and postoperative) grouped together geographically, and should provide proximity to the operating theatre, catheterization laboratory and radiology department, as well as to the regular ward. Age-appropriate medical equipment must be provided. An optimal strategy for running a paediatric cardiac intensive care programme should include: multidisciplinary collaboration and involvement with paediatric cardiology, anaesthesia, cardiac surgery and many other subspecialties; a risk-stratification strategy for quantifying perioperative risk; a personalized patient approach; and anticipatory care. Finally, progressive withdrawal from heavy paediatric cardiac intensive care management should be institutionalized. Although the countries of the European Union do not share any common legislation on the structure and organization of paediatric intensive care or paediatric cardiac intensive care, any paediatric cardiac surgery programme in France that is agreed by the French Health Ministry must perform at least '150 major procedures per year in children' and must provide a 'specialized paediatric intensive care unit'. Copyright © 2010 Elsevier Masson SAS. All rights reserved.
McDonald, Katie; Rubarth, Lori Baas; Miers, Linda J
The purpose of this study was to describe the job satisfaction of neonatal intensive care unit (NICU) nurses in the Midwestern United States. The factors explored in job satisfaction were monetary compensation (pay), job stress, caring for patients in stressful situations, level of autonomy, organizational support, level of knowledge of the specialty, work environment, staffing levels, communication with physicians, communication with neonatal nurse practitioners, interdisciplinary communication, team spirit, and the amount of required "floating" to other nursing units. Participants were 109 NICU nurses working as either staff nurses (n = 72) or advanced practice nurses (n = 37). Of the participants, 96% worked in a level 3 NICU. A descriptive, correlational design was used to study job satisfaction among NICU nurses. Nurses were recruited at 2 regional NICU conferences in 2009 and 2010. The questionnaire was a researcher-developed survey consisting of 14 questions in a Likert-type response rating 1 to 5, with an area for comments. Descriptive statistics and correlations were used to analyze the resulting data. The majority of participants were moderately satisfied overall in their current position and workplace (mean ranking = 4.07 out of 5.0). Kendall's Tau b (TB) revealed that the strongest positive correlations were between organizational support and team spirit with overall job satisfaction (TB = 0.53). : The individual factors with the highest mean scores were caring for patients in a stressful situation, level of autonomy, and communication between nurses and neonatal nurse practitioners. This indicates that our population of NICU nurses feels most satisfied caring for patients in stressful situations (m = 4.48), are satisfied with their level of autonomy (M = 4.17), and are satisfied with the interdisciplinary communication in their units (m = 4.13). Nurses in the NICU are relatively satisfied with their jobs. The small sample size (n = 109) of Midwest NICU
Lamond, E; Murray, S; Gibson, C E
Delirium is described as 'acute brain failure' and constitutes a medical emergency which presents a hazard for people cared for in intensive care units. The Scottish intensive care society audit group recommend that all people cared for in intensive care units be screened for signs of delirium so that treatment and management of complications can be implemented at an early stage. There is inconsistent evidence about when and how the assessment of delirium is carried out by nursing staff in the intensive care setting. This narrative review explores the pathophysiology and current practices of delirium screening in intensive care. Consideration is given to the role of the nurse in detecting and managing delirium and some barriers to routine daily delirium screening are critically debated. It is argued that routine delirium screening is an essential element of safe, effective and person centred nursing care which has potential to reduce morbidity and mortality. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.
Sep 11, 2015 ... Department of Nursing, Surgical Nursing, Medipol University,. Faculty of Health Science, ..... stress felt by married patients at being separated from their spouse or children and .... its effect on burnout. Am J Crit Care 2004 ...
Müller-Werdan, U; Heppner, H-J; Michels, G
Critically ill geriatric patients are vitally endangered due to the aging processes of organs, the frequently existing multimorbidity with subsequent polypharmacy and the typical geriatric syndrome of functional impairments. Aging processes in organs lower the clinical threshold for organ dysfunction and organ failure. Physiological organ aging processes with practical consequences for intensive care medicine are atypical manifestion of sepsis in immunosenescence, altered pharmacokinetics, reduced tolerance to hypovolemia due to proportionally reduced water compartment of the body in old age, the frequently only apparently normal function of the kidneys and the continuous reduction in pulmonary function in old age. The main reasons for changes in therapeutic targets are the will of the patient and risk-benefit considerations. The guidelines of the ethics section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provide assistance and suggestions for a structured decision-making process.
Paonessa, Joseph R; Brennan, Thomas; Pimentel, Marco; Steinhaus, Daniel; Feng, Mengling; Celi, Leo Anthony
Limited information exists on the etiology, prevalence, and significance of hyperdynamic left ventricular ejection fraction (HDLVEF) in the intensive care unit (ICU). Our aim in the present study was to compare characteristics and outcomes of patients with HDLVEF with those of patients with normal left ventricular ejection fraction in the ICU using a large, public, deidentified critical care database. We conducted a longitudinal, single-center, retrospective cohort study of adult patients who underwent echocardiography during a medical or surgical ICU admission at the Beth Israel Deaconess Medical Center using the Multiparameter Intelligent Monitoring in Intensive Care II database. The final cohort had 2867 patients, of whom 324 had HDLVEF, defined as an ejection fraction >70%. Patients with an ejection fraction <55% were excluded. Compared with critically ill patients with normal left ventricular ejection fraction, the finding of HDLVEF in critically ill patients was associated with female sex, increased age, and the diagnoses of hypertension and cancer. Patients with HDLVEF had increased 28-day mortality compared with those with normal ejection fraction in multivariate logistic regression analysis adjusted for age, sex, Sequential Organ Failure Assessment score, Elixhauser score for comorbidities, vasopressor use, and mechanical ventilation use (odds ratio 1.38, 95% confidence interval 1.039-1.842, p =0.02). The presence of HDLVEF portended increased 28-day mortality, and may be helpful as a gravity marker for prognosis in patients admitted to the ICU. Further research is warranted to gain a better understanding of how these patients respond to common interventions in the ICU and to determine if pharmacologic modulation of HDLVEF improves outcomes.
Kubicki, Mark A; McGain, Forbes; O'Shea, Catherine J; Bates, Samantha
The provision of health care has significant direct environmental effects such as energy and water use and waste production, and indirect effects, including manufacturing and transport of drugs and equipment. Recycling of hospital waste is one strategy to reduce waste disposed of as landfill, preserve resources, reduce greenhouse gas emissions, and potentially remain fiscally responsible. We began an intensive care unit recycling program, because a significant proportion of ICU waste was known to be recyclable. To determine the weight and proportion of ICU waste recycled, the proportion of incorrect waste disposal (including infectious waste contamination), the opportunity for further recycling and the financial effects of the recycling program. We weighed all waste and recyclables from an 11-bed ICU in an Australian metropolitan hospital for 7 non-consecutive days. As part of routine care, ICU waste was separated into general, infectious and recycling streams. Recycling streams were paper and cardboard, three plastics streams (polypropylene, mixed plastics and polyvinylchloride [PVC]) and commingled waste (steel, aluminium and some plastics). ICU waste from the waste and recycling bins was sorted into those five recycling streams, general waste and infectious waste. After sorting, the waste was weighed and examined. Recycling was classified as achieved (actual), potential and total. Potential recycling was defined as being acceptable to hospital protocol and local recycling programs. Direct and indirect financial costs, excluding labour, were examined. During the 7-day period, the total ICU waste was 505 kg: general waste, 222 kg (44%); infectious waste, 138 kg (27%); potentially recyclable waste, 145 kg (28%). Of the potentially recyclable waste, 70 kg (49%) was actually recycled (14% of the total ICU waste). In the infectious waste bins, 82% was truly infectious. There was no infectious contamination of the recycling streams. The PVC waste was 37% contaminated
The practice of medicine is often represented as a dualism: is medicine a 'science' or an 'art'? This dualism has been long-lasting, with evident appeal for the medical profession. It also appears to have been rhetorically powerful, for example in enabling clinicians to resist the encroachment of 'scientific' evidence-based medicine into core areas of medical work such as individual clinical judgement. In this article I want to make the case for a more valid conceptualisation of medical practice: that it is a 'craft' activity. The case I make is founded on a theoretical synthesis of the concept of craft, combined with an analysis of ethnographic observations of routine medical practice in intensive care. For this context the craft aspects of medical work can be seen in how biomedical and other types of knowledge are used in practice, the embodied skills and practical judgement of practitioners and the technological and material environment. These aspects are brought together in two conceptual dimensions for 'craft': first, the application of knowledge; second, interaction with the material world. Some practical and political implications of a 'craft' metaphor for medical practice are noted. © 2013 The Author. Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd.
Singhi, Sunit; Deep, Akash
Candidemia and disseminated candidiasis are major causes of morbidity and mortality in hospitalized patients especially in the intensive care units (ICU). The incidence of invasive candidasis is on a steady rise because of increasing use of multiple antibiotics and invasive procedures carried out in the ICUs. Worldwide there is a shifting trend from C. albicans towards non albicans species, with an associated increase in mortality and antifungal resistance. In the ICU a predisposed host in one who is on broad spectrum antibiotics, parenteral nutrition, and central venous catheters. There are no pathognomonic signs or symptoms. The clinical clues are: unexplained fever or signs of severe sepsis or septic shock while on antibiotics, multiple, non-tender, nodular erythematous cutaneous lesions. The spectrum of infection with candida species range from superficial candidiasis of the skin and mucosa to more serious life threatening infections. Treatment of candidiasis involves removal of the most likely source of infection and drug therapy to speed up the clearance of infection. Amphotericin B remains the initial drug of first choice in hemodynamically unstable critically ill children in the wake of increasing resistance to azoles. Evaluation of newer antifungal agents and precise role of prophylactic therapy in ICU patients is needed.
Full Text Available Objectives. Automated, microprocessor-controlled, closed-loop mechanical ventilation has been used in our Medical Intensive Care Unit (MICU at the Hadassah Hebrew-University Medical Center for the past 15 years; for 10 years it has been the primary (preferred ventilator modality. Design and setting. We describe our clinical experience with adaptive support ventilation (ASV over a 6-year period, during which time ASV-enabled ventilators became more readily available and were used as the primary (preferred ventilators for all patients admitted to the MICU. Results. During the study period, 1 220 patients were ventilated in the MICU. Most patients (84% were ventilated with ASV on admission. The median duration of ventilation with ASV was 6 days. The weaning success rate was 81%, and tracheostomy was required in 13%. Sixty-eight patients (6% with severe hypoxia and high inspiratory pressures were placed on pressure-controlled ventilation, in most cases to satisfy a technical requirement for precise and conservative administration of inhaled nitric oxide. The overall pneumothorax rate was less than 3%, and less than 1% of patients who were ventilated only using ASV developed pneumothorax. Conclusions. ASV is a safe and acceptable mode of ventilation for complicated medical patients, with a lower than usual ventilation complication rate.
Maiara Benevides Moreira
Full Text Available Abstract OBJECTIVE To analyze potential intravenous drug interactions, and their level of severity associated with the administration of these drugs based on the prescriptions of an intensive care unit. METHOD Quantitative study, with aretrospective exploratory design, and descriptive statistical analysis of the ICU prescriptions of a teaching hospital from March to June 2014. RESULTS The sample consisted of 319 prescriptions and subsamples of 50 prescriptions. The mean number of drugs per patient was 9.3 records, and a higher probability of drug interaction inherent to polypharmacy was evidenced. The study identified severe drug interactions, such as concomitant administration of Tramadol with selective serotonin reuptake inhibitor drugs (e.g., Metoclopramide and Fluconazole, increasing the risk of seizures due to their epileptogenic actions, as well as the simultaneous use of Ranitidine-Fentanyl®, which can lead to respiratory depression. CONCLUSION A previous mapping of prescriptions enables the characterization of the drug therapy, contributing to prevent potential drug interactions and their clinical consequences.
C. L. Gonçalves
Full Text Available Abstract The presence of airborne fungi in Intensive Care Unit (ICUs is associated with increased nosocomial infections. The aim of this study was the isolation and identification of airborne fungi presented in an ICU from the University Hospital of Pelotas – RS, with the attempt to know the place’s environmental microbiota. 40 Petri plates with Sabouraud Dextrose Agar were exposed to an environment of an ICU, where samples were collected in strategic places during morning and afternoon periods for ten days. Seven fungi genera were identified: Penicillium spp. (15.18%, genus with the higher frequency, followed by Aspergillus spp., Cladosporium spp., Fusarium spp., Paecelomyces spp., Curvularia spp., Alternaria spp., Zygomycetes and sterile mycelium. The most predominant fungi genus were Aspergillus spp. (13.92% in the morning and Cladosporium spp. (13.92% in the afternoon. Due to their involvement in different diseases, the identified fungi genera can be classified as potential pathogens of inpatients. These results reinforce the need of monitoring the environmental microorganisms with high frequency and efficiently in health institutions.
Full Text Available The drug related complications are on the rise warranting special attention towards patient safety in Intensive Care Unit (ICU setup. Pharmacovigilance is the science about the detection, assessment and prevention of drug related problems. This review is aimed to highlight significant problems arising from medication errors with emphasis on special drugs used in ICU (oxygen, antibiotics, sedatives, analgesics and neuromuscular blocking drugs and their risk reduction strategies in ICU utilizing practice of pharmacovigilance. Human error, lack of communication among various health providers, inadequate knowledge about drugs, failure to follow protocols or recommended guidelines are important causes of drug related problems in ICU. It is imperative that ICU administrators and medical directors of hospitals consider adverse drug events (ADEs as system failures. Pharmacovigilance, an observational science is the need of the hour for patients admitted in ICUs. We need to give more emphasis on prevention rather than treating the potentially fatal complications arising from ADEs. Eternal vigilance is the key. Protocol based management, improvement of medication system, frequent audits, improved communication, good team work, a blame free environ-ment, inclusion of a pharmacist, leadership involvement and use of information technology in the ICU are possible solutions.
Cotton, Michael; Henry, Jaymie Ang; Hasek, Lauren
Limited resources in low- and middle-income countries (LMICs) drive tremendous innovation in medicine, as well as in other fields. It is not often recognized that several important surgical tools and methods, widely used in high-income countries, have their origins in LMICs. Surgical care around the world stands much to gain from these innovations. In this paper, we provide a short review of some of these successful innovations and their origins that have had an important impact in healthcare delivery worldwide. Examples of LMIC innovations that have been adapted in high-income countries include the Bogotá bag for temporary abdominal wound closure, the orthopaedic external fixator for complex fractures, a hydrocephalus fluid valve for normal pressure hydrocephalus, and intra-ocular lens and manual small incision cataract surgery. LMIC innovations that have had tremendous potential global impact include mosquito net mesh for inguinal hernia repair, and a flutter valve for intercostal drainage of pneumothorax. Surgical innovations from LMICs have been shown to have comparable outcomes at a fraction of the cost of tools used in high-income countries. These innovations have the potential to revolutionize global surgical care. Advocates should actively seek out these innovations, campaign for the financial gains from these innovations to benefit their originators and their countries, and find ways to develop and distribute them locally as well as globally.
Despite the significant advances in the medical management of inflammatory bowel disease over the last decade, surgery continues to play a major role in the management of pediatric Crohn's disease (CD). While adult and pediatric Crohn's disease may share many clinical characteristics, pediatric Crohn's patients often have a more aggressive phenotype, and the operative care given by the pediatric surgeon to the newly diagnosed Crohn's patient is very different in nature to the surgical needs of adult patients after decades of disease progression. Children also have the unique surgical indication of growth failure to consider in the overall clinical decision making. While surgery is never curative in CD, it has the ability to transform the disease process in children, and appropriately timed operations may have tremendous impact on a child's physical and mental maturation. This monograph aims to address the surgical care of Crohn's disease in general, with a specific emphasis on the surgical treatment of small intestinal and ileocecal involvement. Copyright © 2017 Elsevier Inc. All rights reserved.
Full Text Available Background: The Lagos University Teaching Hospital's Intensive Care Unit (ICU was founded in 1975. It was designed as an eight-bedded ICU, a previous review of outcome of surgical admissions in the ICU in 2002 placed mortality at 40.3%, however, presently run as a five-bed unit with new ICU equipment procured in 2012, arterial blood gas machines, patient monitors, and ventilators with sustained multidisciplinary approach to patient management. We compared the number of admissions, mortality, and discharges to the ward 1 year before (Period I and after the upgrade of the ICU facilities (Period II. Methods: This was a retrospective study of all patients admitted into the ICU between June 2011 and May 2013. We looked at the admission register of the ICU and retrieved biometric data, diagnosis, age, pattern of units admitting patients into ICU, length of stay (LOS, and outcome of ICU care whether the patient died in ICU or was discharged to the ward. Results: There were 122 patients admitted into the ICU in Period I and 156 patients were admitted in Period II with a mean LOS of 6.3 ± 5.4 days and 7.8 ± 7.3 days, respectively. Mortality rate in Period I was 74.6% while mortality fell to 57.7% in Period II (P = 0.005. Conclusion: There was a significant improvement in the ICU outcome with the upgrade of the ICU facilities.
mortality of between 1 and 5%,[2,12] while others have reported .... ICU, and the need for a critical care specialist should be considered. ... Madan I, Jain NJ, Grotegut C, Nelson D, Dandolu V. Characteristics of obstetric intensive care.
Egbe, Alexander C; Uppu, Santosh C; Mittnacht, Alexander J C; Joashi, Umesh; Ho, Deborah; Nguyen, Khanh; Srivastava, Shubhika
Primary repair of tetralogy of Fallot has low surgical mortality, but some patients still experience significant postoperative morbidity. Our objectives were to review our institutional experience with primary tetralogy of Fallot repair, and identify predictors of intensive care unit morbidity. We reviewed all patients with tetralogy of Fallot who underwent primary repair in infancy from 2001 to 2012. Preoperative, operative, and postoperative demographic and morphologic data were analyzed. Intensive care unit morbidity was defined as prolonged intensive care unit stay (≥ 7 days) and/or prolonged duration of mechanical ventilation (≥ 48 h). 97 patients who underwent primary surgical repair during the study period were included in the study. The median age was 4.9 months (range 1-9 months) and the median weight was 5.3 kg (range 3.1-9.8 kg). There was no early surgical mortality. The incidence of junctional ectopic tachycardia and persistent complete heart block was 2% and 1%, respectively. The median intensive care unit stay was 6 days (range 2-21 days) and the median duration of mechanical ventilation was 19 h (range 0-136 h). Age and weight were independent predictors of intensive care unit stay, while surgical era predicted the duration of mechanical ventilation. Primary tetralogy of Fallot repair is a safe procedure with low mortality and morbidity in a medium-sized program with outcomes comparable to national standards. Age and weight at the time of surgery were significant predictors of morbidity. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
Full Text Available Despite the considerable number of studies reported to date, the causative agents of pneumonia are not completely identified. We comprehensively applied modern and traditional laboratory diagnostic techniques to identify microbiota in patients who were admitted to or developed pneumonia in intensive care units (ICUs. During a three-year period, we tested the bronchoalveolar lavage (BAL of patients with ventilator-associated pneumonia, community-acquired pneumonia, non-ventilator ICU pneumonia and aspiration pneumonia, and compared the results with those from patients without pneumonia (controls. Samples were tested by amplification of 16S rDNA, 18S rDNA genes followed by cloning and sequencing and by PCR to target specific pathogens. We also included culture, amoeba co-culture, detection of antibodies to selected agents and urinary antigen tests. Based on molecular testing, we identified a wide repertoire of 160 bacterial species of which 73 have not been previously reported in pneumonia. Moreover, we found 37 putative new bacterial phylotypes with a 16S rDNA gene divergence ≥ 98% from known phylotypes. We also identified 24 fungal species of which 6 have not been previously reported in pneumonia and 7 viruses. Patients can present up to 16 different microorganisms in a single BAL (mean ± SD; 3.77 ± 2.93. Some pathogens considered to be typical for ICU pneumonia such as Pseudomonas aeruginosa and Streptococcus species can be detected as commonly in controls as in pneumonia patients which strikingly highlights the existence of a core pulmonary microbiota. Differences in the microbiota of different forms of pneumonia were documented.
Brown, Evans K H; Harder, Kathleen A; Apostolidou, Ioanna; Wahr, Joyce A; Shook, Douglas C; Farivar, R Saeid; Perry, Tjorvi E; Konia, Mojca R
The cardiac operating room is a complex environment requiring efficient and effective communication between multiple disciplines. The objectives of this study were to identify and rank critical time points during the perioperative care of cardiac surgical patients, and to assess variability in responses, as a correlate of a shared mental model, regarding the importance of these time points between and within disciplines. Using Delphi technique methodology, panelists from 3 institutions were tasked with developing a list of critical time points, which were subsequently assigned to pause point (PP) categories. Panelists then rated these PPs on a 100-point visual analog scale. Descriptive statistics were expressed as percentages, medians, and interquartile ranges (IQRs). We defined low response variability between panelists as an IQR ≤ 20, moderate response variability as an IQR > 20 and ≤ 40, and high response variability as an IQR > 40. Panelists identified a total of 12 PPs. The PPs identified by the highest number of panelists were (1) before surgical incision, (2) before aortic cannulation, (3) before cardiopulmonary bypass (CPB) initiation, (4) before CPB separation, and (5) at time of transfer of care from operating room (OR) to intensive care unit (ICU) staff. There was low variability among panelists' ratings of the PP "before surgical incision," moderate response variability for the PPs "before separation from CPB," "before transfer from OR table to bed," and "at time of transfer of care from OR to ICU staff," and high response variability for the remaining 8 PPs. In addition, the perceived importance of each of these PPs varies between disciplines and between institutions. Cardiac surgical providers recognize distinct critical time points during cardiac surgery. However, there is a high degree of variability within and between disciplines as to the importance of these times, suggesting an absence of a shared mental model among disciplines caring for
Trouillet, Jean-Louis; Collange, Olivier; Belafia, Fouad; Blot, François; Capellier, Gilles; Cesareo, Eric; Constantin, Jean-Michel; Demoule, Alexandre; Diehl, Jean-Luc; Guinot, Pierre-Grégoire; Jegoux, Franck; L'Her, Erwan; Luyt, Charles-Edouard; Mahjoub, Yazine; Mayaux, Julien; Quintard, Hervé; Ravat, François; Vergez, Sébastien; Amour, Julien; Guillot, Max
Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the grading of recommendations assessment, development and evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de réanimation de langue française) and the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie réanimation) with the participation of the French Emergency Medicine Association (Société française de médecine d'urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1±) and 6 a low level of proof (Grade 2±). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced. Copyright © 2018 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.
Mortamet, Guillaume; Merckx, Audrey; Roumeliotis, Nadia; Simonds, Caroline; Renolleau, Sylvain; Hubert, Philippe
The objective of this study was to report family satisfaction with regards to the presence of clowns in the paediatric intensive care unit (PICU). This is a single-centre survey-based study, conducted over 4 months in a 12-bed third level PICU in a university hospital. All parents present at the bedside of their child during clowning were considered as potential participants. Eligible parents were approached by one of the two intensivists as investigators and asked to complete a survey within the 48 h following the clowns' intervention. Thirty-three parents consented to complete the survey. Median age of children was 14 months (15 days to 16 years) and median Pediatric Logistic Organ Dysfunction (PELOD) score was 1 (0-22). Twenty-four (72.7%) were considered as clinically stable while the clowns intervened. Twenty-eight parents (84.8%) and 27 (81.8%) considered that clowns had a positive effect on themselves and on their child, respectively. Clown care was considered as necessary in 19 cases (57.6%), optional in 13 (39.4%) and unnecessary in 1 (3.0%). The degree of parental satisfaction was not significantly associated with the child's clinical stability. We suggested that medical clowning in the PICU is well accepted by parents, regardless of severity of their child's condition. This study supports the adoption of medical clowning in PICUs as a patient- and family-centred care practice. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).
Kjer, C K W; Estrup, S; Poulsen, L M
common early ICU-aftercare items were as follows: respiratory care (82%), tracheostomy care (59%) and nutritional care (59%). For late ICU-aftercare, the most common eligibility criterion was LOS (41%). Guidelines (71%), but not checklist at patient contact (35%), were more common. Most frequent late ICU...
S. Samiee-Zafarghandy; S.R. Raman (Sudha R.); J.N. van den Anker (John); K. McHutchison (Kerstin); C.P. Hornik; R.H. Clark; P.B. Smith; D.K. Benjamin (Daniel K.); K. Berezny (Katherine); J. Barrett (Jeffrey); E.V. Capparelli (Edmund); M. Cohen-Wolkowiez (Michael); G.L. Kearns (Greg); M. Laughon (Matthew); A. Muelenaer (Andre); T. Michael O'Shea; I.M. Paul (Ian M.); K. Wade (Kelly); T.J. Walsh (Thomas J.)
textabstractBackground: Milrinone use in the neonatal intensive care unit has increased over the last 10. years despite a paucity of published safety data in infants. We sought to determine the safety of milrinone therapy among infants in the neonatal intensive care unit. Methods: We conducted a
Moreira, Maiara Benevides; Mesquita, Maria Gefé da Rosa; Stipp, Marluci Andrade Conceição; Paes, Graciele Oroski
To analyze potential intravenous drug interactions, and their level of severity associated with the administration of these drugs based on the prescriptions of an intensive care unit. Quantitative study, with aretrospective exploratory design, and descriptive statistical analysis of the ICU prescriptions of a teaching hospital from March to June 2014. The sample consisted of 319 prescriptions and subsamples of 50 prescriptions. The mean number of drugs per patient was 9.3 records, and a higher probability of drug interaction inherent to polypharmacy was evidenced. The study identified severe drug interactions, such as concomitant administration of Tramadol with selective serotonin reuptake inhibitor drugs (e.g., Metoclopramide and Fluconazole), increasing the risk of seizures due to their epileptogenic actions, as well as the simultaneous use of Ranitidine-Fentanyl®, which can lead to respiratory depression. A previous mapping of prescriptions enables the characterization of the drug therapy, contributing to prevent potential drug interactions and their clinical consequences. Analisar as potenciais interações medicamentosas intravenosas e seu grau de severidade associadas à administração desses medicamentos a partir das prescrições do Centro de Terapia Intensiva. Estudo quantitativo, tipologia retrospectiva exploratória, com análise estatística descritiva das prescrições medicamentosas do Centro de Terapia Intensiva de um Hospital Universitário, no período de março-junho/2014. A amostra foi composta de 319 prescrições e subamostras de 50 prescrições. Constatou-se que a média de medicamentos por paciente foi de 9,3 registros, e evidenciou-se maior probabilidade para ocorrência de interação medicamentosa inerente à polifarmácia. O estudo identificou interações medicamentosas graves, como a administração concomitante de Tramadol com medicamentos inibidores seletivos da recaptação da serotonina, (exemplo: Metoclopramida e Fluconazol
Rosenberger, Laura H; Politano, Amani D; Sawyer, Robert G
In response to inconsistent compliance with infection prevention measures, the Centers for Medicare & Medicaid Services collaborated with the U.S. Centers for Disease Control and Prevention on the Surgical Infection Prevention (SIP) project, introduced in 2002. Quality improvement measures were developed to standardize processes to increase compliance. In 2006, the Surgical Care Improvement Project (SCIP) developed out of the SIP project and its process measures. These initiatives, published in the Specifications Manual for National Inpatient Quality Measures, outline process and outcome measures. This continually evolving manual is intended to provide standard quality measures to unify documentation and track standards of care. Seven of the SCIP initiatives apply to the peri-operative period: Prophylactic antibiotics should be received within 1 h prior to surgical incision (1), be selected for activity against the most probable antimicrobial contaminants (2), and be discontinued within 24 h after the surgery end-time (3); (4) euglycemia should be maintained, with well-controlled morning blood glucose concentrations on the first two post-operative days, especially in cardiac surgery patients; (6) hair at the surgical site should be removed with clippers or by depilatory methods, not with a blade; (9) urinary catheters are to be removed within the first two post-operative days; and (10) normothermia should be maintained peri-operatively. There is strong evidence that implementation of protocols that standardize practices reduce the risk of surgical infection. The SCIP initiative targets complications that account for a significant portion of preventable morbidity as well as cost. One of the goals of the SCIP guidelines was a 25% reduction in the incidence of surgical site infections from implementation through 2010. Process measures are becoming routine, and as we practice more evidence-based medicine, it falls to us, the surgeons and scientists, to be active
Fuller, Jennifer C; Shaye, David A
The field of global surgery is undergoing rapid transformation, owing to several recent prominent reports positioning it as a cost-effective means of relieving global disease burden. The purpose of this article is to review the recent advances in the field of global surgery. Efforts to grow the global surgical workforce and procedural capacity have focused on innovative methods to increase surgeon training, enhance international collaboration, leverage technology, optimize existing health systems, and safely implement task-sharing. Computer modeling offers a novel means of informing policy to optimize timely access to care, equitably promote health and financial protection, and efficiently grow infrastructure. Tools and checklists have recently been developed to enhance data collection and ensure methodologically rigorous publications to inform planning, benchmark surgical systems, promote accurate modeling, track key health indicators, and promote safety. Creation of institutional partnerships and trainee exchanges can enrich training, stimulate commitment to humanitarian work, and promote the equal exchange of ideas and expertise. The recent body of work creates a strong foundation upon which work toward the goal of universal access to safe, affordable surgical care can be built; however, further collection and analysis of country-specific data is necessary for accurate modeling and outcomes research into the efficacy of policies such as task-sharing is greatly needed.
Arena, Fabio; Scolletta, Sabino; Marchetti, Luca; Galano, Angelo; Maglioni, Enivarco; Giani, Tommaso; Corsi, Elisabetta; Lombardi, Silvia; Biagioli, Bonizella; Rossolini, Gian Maria
A preintervention-postintervention study was carried out over a 4-year period to assess the impact of an antimicrobial stewardship intervention, based on clinical microbiologist ward rounds (clinical microbiology-intensive care partnership [CMICP]), at a cardiothoracic intensive care unit. Comparison of clinical data for 37 patients with diagnosis of bacteremia (18 from preintervention period, 19 from postintervention period) revealed that CMICP implementation resulted in (1) significant increase of appropriate empirical treatments (+34%, P = .029), compliance with guidelines (+28%, P = .019), and number of de-escalations (+42%, P = .032); and (2) decrease (average = 2.5 days) in time to optimization of antimicrobial therapy and levofloxacin (Δ 2009-2012 = -74 defined daily dose [DDD]/1,000 bed days) and teicoplanin (Δ 2009-2012 = -28 DDD/1,000 bed days) use. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Madsen, Kristian Rørbæk; Guldager, Henrik; Rewers, Mikael
Percutaneous dilatational tracheostomy is a common procedure in intensive care. This guideline from the Danish Society of Intensive Care Medicine (DSIT) and the Danish Society of Anesthesiology and Intensive Care Medicine (DASAIM) describes indications and contraindications, timing, complications...
Everingham, Kirsty; Fawcett, Tonks; Walsh, Tim
To discuss the findings from a phenomenological study that provides insights into the intensive care nurses' 'world' following changes in the sedation management of patients in an intensive care unit. Intensive care sedation practices have undergone significant changes. Patients, where possible, are now managed on lighter levels of sedation, often achieved through the performance of sedation holds (SHs). The performance of SHs is normally carried out by the bedside nurse but compliance is reported to be poor. There has been little exploration of the nurses' experiences of these changes and the implications of SHs and subsequent wakefulness on their delivery of care. Following ethical approval, 16 intensive care nurses, experienced and inexperienced, from within a general intensive care unit. A Heideggerian phenomenological approach was used. Data collection consisted of interviews guided by an aide memoir and a framework adapted from Van Manen informed the analysis. The findings reveal new insights into the world of the intensive care nurse in the light of the changes to sedation management. They demonstrate that there have been unforeseen outcomes from well-intentioned initiatives to improve the quality of patients' care. There were implications from the changes introduced for the nurses care delivery. The main themes that emerged were 'working priorities' and 'unintended consequences', in turn revealing embedded tensions between evidence-based targets and holistic care. Intensive care nurses find that the current approach to the changes in sedation management can threaten their professional obligation and personal desire to provide holistic care. The 'targeted' approach by healthcare organisations is perceived to militate against the patient-centred care they want to deliver. Sedation management is complex and needs further consideration particularly the potential constraints 'target-led' care has on nursing practice. © 2013 Blackwell Publishing Ltd.
Hyder, Joseph A; Haring, R Sterling; Sturgeon, Daniel; Gazarian, Priscilla K; Jiang, Wei; Cooper, Zara; Lipsitz, Stuart R; Prigerson, Holly G; Weissman, Joel S
End-of-life (EOL) care intensity is known to vary by secular and geographic patterns. US physicians receive less aggressive EOL care than the general population, presumably the result of preferences shaped by work-place experience with EOL care. We investigated occupation as a source of variation in EOL care intensity. Across 4 states, we identified 660 599, nonhealth maintenance organization Medicare beneficiaries aged ≥66 years who died between 2004 and 2011. Linking death certificates, we identified beneficiaries with prespecified occupations: nurses, farmers, clergy, mortuary workers, homemakers, first-responders, veterinary workers, teachers, accountants, and the general population. End-of-life care intensity over the last 6 months of life was assessed using 5 validated measures: (1) Medicare expenditures, rates of (2) hospice, (3) surgery, (4) intensive care, and (5) in-hospital death. Occupation was a source of large variation in EOL care intensity across all measures, before and after adjustment for sex, education, age-adjusted Charlson Comorbidity Index, race/ethnicity, and hospital referral region. For example, absolute and relative adjusted differences in expenditures were US$9991 and 42% of population mean expenditure ( P EOL care intensity measures, teachers (5 of 5), homemakers (4 of 5), farmers (4 of 5), and clergy (3 of 5) demonstrated significantly less aggressive care. Mortuary workers had lower EOL care intensity (4 of 5) but small numbers limited statistical significance. Occupations with likely exposure to child development, death/bereavement, and naturalistic influences demonstrated lower EOL care intensity. These findings may inform patients and clinicians navigating choices around individual EOL care preferences.
I.A. Meynaar (Iwan)
textabstractMany decisions are made during a day’s work in critical care. Should this octogenarian with pneumonia and cancer be admitted to the ICU or left on the ward with palliative care? And if admitted to the ICU, will she benefit from being ventilated or should she only be treated with
Wlody, Ginger Schafer
This article describes organizational ethics issues involved in nursing management of an intensive care unit. The intensive care team and medical center management have the dual responsibility to create an ethical environment in which to provide optimum patient care. Addressing organizational ethics is key to creating that ethical environment in the intensive care unit. During the past 15-20 yrs, increasing costs in health care, competitive markets, the effect of high technology, and global business changes have set the stage for business and healthcare organizational conflicts that affect the ethical environment. Studies show that critical care nurses experience moral distress and are affected by the ethical climate of both the intensive care unit and the larger organization. Thus, nursing moral distress may result in problems related to recruitment and retention of staff. Other issues with organizational ethics ramifications that may occur in the intensive care unit include patient safety issues (including those related to disruptive behavior), intensive care unit leadership style, research ethics, allocation of resources, triage, and other economic issues. Current organizational ethics conflicts are discussed, a professional practice model is described, and multidisciplinary recommendations are put forth.
Antimicrobial therapies in the Intensive Care Unit (ICU) need to be appropriate in both their antimicrobial cover and duration. We performed a prospective observational study of admissions to our semi-closed ICU over a three-month period and recorded the indications for antimicrobial therapy, agents used, duration of use, changes in therapy and reasons for changes in therapy. A change in therapy was defined as the initiation or discontinuation of an antimicrobial agent. There were 51 patients admitted during the three-month study period and all received antimicrobial therapy. There were 135 changes in antimicrobial therapy. 89 (66%) were made by the ICU team and 32 (24%) were made by the primary team. Changes were made due to a deterioration or lack of clinical response in 41 (30%) cases, due to the completion of prescribed course in 36 (27%) cases, and in response to a sensitivity result in 25 (19%) cases. Prophylactic antibiotic courses (n=24) were of a duration greater than 24 hours in 15 (63%) instances. In conclusion, the majority of changes in antimicrobial therapy were not culture-based and the duration of surgical prophylaxis was in excess of current recommended guidelines.
Dr. A.L. van Staa; O.K. Helder; J.C.M. Verweij
To explore parents' and nurses' experiences with the transition of infants from the neonatal intensive care unit to a special care nursery. Qualitative explorative study in two phases. Level IIID neonatal intensive care unit in a university hospital and special care nurseries (level II) in five
Minton, Claire; Batten, Lesley
With consideration of an environmental concept, this paper explores evidence related to the negative impacts of the intensive care unit environment on patient outcomes and explores the potential counteracting benefits of 'nature-based' nursing interventions as a way to improve care outcomes. The impact of the environment in which a patient is nursed has long been recognised as one determinant in patient outcomes. Whilst the contemporary intensive care unit environment contains many features that support the provision of the intensive therapies the patient requires, it can also be detrimental, especially for long-stay patients. This narrative review considers theoretical and evidence-based literature that supports the adoption of nature-based nursing interventions in intensive care units. Research and theoretical literature from a diverse range of disciplines including nursing, medicine, psychology, architecture and environmental science were considered in relation to patient outcomes and intensive care nursing practice. There are many nature-based interventions that intensive care unit nurses can implement into their nursing practice to counteract environmental stressors. These interventions can also improve the environment for patients' families and nurses. Intensive care unit nurses must actively consider and manage the environment in which nursing occurs to facilitate the best patient outcomes. © 2015 John Wiley & Sons Ltd.
the patient's best interests, when patient safety is compromised or when the medical team ... exacerbated in the acute-care environment and add to the potentially .... income and request to work in ICU, relying on the expertise of the.
Koterba, A M; Drummond, W H; Kosch, P
The basic concepts of diagnosis and treatment in the abnormal neonatal foal are presented. Methods of restraint, sedation, and general nursing care are discussed, as well as more specific techniques of respiratory and circulatory system support.
Puentes, Wilfredo; Jerath, Angela; Djaiani, George; Cabrerizo Sanchez, Rosa; Wąsowicz, Marcin
Benefits of tracheostomy have been well established. Most of the literature, refers these benefits to general intensive care population, excluding cardiac surgery or including only small number of these patients. On the other hand, there is no clear definition describing the proper time to perform the procedure and defining what are potential benefits of early compared to late tracheostomy. This retrospective cohort aims to assess the potential benefits of early tracheostomy on post-operative outcomes, length of stay and post-tracheostomy complications within cardiac surgical population. After obtaining REB approval, we conducted a retrospective chart review in a single, tertiary care institution, identifying patients who underwent tracheostomy after cardiac surgery from 1999 to 2006. Time-to-tracheostomy was defined as "early" if tracheostomy. 32 (22%) patients underwent early tracheostomy and 115 (78%) late tracheostomy. Incidence of atrial fibrillation (31.2% vs 61.7%; P = 0.003), kidney dysfunction (6.3% vs 27.2%; P=0.015) and kidney failure 18.8% vs 43.5%; P = 0.013) were lower in the early tracheostomy group. There were no differences on post tracheostomy infection or presence of acute respiratory distress syndrome. Both the ICU and hospital length of stay were significantly shorter in early tracheostomy group, 21.5 (ET) vs 36.9 (LT) days and 37.5 (ET) vs 57.6 (LT) days respectively. There were no differences in mortality between groups. There are significant benefits in reduction of postoperative morbidities with overall shorter ICU and hospital stay. These benefits may promote faster patient rehabilitation with reduced healthcare costs.
Carno, Margaret-Ann; Connolly, Heidi V
Sleep is an important and necessary function of the human body. Somatic growth and cellular repair occur during sleep. Critically ill children have disturbed sleep while in the pediatric intensive care unit related both to the illness itself and to light, noise, and caregiver activities disrupting an environment conducive to sleep. Medications administered in the pediatric intensive care unit can also disrupt sleep. This article reviews what is known about sleep in the pediatric intensive care unit and the effects of common sedation medications on sleep.
Scherillo, Marino; Miceli, Domenico; Tubaro, Marco; Guiducci, Umberto
The early invasive strategy for the treatment of acute coronary syndromes and the increasing number of older and sicker patients requiring prolonged and more complex intensive care have induced many changes in the function of the intensive care units. These changes include the statement that specially trained cardiologists and cardiac nurses who can manage patients with acute cardiac conditions should staff the intensive care units. This document indicates the structure of the units and specific recommendations for the number of beds, monitoring system, respirators, pacemaker/defibrillators and additional equipment.
Madsen, Kristian Rørbaek; Lorentzen, Kristian; Clausen, Niels
Stress ulcer prophylaxis (SUP) is commonly used in the intensive care unit (ICU), and is recommended in the Surviving Sepsis Campaign guidelines 2012. The present guideline from the Danish Society of Intensive Care Medicine and the Danish Society of Anesthesiology and Intensive Care Medicine sums...... critically ill patients in the ICU outside the context of randomized controlled trials (GRADE 1C). No robust evidence supports recommendations for subpopulations in the ICU such as septic, burn, trauma, cardiothoracic or enterally fed patients. However, if SUP is considered clinically indicated in individual...
Serviá Goixart, L; Badía, M; Campi, D; Trujillano, J; Alcega, R; Vilanova, J
Post-anesthesic parotiditis is a little known entity related with anesthesic procedures but described in any situation that motivates manipulation of the oropharyngeal cavity. Its physiopathological mechanism is not well-defined, although it could have a multifactorial origin. A case of a male who was admitted for post-operative control of brain tumor exeresis and who had preauricular and submaxillary inflammation after a routinely performed tracheostomy is presented. Coincidence with the performing of a tracheostomy required us to propose the differential diagnosis with the complications associated to said surgical act. Post-anesthesic parotiditis, even though it is a rare complication and has no clinical significance, should be kept in mind when there is facial edema after any manipulation of the oropharyngeal cavity.
Garrouste-Orgeas, Maité; Montuclard, Luc; Timsit, Jean-François; Reignier, Jean; Desmettre, Thibault; Karoubi, Philippe; Moreau, Delphine; Montesino, Laurent; Duguet, Alexandre; Boussat, Sandrine; Ede, Christophe; Monseau, Yannick; Paule, Thierry; Misset, Benoit; Carlet, Jean
To identify factors associated with granting or refusing intensive care unit (ICU) admission, to analyze ICU characteristics and triage decisions, and to describe mortality in admitted and refused patients. Observational, prospective, multiple-center study. Four university hospitals and seven primary-care hospitals in France. None. Age, underlying diseases (McCabe score and Knaus class), dependency, hospital mortality, and ICU characteristics were recorded. The crude ICU refusal rate was 23.8% (137/574), with variations from 7.1% to 63.1%. The reasons for refusal were too well to benefit (76/137, 55.4%), too sick to benefit (51/137, 37.2%), unit too busy (9/137, 6.5%), and refusal by the family (1/137). In logistic regression analyses, two patient-related factors were associated with ICU refusal: dependency (odds ratio [OR], 14.20; 95% confidence interval [CI], 5.27-38.25; p refused patients, and 1.03 (95% CI, 0.28-1.75) for later-admitted patients. ICU refusal rates varied greatly across ICUs and were dependent on both patient and organizational factors. Efforts to define ethically optimal ICU admission policies might lead to greater homogeneity in refusal rates, although case-mix variations would be expected to leave an irreducible amount of variation across ICUs.
Hariharan, Seetharaman; Dey, Prasanta Kumar
The purpose of this paper is to develop a comprehensive framework for improving intensive care unit performance. The study introduces a quality management framework by combining cause and effect diagram and logical framework. An intensive care unit was identified for the study on the basis of its performance. The reasons for not achieving the desired performance were identified using a cause and effect diagram with the stakeholder involvement. A logical framework was developed using information from the cause and effect diagram and a detailed project plan was developed. The improvement projects were implemented and evaluated. Stakeholders identified various intensive care unit issues. Managerial performance, organizational processes and insufficient staff were considered major issues. A logical framework was developed to plan an improvement project to resolve issues raised by clinicians and patients. Improved infrastructure, state-of-the-art equipment, well maintained facilities, IT-based communication, motivated doctors, nurses and support staff, improved patient care and improved drug availability were considered the main project outputs for improving performance. The proposed framework is currently being used as a continuous quality improvement tool, providing a planning, implementing, monitoring and evaluating framework for the quality improvement measures on a sustainable basis. The combined cause and effect diagram and logical framework analysis is a novel and effective approach to improving intensive care performance. Similar approaches could be adopted in any intensive care unit. The paper focuses on a uniform model that can be applied to most intensive care units.
Full Text Available The concept of ethics in the intensive care unit has developed in the last 50 years along with the advancements and regulations in this area of medicine. Especially by the use of life-supportive equipment in the intensive care units and the resulting elongation in the terminal stage of life has led to newly described clinical conditions. These conditions include vegetative state, brain death, dissociated heart death. The current trend aiming to provide the best health care facilities with optimal costs resulted with regulations. The conflicts in the patient-physician relations resulting from these regulations has resolved to some extent by the studies of intensive care unit ethics. The major ethical topics in the intensive care are the usage of autonomy right, the selection of patients to be admitted to the intensive care unit and the limitation of the treatment. The patient selection is optimized by triage and allocation, the limitation of the treatment is done by the means of withdrawal and withhold, and the usage of autonomy right is tried to be solved by proxy, living will and ethics committee regulations. The ethical regulations have found partial solutions to the conflicts. For the ultimate solution much work about the subject has to be done. (Journal of the Turkish Society of Intensive Care 2010; 8: 77-84
Richardson, Joanne; West, Michael A; Cuthbertson, Brian H
It has recently been argued that the future of intensive care medicine will rely on high quality management and teamwork. Therefore, this review takes an organizational psychology perspective to examine the most recent research on the relationship between teamwork, care processes, and patient outcomes in intensive care. Interdisciplinary communication within a team is crucial for the development of negotiated shared treatment goals and short-team patient outcomes. Interventions for maximizing team communication have received substantial interest in recent literature. Intensive care coordination is not a linear process, and intensive care teams often fail to discuss how to implement goals, trigger and align activities, or reflect on their performance. Despite a move toward interdisciplinary team working, clinical decision-making is still problematic and continues to be perceived as a top-down and authoritative process. The topic of team leadership in intensive care is underexplored and requires further research. Based on findings from the most recent research evidence in medicine and management, four principles are identified for improving the effectiveness of team working in intensive care: engender professional efficacy, create stable teams and leaders, develop trust and participative safety, and enable frequent team reflexivity.
The movement for quality in medicine is starting to take on the dimensions of a crusade. Quite logically it has also reached the intensive care community. Due to their complex multidisciplinary functioning and because of the high costs involved, ICUs are model services reflecting the overall situation in our hospitals. The situation of Swiss intensive care is particularly interesting, because for over 25 years standards for design and staffing of Swiss ICUs have been in effect and were enforced via onsite visits by the Swiss Society of Intensive Care without government involvement. Swiss intensive care thus defined its structures long before the word "accreditation" had even been used in this context. While intensive care in Switzerland is practised in clearly defined, well equipped and adequately staffed units, much less is known about process quality and outcomes of these services. Statistics on admissions, length of stay and length of mechanical ventilation, as well as severity data based on a simple classification system, are collected nationwide and allow some limited insight into the overall process of care. Results of intensive care are not systematically assessed. In response to the constant threat of cost containment, Swiss ICUs should increasingly focus on process quality and results, while maintaining their existing good structures.
Intensive care management of severe tetanus at the university of Benin teaching ... Journal Home > Vol 14, No 1 (2015) > ... Open Access DOWNLOAD FULL TEXT ... protocol in the centre, in line with evidence-based medical principles.
Aug 22, 2007 ... of neonatal intensive care facilities for public sector patients ... The main differences between the survivors and non-survivors were in their birth weight and ..... private hospital: comparison of individual physicians' rates, risk.
Beardsall, K; Ogilvy-Stuart, A; Ahluwalia, J; Thompson, M; Dunger, D
Objective: To determine the feasibility of continuous glucose monitoring in the very low birthweight baby requiring intensive care, as these infants are known to be at high risk of abnormalities of glucose control.
Guerra, Tatiana Lopes de Souza; Mendonça, Simone Sotero; Guimarães Marshall, Norma
Objectives To evaluate the incidence of constipation in critical patients on enteral nutrition in a hospital intensive care unit and to correlate this incidence with the variables found for critical patients. Methods The present investigation was a retrospective analytical study conducted in the intensive care unit of Hospital Regional da Asa Norte (DF) via the analysis of medical records of patients admitted during the period from January to December 2011. Data on the incidence of constipati...
Sakaguchi, Hideya; Yamashita, Satoshi; Hirano, Teruyuki; Nakajima, Makoto; Kimura, En; Maeda, Yasushi; Uchino, Makoto
The purpose of this report was to investigate predictive factors that necessitate intensive care in myasthenic crisis (MC). We retrospectively reviewed MC patients at our institution and compared ICU and ward management groups. Higher MG-ADL scale scores, non-ocular initial symptoms, infection-triggered findings, and higher MGFA classification were observed more frequently in the ICU group. In patients with these prognostic factors, better outcomes may be obtained with early institution of intensive care. Copyright © 2012 Wiley Periodicals, Inc.
Danbury, C M; Waldmann, C S
Intensive Care Medicine epitomises the difficulties inherent in modern medicine. In this chapter we examine some key medicolegal and ethical areas that are evolving. The principles of autonomy and consent are well established, but developments in UK caselaw have shown that the courts may be moving away from their traditional deference of the medical profession. We examine some recent cases and discuss the impact that these cases may have on practice in Intensive Care.
Full Text Available Background: Clinical risk management focuses on improving the quality and safety of health care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks. The goal of this study is to identify and assess the failure modes in the ICU of Qazvin′s Social Security Hospital (Razi Hospital through Failure Mode and Effect Analysis (FMEA. Methods: This was a qualitative-quantitative research by Focus Discussion Group (FDG performed in Qazvin Province, Iran during 2011. The study population included all individuals and owners who are familiar with the process in ICU. Sampling method was purposeful and the FDG group members were selected by the researcher. The research instrument was standard worksheet that has been used by several researchers. Data was analyzed by FMEA technique. Results: Forty eight clinical errors and failure modes identified, results showed that the highest risk probability number (RPN was in respiratory care "Ventilator′s alarm malfunction (no alarm" with the score 288, and the lowest was in gastrointestinal "not washing the NG-Tube" with the score 8. Conclusions: Many of the identified errors can be prevented by group members. Clinical risk assessment and management is the key to delivery of effective health care.
McMillan, Tracy R; Hyzy, Robert C
During the last several years, many governmental and nongovernmental organizations have championed the application of the principles of quality improvement to the practice of medicine, particularly in the area of critical care. To review the breadth of approaches to quality improvement in the intensive care unit, including measures such as mortality and length of stay, and the use of protocols, bundles, and the role of large, multiple-hospital collaboratives. Several agencies have participated in the application of the quality movement to medicine, culminating in the development of standards such as the intensive care unit core measures of the Joint Commission on Accreditation of Healthcare Organizations. Although "zero defects" may not be possible in all measurable variables of quality in the intensive care unit, several measures, such as catheter-related bloodstream infections, can be significantly reduced through the implementation of improved processes of care, such as care bundles. Large, multiple-center, quality improvement collaboratives, such as the Michigan Keystone Intensive Care Unit Project, may be particularly effective in improving the quality of care by creating a "bandwagon effect" within a geographic region. The quality revolution is having a significant effect in the critical care unit and is likely to be facilitated by the transition to the electronic medical record.
Cubrilo-Turek, Mirjana; Urek, Roman; Turek, Stjepan
The purpose of the study was to investigate the degree of burnout experienced by intensive care staff particularly, in Medical (MICU) and Surgical Intensive Care Units (SICU) General Hospital "Sveti Duh", Zagreb. A sample group of 41 emergency physicians and nurses from MICU and 30 from SICU was tested. The survey included demographic data and Maslach Burnout Inventory (MBI) scoring test identified by the three main components associated with burnout: emotional exhaustion (MBI-EE), depersonalization (MBI-DEP), and personal accomplishment (MBI-PA) were assessed using 22-item questionnaire. The degrees of burnout were stratified into low, moderate, and high range. Mean total MBI (X +/- SD) were high in both groups: higher for the MICU (65.5 +/- 6.7) than for SICU staff (55.7 +/- 3.8, p burnout represented in a moderate degree. The presence of burnout is a serious phenomenon, because it can lead to psychosomatic complaints, work-associated withdrawal behaviour, and a lower quality of care at intensive care units. Early recognition of burnout phenomenon as a result of prolonged stress and frustration among intensive care staff, contributes to better professional behavior, organizational structure changes in the work environment and better health care quality for critically ill patients.
Idenburg, Floris J; van Dongen, Thijs T C F; Tan, Edward C T H; Hamming, Jaap H; Leenen, Luke P H; Hoencamp, Rigo
From August 2006-August 2010, as part of the ISAF mission, the Armed Forces of the Netherlands deployed a role 2 enhanced Medical Treatment Facility (R2E-MTF) to Uruzgan province, Afghanistan. Although from the principle doctrine not considered a primary task, care was delivered to civilians, including many children. Humanitarian aid accounted for a substantial part of the workload, necessitating medical, infrastructural, and logistical adaptations. Particularly pediatric care demanded specific expertise and equipment. In our pre-deployment preparations this aspect had been undervalued. Because these experiences could be influential in future mission planning, we analyzed our data and compared them with international reports. This is a retrospective, descriptive study. Using the hospital's electronic database, all pediatric cases, defined as patients Afghanistan were analyzed. Of the 2736 admissions, 415 (15.2 %) were pediatric. The majority (80.9 %, 336/415) of these admissions were for surgical, often trauma-related, pathology and required 610 surgical procedures, being 26 % of all procedures. Mean length of stay was 3.1 days. The male to female ratio was 70:30. Girls were significantly younger of age than boys. In-hospital mortality was 5.3 %. Pediatric patients made up a considerable part of the workload at the Dutch R2E-MTF in Uruzgan, Afghanistan. This is in line with other reports from the recent conflicts in Iraq and Afghanistan, but used definitions in reported series are inconsistent, making comparisons difficult. Our findings stress the need for a comprehensive, prospective, and coalition-wide patient registry with uniformly applied criteria. Civilian disaster and military operational planners should incorporate reported patient statistics in manning documents, future courses, training manuals, logistic planning, and doctrines, because pediatric care is a reality that cannot be ignored.
Divatia, Jigeeshu V; Amin, Pravin R; Ramakrishnan, Nagarajan; Kapadia, Farhad N; Todi, Subhash; Sahu, Samir; Govil, Deepak; Chawla, Rajesh; Kulkarni, Atul P; Samavedam, Srinivas; Jani, Charu K; Rungta, Narendra; Samaddar, Devi Prasad; Mehta, Sujata; Venkataraman, Ramesh; Hegde, Ashit; Bande, B D; Dhanuka, Sanjay; Singh, Virendra; Tewari, Reshma; Zirpe, Kapil; Sathe, Prachee
To obtain information on organizational aspects, case mix and practices in Indian Intensive Care Units (ICUs). An observational, 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 ICUs. ICU and patient characteristics, and interventions were recorded for 24 h of the study day, and outcomes till 30 days after the study day. Data were analyzed for 4038 adult patients from 120 ICUs. On the study day, mean age, Acute Physiology and Chronic Health Evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 54.1 ± 17.1 years, 17.4 ± 9.2 and 3.8 ± 3.6, respectively. About 46.4% patients had ≥1 organ failure. Nearly, 37% and 22.2% patients received mechanical ventilation (MV) and vasopressors or inotropes, respectively. Nearly, 12.2% patients developed an infection in the ICU. About 28.3% patients had severe sepsis or septic shock (SvSpSS) during their ICU stay. About 60.7% patients without infection received antibiotics. There were 546 deaths and 183 terminal discharges (TDs) from ICU (including left against medical advice or discharged on request), with ICU mortality 729/4038 (18.1%). In 1627 patients admitted within 24 h of the study day, the standardized mortality ratio was 0.67. The APACHE II and SOFA scores, public hospital ICUs, medical ICUs, inadequately equipped ICUs, medical admission, self-paying patient, presence of SvSpSS, acute respiratory failure or cancer, need for a fluid bolus, and MV were independent predictors of mortality. The high proportion of TDs and the association of public hospitals, self-paying patients, and inadequately equipped hospitals with mortality has important implications for critical care in India.
Dias, Douglas de Sá; Resende, Mariane Vanessa; Diniz, Gisele do Carmo Leite Machado
Objective To evaluate and compare stressors identified by patients of a coronary intensive care unit with those perceived by patients of a general postoperative intensive care unit. Methods This cross-sectional and descriptive study was conducted in the coronary intensive care and general postoperative intensive care units of a private hospital. In total, 60 patients participated in the study, 30 in each intensive care unit. The stressor scale was used in the intensive care units to identify the stressors. The mean score of each item of the scale was calculated followed by the total stress score. The differences between groups were considered significant when p < 0.05. Results The mean ages of patients were 55.63 ± 13.58 years in the coronary intensive care unit and 53.60 ± 17.47 years in the general postoperative intensive care unit. For patients in the coronary intensive care unit, the main stressors were “being in pain”, “being unable to fulfill family roles” and “being bored”. For patients in the general postoperative intensive care unit, the main stressors were “being in pain”, “being unable to fulfill family roles” and “not being able to communicate”. The mean total stress scores were 104.20 ± 30.95 in the coronary intensive care unit and 116.66 ± 23.72 (p = 0.085) in the general postoperative intensive care unit. When each stressor was compared separately, significant differences were noted only between three items. “Having nurses constantly doing things around your bed” was more stressful to the patients in the general postoperative intensive care unit than to those in the coronary intensive care unit (p = 0.013). Conversely, “hearing unfamiliar sounds and noises” and “hearing people talk about you” were the most stressful items for the patients in the coronary intensive care unit (p = 0.046 and 0.005, respectively). Conclusion The perception of major stressors and the total stress score were similar between patients
Марина Александровна Макарова
Full Text Available In spite of success in treatment and diagnostics attained last years the problem of an acute pneumonia remains actual, this fact is caused by the growing rate of prolonged clinical course and unfavorable clinical outcomes. The growth of antibiotic resistance of microflora is a substantial problem. In addition even the most vigorous modern antibacterial preparations are not effective without an adequate surgical sanitation of the nidus of infection.The aim of the work is to improve the therapy of destructive pneumonia in children that need an intensive care.Methods. 12 patients 9 month – 12 years old who underwent the treatment of heavy community-acquired pneumonia were under observation. There was carried out an X-ray examination at admission and in dynamics, microbiological examination of lavages from the respiratory tract, pleural exudate and blood, determination of laboratory indexes of intoxication (by Kalf-Kalif, Dashtayants, Lubimova and the level of the middle molecules. The statistical analysis was done using the program package "Microsoft Excel" and "StatSoft 6".Results. In the course of microbiological examination it was demonstrated the prevalence of gram-negative flora and its associations with gram-positive one, the purely gram-positive flora was detected only in 25 % of children. So there was proved an inefficiency of antibiotics that effect mainly on the gram-positive microorganisms. In addition the cephalosporins of the third generation were found insufficiently effective. Such preparations as carbapenems or protected penicillins were chosen in vitro and according to its clinical efficiency. Plasmapheresis and bronchoscopy are useful in the complex therapy. Thoracoscopy must be carried out if the conservative treatment is not effectiveConclusions. At present the gram-negative flora and its associations with gram-positive one prevails in etiological structure of the heavy community-acquired pneumonias that must be taken into
Full Text Available Accurate diagnosis of Takotsubo Cardiomyopathy has substantial prognostic implications in an intensive care unit, given its increased mortality risk and association with life-threatening complications. This report seeks to discuss diagnostic modalities that can be useful in accurately differentiating Takotsubo Cardiomyopathy from Acute Coronary Syndrome, and also briefly discuss prevention and management of this cardiomyopathy in an intensive care unit. For critically ill Takotsubo patients, intensive clinicians can consider establishment of diagnosis by specific electrocardiograph changes, distinctive marked release of cardiac enzymes, characteristic echocardiograph findings, as well as invasive coronary angiography or noninvasive cardiac magnetic imaging.
Mondrup, Frederik; Skjelsager, Karen; Madsen, Kristian Rørbæk
When patients are transferred from intensive care units (ICUs) to general wards with a tracheostomy in situ, there is a risk of suboptimal care and increased morbidity. The aim of this study was to elucidate the management of patients with a tracheostomy in situ at discharge from the ICU...
Magnesium, calcium and phosphorus are important electrolytes involved in the regulation of homeostasis. However the utility in monitoring them in critically ill patients is still unclear. We therefore undertook a prospective, non-interventional, single center study in the intensive care unit of a tertiary care hospital in ...
de Keizer, N. F.; Abu-Hanna, A.; Cornet, R.
Evaluative research and the introduction of the Patient Data Management System to support care have increased the need for structured and standardized registration of diagnostic information in Dutch intensive cares (IC). To this end a terminological system to describe diagnoses is needed. A
Parents of infants who are admitted to the neonatal intensive care unit (NICU) need to be empowered to improve bonding, attachment and care-giving skills. Neonatal nurses play a critical role in the empowerment of such parents, but often find it difficult due to a lack of clarity on how it has to be done. A qualitative contextual ...
Improvement in the care and treatment of neonates had contributed to their increased survival. Nosocomial infection remains an important problem in intensive care units. Hospital wards had been shown to act as reservoirs of pathogenic microorganisms associated with infection. To assess the prevalence of pathogenic ...
In this study, eight mothers of pre-term infants under the care of nursing staff and neonatologists in the Neonatal Intensive Care Unit (NICU) of Children's Hospital in Vancouver, British Columbia, were observed and interviewed about their birth experience and their images of themselves as mothers during their stay. Patterns and themes in the…
Hales, Caz; de Vries, Kay; Coombs, Maureen
Critically ill morbidly obese patients pose considerable healthcare delivery and resource utilisation challenges in the intensive care setting. These are resultant from specific physiological responses to critical illness in this population and the nature of the interventional therapies used in the intensive care environment. An additional challenge arises for this population when considering the social stigma that is attached to being obese. Intensive care staff therefore not only attend to the physical and care needs of the critically ill morbidly obese patient but also navigate, both personally and professionally, the social terrain of stigma when providing care. To explore the culture and influences on doctors and nurses within the intensive care setting when caring for critically ill morbidly obese patients. A focused ethnographic approach was adopted to elicit the 'situated' experiences of caring for critically ill morbidly obese patients from the perspectives of intensive care staff. Participant observation of care practices and interviews with intensive care staff were undertaken over a four month period. Analysis was conducted using constant comparison technique to compare incidents applicable to each theme. An 18 bedded tertiary intensive care unit in New Zealand. Sixty-seven intensive care nurses and 13 intensive care doctors involved with the care and management of seven critically ill patients with a body mass index ≥40kg/m(2). Interactions between intensive care staff and morbidly obese patients were challenging due to the social stigma surrounding obesity. Social awkwardness and managing socially awkward moments were evident when caring for morbidly obese patients. Intensive care staff used strategies of face-work and mutual pretence to alleviate feelings of discomfort when engaged in aspects of care and caring. This was a strategy used to prevent embarrassment and distress for both the patients and staff. This study has brought new understandings
Andersen, J H; Boesen, Hans Christian Toft; Olsen, Karsten Skovgaard
Sleep deprivation has deleterious effects on most organ systems. Patients in the Intensive care unit (ICU) report sleep deprivation as the second worst experience during their stay only superseded by pain. The aim of the review is to provide the clinician with knowledge of the optimal sleep-frien......-friendly care and environment.......Sleep deprivation has deleterious effects on most organ systems. Patients in the Intensive care unit (ICU) report sleep deprivation as the second worst experience during their stay only superseded by pain. The aim of the review is to provide the clinician with knowledge of the optimal sleep...
The purpose of this paper is to define the role of environmental design in improving family integration with patient care in Intensive Care Units (ICUs). It argues that it is necessary to understand family needs, experience and behavioral responses in ICUs to develop effective models for family integration. With its two components—the “healing culture” promoting effective relationships between caregivers and care seekers, and the “environmental design” supporting the healing culture—a “healin...
After intensive care and before classic neurological rehabilitation is possible, patients in an altered state of consciousness are cared for at early stages in so-called coma awakening units. The care involves, on the one hand, the complex support of the patient's awakening from coma as a neurological and existential process, and on the other, support for their families. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Serrano-Gemes, G; Rich-Ruiz, M
To measure the intensity of interprofessional collaboration (IPC) in nurses of an intensive care unit (ICU) at a tertiary hospital, to check differences between the dimensions of the Intensity of Interprofessional Collaboration Questionnaire, and to identify the influence of personal variables. A cross-sectional descriptive study was conducted with 63 intensive care nurses selected by simple random sampling. Explanatory variables: age, sex, years of experience in nursing, years of experience in critical care, workday type and work shift type; variable of outcome: IPC. The IPC was measured by: Intensity of Interprofessional Collaboration Questionnaire. Descriptive and bivariate statistical analysis (IPC and its dimensions with explanatory variables). 73.8% were women, with a mean age of 46.54 (±6.076) years. The average years experience in nursing and critical care was 23.03 (±6.24) and 14.25 (±8.532), respectively. 77% had a full time and 95.1% had a rotating shift. 62.3% obtained average IPC values. Statistically significant differences were found (P<.05) between IPC (overall score) and overall assessment with years of experience in critical care. This study shows average levels of IPC; the nurses with less experience in critical care obtained higher IPC and overall assessment scores. Copyright © 2016 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.
Kubatbek S. Urmanbetov
Full Text Available Objective: A study of accessibility of surgical care to elderly patients (aged 60 and above with valvular heart disease has been conducted at the BSCCS "Bakulev Scientific Center of Cardiovascular Surgery» of the Ministry of Health of the Russian Federation. Methods: A retrospective analysis of structure of hospitalizations of 1726 patients, that were hospitalized between 2009 and 2010 at the BSCCS for surgical correction of valvular heart disease was performed. Results: Our study demonstrated that age, on one hand, is not the most significant barrier in the geographical accessibility of cardiac surgical care. On the other hand, it can influence the availability in general, taking into account other factors (urban / rural areas, the presence of cardiac surgical clinics, and clinical status. Provision of cardiac surgical care for patients with heart defects at the BSCCS per 1 million population varies considerably in the context of federal districts and is 0.4 for the Siberian Federal District 30 for the Central Federal District (the highest is 42 for the Moscow Region. Conclusion: Thus, our study demonstrated accessibility of surgical care for elderly patients is the highest for the urban areas with specialized cardiac surgery centers, where patients referred from rural regions
Kleinpell, Ruth; Barden, Connie; Rincon, Teresa; McCarthy, Mary; Zapatochny Rufo, Rebecca J
Information on the impact of tele-intensive care on nursing and priority areas of nursing care is limited. To conduct a national benchmarking survey of nurses working in intensive care telemedicine facilities in the United States. In a 2-phased study, an online survey was used to assess nurses' perceptions of intensive care telemedicine, and a modified 2-round Delphi study was used to identify priority areas of nursing. In phase 1, most of the 1213 respondents agreed to strongly agreed that using tele-intensive care enables them to accomplish tasks more quickly (63%), improves collaboration (65.9%), improves job performance (63.6%) and communication (60.4%), is useful in nursing assessments (60%), and improves care by providing more time for patient care (45.6%). Benefits of tele-intensive care included ability to detect trends in vital signs, detect unstable physiological status, provide medical management, and enhance patient safety. Barriers included technical problems (audio and video), interruptions in care, perceptions of telemedicine as an interference, and attitudes of staff. In phase 2, 60 nurses ranked 15 priority areas of care, including critical thinking skills, intensive care experience, skillful communication, mutual respect, and management of emergency patient care. The findings can be used to further inform the development of competencies for tele-intensive care nursing, match the tele-intensive care nursing practice guidelines of the American Association of Critical-Care Nurses, and highlight concepts related to the association's standards for establishing and sustaining healthy work environments. ©2016 American Association of Critical-Care Nurses.
Nilsson, Krister; Ekström-Jodal, Barbro; Meretoja, Olli; Valentin, Niels; Wagner, Kari
The initiation and development of pediatric anesthesia and intensive care have much in common in the Scandinavian countries. The five countries had to initiate close relations and cooperation in all medical disciplines. The pediatric anesthesia subspecialty took its first steps after the Second World War. Relations for training and exchange of experiences between Scandinavian countries with centers in Europe and the USA were a prerequisite for development. Specialized pediatric practice was not a full-time position until during the 1950s, when the first pediatric anesthesia positions were created. Scandinavian anesthesia developed slowly. In contrast, Scandinavia pioneered both adult and certainly pediatric intensive care. The pioneers were heavily involved in the teaching and training of anesthetists and nurses. This was necessary to manage the rapidly increasing work. The polio epidemics during the 1950s initiated a combination of clinical development and technical innovations. Blood gas analyses technology and interpretation in combination with improved positive pressure ventilators were developed in Scandinavia contributing to general and pediatric anesthesia and intensive care practice. Scandinavian specialist training and accreditation includes both anesthesia and intensive care. Although pediatric anesthesia/intensive care is not a separate specialty, an 'informal accreditation' for a specialist position is obtained after training. The pleasure of working in a relatively small group of devoted colleagues and staff has persisted from the pioneering years. It is still one of the most inspiring and pleasant gifts for those working in this demanding specialty. © 2014 John Wiley & Sons Ltd.
Korhan, Esra Akin; Hakverdioglu, Gulendam; Ozlem, Maryem; Ozlem, Maryem; Yurekli, Ismail; Gurbuz, Ali; Alp, Nilgun Akalin
To determine hospitalization durations and mortalities of elderly in the Cardiovascular Surgery Intensive Care Unit. The retrospective study was conducted in a Cardiovascular Surgery Intensive Care Unit in Turkey and comprised patient records from January 1 to December 31, 2011. Computerized epicrisis reports of 255, who had undergone a cardiac surgery were collected. The patients were grouped according to their ages, Group I aged 65-74 and Group II aged 75 and older. European society for Cardiac Operative Risk Evaluation scores of the two groups were compared using SPSS 17. Overall, there were 80 (31.37%) females and 175 (68.62%) males. There were 138 (54.1%) patients in Group I and 117 (45.9%) in Group II. Regarding their hospitalization reasons, it was determined that 70 (27.5%) patients in Group I and 79 (30.9%) patients in Group II were treated with the diagnosis ofcoronary artery disease. The average hospitalization duration of patients in the intensive care unit was determined to be 11.57 +/- 0.40 days. Regarding the EuroSCORE score intervals of patients, 132 (51.8%) had 3-5 and 225 (88.2%) patients were transferred to the Cardiovascular Surgery and then all of them were discharged; 5 (4.1%) had a mortal course; and 11 (7.7%) were transferred to the anaesthesia intensive care unit. The general mortality rates are very low in the Cardiovascular Surgery Intensive Care Unit and the patients have a good prognosis.
Arora, C; Savulescu, J; Maslen, H; Selgelid, M; Wilkinson, D
Resuscitation and treatment of critically ill newborn infants is associated with relatively high mortality, morbidity and cost. Guidelines relating to resuscitation have traditionally focused on the best interests of infants. There are, however, limited resources available in the neonatal intensive care unit (NICU), meaning that difficult decisions sometimes need to be made. This study explores the intuitions of lay people (non-health professionals) regarding resource allocation decisions in the NICU. The study design was a cross-sectional quantitative survey, consisting of 20 hypothetical rationing scenarios. There were 119 respondents who entered the questionnaire, and 109 who completed it. The respondents were adult US and Indian participants of the online crowdsourcing platform Mechanical Turk. Respondents were asked to decide which of two infants to treat in a situation of scarce resources. Demographic characteristics, personality traits and political views were recorded. Respondents were also asked to respond to a widely cited thought experiment involving rationing. The majority of respondents, in all except one scenario, chose the utilitarian option of directing treatment to the infant with the higher chance of survival, higher life expectancy, less severe disability, and less expensive treatment. As discrepancy between outcomes decreased, however, there was a statistically significant increase in egalitarian responses and decrease in utilitarian responses in scenarios involving chance of survival (P = 0.001), life expectancy (P = 0.0001), and cost of treatment (P = 0.01). In the classic 'lifeboat' scenario, all but two respondents were utilitarian. This survey suggests that in situations of scarcity and equal clinical need, non-health professionals support rationing of life-saving treatment based on probability of survival, duration of survival, cost of treatment or quality of life. However, where the difference in prognosis or cost is very
Li-Ying, Jason; Paunova, Minna; Egerod, Ingrid
Aims This study investigates the influence of intensive care unit nurses’ knowledge sharing behaviour on nurse innovation, given different conditions of care quality control. Background Health-care organisations face an increasing pressure to innovate while controlling care quality. We have littl...
Lee, Eugenia E; Stewart, Barclay; Zha, Yuanting A; Groen, Thomas A; Burkle, Frederick M; Kushner, Adam L
Climate extremes will increase the frequency and severity of natural disasters worldwide. Climate-related natural disasters were anticipated to affect 375 million people in 2015, more than 50% greater than the yearly average in the previous decade. To inform surgical assistance preparedness, we estimated the number of surgical procedures needed. The numbers of people affected by climate-related disasters from 2004 to 2014 were obtained from the Centre for Research of the Epidemiology of Disasters database. Using 5,000 procedures per 100,000 persons as the minimum, baseline estimates were calculated. A linear regression of the number of surgical procedures performed annually and the estimated number of surgical procedures required for climate-related natural disasters was performed. Approximately 140 million people were affected by climate-related natural disasters annually requiring 7.0 million surgical procedures. The greatest need for surgical care was in the People's Republic of China, India, and the Philippines. Linear regression demonstrated a poor relationship between national surgical capacity and estimated need for surgical care resulting from natural disaster, but countries with the least surgical capacity will have the greatest need for surgical care for persons affected by climate-related natural disasters. As climate extremes increase the frequency and severity of natural disasters, millions will need surgical care beyond baseline needs. Countries with insufficient surgical capacity will have the most need for surgical care for persons affected by climate-related natural disasters. Estimates of surgical are particularly important for countries least equipped to meet surgical care demands given critical human and physical resource deficiencies.
Hanson, C W; Marshall, B E
To review the history and current applications of artificial intelligence in the intensive care unit. The MEDLINE database, bibliographies of selected articles, and current texts on the subject. The studies that were selected for review used artificial intelligence tools for a variety of intensive care applications, including direct patient care and retrospective database analysis. All literature relevant to the topic was reviewed. Although some of the earliest artificial intelligence (AI) applications were medically oriented, AI has not been widely accepted in medicine. Despite this, patient demographic, clinical, and billing data are increasingly available in an electronic format and therefore susceptible to analysis by intelligent software. Individual AI tools are specifically suited to different tasks, such as waveform analysis or device control. The intensive care environment is particularly suited to the implementation of AI tools because of the wealth of available data and the inherent opportunities for increased efficiency in inpatient care. A variety of new AI tools have become available in recent years that can function as intelligent assistants to clinicians, constantly monitoring electronic data streams for important trends, or adjusting the settings of bedside devices. The integration of these tools into the intensive care unit can be expected to reduce costs and improve patient outcomes.
Sirovich, Brenda E; Gottlieb, Daniel J; Welch, H Gilbert; Fisher, Elliott S
Research has documented dramatic differences in health care utilization and spending across U.S. regions with similar levels of patient illness. Although patient outcomes and quality of care have been found to be no better in regions of high health care intensity, it is unknown whether physicians in these regions feel more capable of providing good patient care than those in low-intensity regions. To determine whether physicians in high-intensity regions feel better able to care for patients than physicians in low-intensity regions. Physician telephone survey. 51 metropolitan and 9 nonmetropolitan areas of the United States and a supplemental national sample. 10,577 physicians who provided care to adults in 1998 or 1999 were surveyed for the Community Tracking Study (response rate, 61%). The End-of-Life Expenditure Index, a measure of spending that reflects differences in the overall quantity of medical services provided rather than differences in illness or price, was used to determine health care intensity in the physicians' community. Outcomes included physicians' perceived availability of clinical services, ability to provide high-quality care to patients, and career satisfaction. Although the highest-intensity regions have substantially more hospital beds and specialists per capita, physicians in these regions reported more difficulty obtaining needed services for their patients. The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50% in high-intensity regions to 64% in the lowest-intensity region (P market factors (for example, managed care penetration); the difference in perceived ability to provide high-quality care was no longer statistically significant (P = 0.099). The cross-sectional design prevented demonstration of a causal relationship between intensity and physician perceptions of quality. Despite more resources, physicians in regions of high health care intensity did not report greater ease in obtaining
It is vital that children's nursing students are fit for practice when they qualify and are able to meet various essential skills as defined by the Nursing and Midwifery Council (NMC). To gain the knowledge and skills required, students need placements in areas where high dependency and potentially intensive care are delivered. Efforts to maximise the number of students experiencing intensive care as a placement have led to the development of the paediatric intensive care unit (PICU) rotation, increasing placements on the PICU from 5 to 40 per cent of the student cohort per year. The lecturer practitioner organises the rotation, providing credible links between university and practice areas, while supporting students and staff in offering a high-quality placement experience. Students say the rotation offers a positive insight into PICU nursing, helping them develop knowledge and skills in a technical area and creating an interest in this specialty.
Full Text Available Intensive care is a critical area of medicine having a multidisciplinary nature requiring all types of healthcare professionals. Given the critical environment of intensive care units (ICUs, the need to use information technologies, like decision support systems, to improve healthcare services and ICU management is evident. It is proven that unplanned and prolonged admission to the ICU is not only prejudicial to a patient's health, but also such a situation implies a readjustment of ICU resources, including beds, doctors, nurses, financial resources, among others. By discovering the common characteristics of the admitted patients, it is possible to improve these outcomes. In this study clustering techniques were applied to data collected from admitted patients in an intensive care unit. The best results presented a silhouette of 1, with a distance to centroids of 6.2 × 10−17 and a Davies–Bouldin index of −0.652.
Krag, Morten Brøgger; Perner, A; Wetterslev, J
Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta-analyses have questioned the rationale and level of evidence for this recommendation. The aim of the present systematic review was to evaluate...... incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care...... patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive...
Ilusca Cardoso de Paula
Full Text Available Background and objectives: anemia is a common clinical finding in intensive care units. The red blood cell transfusion is the main form of treatment, despite the associated risks. Thus, we proposed to evaluate the profile of transfusional patients in different intensive care units. Methods: prospective analysis of patients admitted in the intensive care units of a tertiary university hospital with an indication for transfusion of packed red blood cells. Demographic profile and transfusional profile were collected, a univariate analysis was done, and the results were considered significant at p = 0.05. Results: 408 transfusions were analyzed in 71 patients. The mean hemoglobin concentration on admission was 9.7 ± 2.3 g/dL and the pre-transfusional concentration was 6.9 ± 1.1 g/dL. The main indications for transfusion were hemoglobin concentration (49% and active bleeding (32%. The median number of units transfused per episode was 2 (1-2 and the median storage time was 14 (7-21 days. The number of patients transfused with hemoglobin levels greater than 7 g/dL and the number of bags transfused per episode were significantly different among intensive care units. Patients who received three or more transfusions had longer mechanical ventilation time and intensive care unit stay and higher mortality after 60 days. There was an association of mortality with disease severity but not with transfusional characteristics. Conclusions: the practice of blood products transfusion was partially in agreement with the guidelines recommended, although there are differences in behavior between the different profiles of intensive care units. Transfused patients evolved with unfavorable outcomes. Despite the scarcity of blood in blood banks, the mean storage time of the bags was high.
Fan, Emily P; Abbott, Sabra M; Reid, Kathryn J; Zee, Phyllis C; Maas, Matthew B
We sought to characterize ambient light exposure in the intensive care unit (ICU) environment to identify patterns of light exposure relevant to circadian regulation. A light monitor was affixed to subjects' bed at eye level in a modern intensive care unit and continuously recorded illuminescence for at least 24h per subject. Blood was sampled hourly and measured for plasma melatonin. Subjects underwent hourly vital sign and bedside neurologic assessments. Care protocols and the ICU environment were not modified for the study. A total of 67,324 30-second epochs of light data were collected from 17 subjects. Light intensity peaked in the late morning, median 64.1 (interquartile range 19.7-138.7) lux. The 75th percentile of light intensity exceeded 100lx only between 9AM and noon, and never exceeded 150lx. There was no correlation between melatonin amplitude and daytime, nighttime or total light exposure (Spearman's correlation coefficients all 0.5). Patients' environmental light exposure in the intensive care unit is consistently low and follows a diurnal pattern. No effect of nighttime light exposure was observed on melatonin secretion. Inadequate daytime light exposure in the ICU may contribute to abnormal circadian rhythms. Copyright © 2017 Elsevier Inc. All rights reserved.
Plantinga, Nienke L; Wittekamp, Bastiaan H J; van Duijn, Pleun J; Bonten, Marc J M
Antibiotic resistance is a global and increasing problem that is not counterbalanced by the development of new therapeutic agents. The prevalence of antibiotic resistance is especially high in intensive care units with frequently reported outbreaks of multidrug-resistant organisms. In addition to classical infection prevention protocols and surveillance programs, counterintuitive interventions, such as selective decontamination with antibiotics and antibiotic rotation have been applied and investigated to control the emergence of antibiotic resistance. This review provides an overview of selective oropharyngeal and digestive tract decontamination, decolonization of methicillin-resistant Staphylococcus aureus and antibiotic rotation as strategies to modulate antibiotic resistance in the intensive care unit.
Cook, Deborah; Swinton, Marilyn; Toledo, Feli; Clarke, France; Rose, Trudy; Hand-Breckenridge, Tracey; Boyle, Anne; Woods, Anne; Zytaruk, Nicole; Heels-Ansdell, Diane; Sheppard, Robert
Dying in the complex, efficiency-driven environment of the intensive care unit can be dehumanizing for the patient and have profound, long-lasting consequences for all persons attendant to that death. To bring peace to the final days of a patient's life and to ease the grieving process. Mixed-methods study. 21-bed medical-surgical intensive care unit. Dying patients and their families and clinicians. To honor each patient, a set of wishes was generated by patients, family members, or clinicians. The wishes were implemented before or after death by patients, families, clinicians (6 of whom were project team members), or the project team. Quantitative data included demographic characteristics, processes of care, and scores on the Quality of End-of-Life Care-10 instrument. Semistructured interviews of family members and clinicians were transcribed verbatim, and qualitative description was used to analyze them. Participants included 40 decedents, at least 1 family member per patient, and 3 clinicians per patient. The 159 wishes were implemented and classified into 5 categories: humanizing the environment, tributes, family reconnections, observances, and "paying it forward." Scores on the Quality of End-of-Life Care-10 instrument were high. The central theme from 160 interviews of 170 persons was how the 3 Wishes Project personalized the dying process. For patients, eliciting and customizing the wishes honored them by celebrating their lives and dignifying their deaths. For families, it created positive memories and individualized end-of-life care for their loved ones. For clinicians, it promoted interprofessional care and humanism in practice. Impaired consciousness limited understanding of patients' viewpoints. The 3 Wishes Project facilitated personalization of the dying process through explicit integration of palliative and spiritual care into critical care practice. Hamilton Academy of Health Science Research Organization, Canadian Intensive Care Foundation.
Full Text Available Introduction. The TISS-28 scale, which may be used for nursing staff scheduling in ICU, does not reflect the complete scope of nursing resulting from varied cultural and organizational conditions of individual systems of health care. Aim. The objective of the study was an attempt to provide an answer to the question what scope of nursing care provided by Polish nurses in ICU does the TISS-28 scale reflect? Material and Methods. The methods of working time measurement were used in the study. For the needs of the study, 252 hours of continuous observation (day-long observation and 3.697 time-schedule measurements were carried out. Results. The total nursing time was 4125.79 min. (68.76 hours, that is, 60.15% of the total working time of Polish nurses during the period analyzed. Based on the median test, the difference was observed on the level of χ2=16945.8, P<0.001 between the nurses’ workload resulting from performance of activities qualified into the TISS-28 scale and load resulting from performance of interventions within the scopes of care not considered in this scale in Polish ICUs. Conclusions. The original version of the TISS-28 scale does not fully reflect the workload among Polish nurses employed in ICUs.
Vinicia de Holanda Cabral
Full Text Available To identify the main nursing diagnostic titles used in the care of critically ill patients hospitalized in an Intensive Care Unit, verifying the presence thereof in the diagnoses of NANDA International’s Taxonomy II. Methods: descriptive and documental study, in which 69 medical records of patients aged over 18 years were consulted. Results: 22 nursing diagnostic titles were found; the most frequent was risk for infection (99.0%, risk for skin integrity (75.0% and risk for aspiration (61.0%. Most diagnoses were in the domains safety/ protection (43.0% and activity/rest (26.5%. Conclusions: authors identified the main nursing diagnostic titles used in the care of critically ill patients admitted to the Intensive Care Unit and the presence thereof in the diagnoses of NANDA International’s Taxonomy II.
LeBlanc, Allana; Bourbonnais, Frances Fothergill; Harrison, Denise; Tousignant, Kelly
The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) To examine intensive care nurses' experiences of caring for adult patients with delirium; 2) To identify factors that facilitate or hinder intensive care nurses caring for these patients. This study utilised an interpretive phenomenological approach as described by van Manen. Individual conversational interviews were conducted with eight intensive care nurses working in a tertiary level, university-affiliated hospital in Canada. The essence of the experience of nurses caring for patients with delirium in intensive care was revealed to be finding a way to help them come through it. Six main themes emerged: It's Exhausting; Making a Picture of the Patient's Mental Status; Keeping Patients Safe: It's aReally Big Job; Everyone Is Unique; Riding It Out With Families and Taking Every Experience With You. The findings contribute to an understanding of how intensive care nurses help patients and their families through this complex and distressing experience. Copyright © 2017 Elsevier Ltd. All rights reserved.
Scheffold, N; Paoli, A; Gross, J; Riemann, U; Hennersdorf, M
Ethical problems, such as medical end-of-life decisions or withdrawing life-sustaining treatment are viewed as an essential task in intensive care units. This article presents the ethics rounds as an instrument for evaluation of ethical problems in intensive care medicine units. The benchmarks of ethical reflection during the ethics rounds are considerations of ethical theory of principle-oriented medical ethics. Besides organizational aspects and the institutional framework, the role of the ethicist is described. The essential evaluation steps, as a basis of the ethics rounds are presented. In contrast to the clinical ethics consultation, the ethicist in the ethics rounds model is integrated as a member of the ward round team. Therefore ethical problems may be identified and analyzed very early before the conflict escalates. This preventive strategy makes the ethics rounds a helpful instrument in intensive care units.
Background. Little is known about parental experience and decision making with regard to premature infants requiring intensive care in developing countries. We undertook this study to characterise parents' experience of physician counselling and their role in making life-support decisions for very low-birth-weight (VLBW) ...
Veelo, Denise P.; Schultz, Marcus J.; Phoa, Kai Y. N.; Dongelmans, Dave A.; Binnekade, Jan M.; Spronk, Peter E.
OBJECTIVE: To determine tracheostomy-management practices in Dutch intensive care units (ICUs) and post-ICU step-down facilities. METHODS: We surveyed the physician medical directors of all Dutch nonpediatric ICUs that have : 5 beds suitable for mechanical ventilation. The survey asked for
Le Blanc, Pascale M.; Schaufeli, Wilmar B.; Salanova, Marisa; Llorens, Susana; Nap, Raoul E.
P>Aim. This paper is a report of an investigation of whether intensive care nurses' efficacy beliefs predict future collaborative practice, and to test the potential mediating role of team commitment in this relationship. Background. Recent empirical studies in the field of work and organizational
Life-threatening attacks of asthma requiring intensive care unit (ICU) management at Red Cross War Memorial Children's Hospital in Cape Town were noted to occur in some patients in the same or adjacent months of different years. A retrospective case-controlled study was performed of 21 such 'seasonal' patients who ...
Samiee-Zafarghandy, Samira; Raman, Sudha R; van den Anker, John N; McHutchison, Kerstin; Hornik, Christoph P; Clark, Reese H; Brian Smith, P
Milrinone use in the neonatal intensive care unit has increased over the last 10 years despite a paucity of published safety data in infants. We sought to determine the safety of milrinone therapy among infants in the neonatal intensive care unit. We conducted a retrospective data analysis, identifying all infants who were exposed to milrinone and discharged from 322 neonatal intensive care units managed by the Pediatrix Medical Group from 1997-2010. We identified adverse events (AEs) during milrinone exposure. The unit of observation for clinical AEs was the first course of milrinone and for laboratory AEs it was an infant-day of exposure to milrinone. Overall, 1446 of 716,821 (0.2%) infants received milrinone for a total of 6894 infant-days. The proportion of infants exposed to milrinone increased from 0 in 1997 to 4/1000 infant cases in 2010. Persistent pulmonary hypertension (40%) was the most commonly reported diagnosis at the start of milrinone administration. Overall, 606/1446 (42%) of infants had at least 1 clinical AE recorded during milrinone therapy. Hypotension requiring pressors and thrombocytopenia (milrinone therapy. Among infants hospitalized in the neonatal intensive care unit, there was an increase in the use of milrinone over the past 13 years. The safety, dosing, and efficacy of milrinone in infants should be determined in prospective clinical trials. Copyright © 2014 Elsevier Ltd. All rights reserved.
It is, however, potentially preventable. Objective. To determine the incidence of hypoxaemia on arrival in a tertiary multidisciplinary intensive care unit (ICU) and to identify risk factors for this complication. Method. A retrospective observational study was conducted at King Edward VIII Hospital, Durban, South Africa, from May ...
In paediatric intensive care, children develop pressure sores as a result of various mechanical and clinical factors. The prevention and assessment of the risk of pressure sores constitute a key concern for the nursing teams which establish prevention strategies adapted to the young patients.
Rogowski, JA; Horbar, JD; Plsek, PE; Baker, LS; Deterding, J; Edwards, WH; Hocker, J; Kantak, AD; Lewallen, P; Lewis, W; Lewit, E; McCarroll, CJ; Mujsce, D; Payne, NR; Shiono, P; Soll, RF; Leahy, K
Objective. To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. Design. Interventional study. Data on treatment costs were collected for infants with birth weight 501 to 1500 g for the period of January
Reis Miranda, D; Citerio, G; Perner, A
BACKGROUND: Several studies have shown that the use of selective digestive tract decontamination (SDD) reduces mortality. However, fear for increasing multi drug resistance might prevent wide acceptance. A survey was performed among the units registered in the European Registry for Intensive Care...
Sparr, H.J; Wierda, J.MKH; Proost, Johannes H.; Keller, C; Khuenl-Brady, K.S
We have studied dose requirements, recovery times and pharmacokinetics of rocuronium in 32 intensive care patients. After an initial dose of 50 mg, rocuronium was administered as maintenance doses of 25 mg whenever two responses to train-of-four (TOF) stimulation reappeared (bolus group; n=27) or by
Mook, W.N. van; Grave, W.S. De; Gorter, S.L.; Zwaveling, J.H.; Schuwirth, L.W.; Vleuten, C.P.M. van der
The Competency-Based Training program in Intensive Care Medicine in Europe identified 12 competency domains. Professionalism was given a prominence equal to technical ability. However, little information pertaining to fellows' views on professionalism is available. A nationwide qualitative study was
Objectives. Automated, microprocessor-controlled, closed-loop mechanical ventilation has been used in our Medical Intensive Care Unit (MICU) at the Hadassah Hebrew-University Medical Center for the past 15 years; for 10 years it has been the primary (preferred) ventilator modality. Design and setting. We describe our ...
van den Hoogen, A.
Neonatal infections are an important cause of morbidity in neonatal intensive care units (NICUs). Prematurity or very low birth weight is an important predisposing factor for neonatal infection. In addition, preterm infants have a compromized immune system and they often require invasive procedures
Çelik, Sevim; Taşdemir, Nurten; Kurt, Aylin; İlgezdi, Ebru; Kubalas, Özge
Fatigue negatively affects the performance of intensive care nurses. Factors contributing to the fatigue experienced by nurses include lifestyle, psychological status, work organization and sleep problems. To determine the level of fatigue among nurses working in intensive care units and the related factors. This descriptive study was conducted with 102 nurses working in intensive care units in the West Black Sea Region of Turkey. Data were collected between February and May 2014 using a personal information form, the Visual Analogue Scale for Fatigue (VAS-F), the Hospital Anxiety and Depression Scale and the Pittsburg Sleep Quality Index. The intensive care nurses in the study were found to be experiencing fatigue. Significant correlations were observed between scores on the VAS-F Fatigue and anxiety (p=0.01), depression (p=0.002), and sleep quality (pnurses' levels of fatigue. These results can be of benefit in taking measures which may be used to reduce fatigue in nurses, especially the fatigue related to work organization and social life.
Delirium poses a significant burden on our healthcare, with patients in the intensive care unit (ICU) at an increased risk for developing this disorder. In addition, the ICU environment poses unique challenges in the assessment of delirium. It is paramount that the healthcare provider has an understanding of delirium in ICU, ...
van de Leur, JP; van der Schans, CP; Loef, BG; Deelman, BG; Geertzen, JHB; Zwaveling, JH
Introduction A stay in the intensive care unit (ICU), although potentially life-saving, may cause considerable discomfort to patients. However, retrospective assessment of discomfort is difficult because recollection of stressful events may be impaired by sedation and severe illness during the ICU
In this thesis, the occurrence of stress-related psychopathology after cardiac surgery and intensive care treatment is assessed. We primarily focused on post-traumatic stress disorder (PTSD) and depression symptomatology, but the effects of benzodiazepine administration, delirium, anxiety, and
Plantinga, Nienke L.; Wittekamp, Bastiaan H J; Van Duijn, Pleun J.; Bonten, Marc J M
Antibiotic resistance is a global and increasing problem that is not counterbalanced by the development of new therapeutic agents. The prevalence of antibiotic resistance is especially high in intensive care units with frequently reported outbreaks of multidrug-resistant organisms. In addition to
Background: Organophosphate (OP) compounds are used as insecticides. Given the widespread availability and use of these chemicals, OP poisoning is quite common following either accidental or intentional exposures. Immediate intensive care management can save lives in these patients. We aimed to investigate ...
Mulkey, Sarah B.; Swearingen, Christopher J.
Neonatal neurology is a growing sub-specialty area. Given the considerable amount of neurologic problems present in the neonatal intensive care unit, a neurologist with expertise in neonates is becoming more important. We sought to evaluate the change in neurologic care in the neonatal intensive care unit at our tertiary care hospital by having a dedicated neonatal neurologist. The period post-neonatal neurologist showed a greater number of neurology consultations (Pneurology encounters per patient (Pneurology became part of the multi-disciplinary team providing focused neurologic care to newborns. PMID:23271754
Fischer, M; Wohlrab, J; Radke, J; Marsch, W C; Soukup, J
Herpes simplex infections are potentially a life-threatening situation for immunocompromised as well as critically ill patients. The correct diagnosis is made more difficult in comatose patients by the fact that the characteristic symptom of extreme pain cannot be registered. The clinical dermatological findings (polycyclic configuration, easily bleeding ulcers) are thus especially important in patients under intensive care conditions. As examples, the cases of 3 critically ill patients (subarachnoid bleeding or head injury) developing therapy-resistant, flat sacral or perioral skin ulcers with peripheral blisters are presented. Herpes simplex virus was confirmed immunohistologically and in the smear test. All patients subsequently died. These cases emphasize that patients in the intensive care unit are in danger of developing a chronic persistent Herpes simplex infection due to latent immunosuppression. Chronic persistent Herpes infections may be underrated in intensive therapy, and must always be ruled out in case of therapy-resistant erosions or ulcerations.
G S Umamaheswara Rao
Full Text Available Trauma to the cervical spine may have devastating consequences. Timely interventions are essential to prevent avoidable neurological deterioration. In the initial stabilization of patients with acute cervical spine injuries, physiological disturbances, especially those involving cardiac and respiratory function require careful attention. Early surgery, which facilitates rapid mobi-lization of the patient, is fraught with important management considerations in the intraopoerative period and the subsequent critical care. Airway management poses a crucial challenge at this stage. Those patients who survive the injury with quadriplegia or quadriparesis may present themselves for incidental surgical procedures. Chronic systemic manifestations in these patients require attention in providing anaesthesia and postoperative care at this stage. The current review provides an insight into the physiological disturbances and the management issues in both acute and chronic phases of traumatic cervical spine injury.
Full Text Available Ventilator associated pneumonia (VAP is the most common nosocomial infection in Intensive Care Unit. One major factor causing VAP is the aspiration of oral colonization because of poor oral care practices. We feel the role of simple measure like oral care is neglected, despite the ample evidence of it being instrumental in preventing VAP.
Gupta, A; Gupta, A; Singh, T K; Saxsena, A
Ventilator associated pneumonia (VAP) is the most common nosocomial infection in Intensive Care Unit. One major factor causing VAP is the aspiration of oral colonization because of poor oral care practices. We feel the role of simple measure like oral care is neglected, despite the ample evidence of it being instrumental in preventing VAP.
A Gupta; A Gupta; T K Singh; A Saxsena
Ventilator associated pneumonia (VAP) is the most common nosocomial infection in Intensive Care Unit. One major factor causing VAP is the aspiration of oral colonization because of poor oral care practices. We feel the role of simple measure like oral care is neglected, despite the ample evidence of it being instrumental in preventing VAP.
Paunova, Minna; Li-Ying, Jason; Egerod, Ingrid Eugenie
This study investigates the influence of nurse knowledge sharing behavior on nurse innovation, given different conditions of control of care quality within the intensive care unit (ICU). After conducting a number of interviews and a pilot study, we carried out a multi-source survey study of more...... control of care quality and innovate may be conflicting, unless handled properly....
Piedrafita-Susín, A B; Yoldi-Arzoz, E; Sánchez-Fernández, M; Zuazua-Ros, E; Vázquez-Calatayud, M
Adequate provision of palliative care by nursing in intensive care units is essential to facilitate a "good death" to critically ill patients. To determine the perceptions, experiences and knowledge of intensive care nurses in caring for terminal patients. A literature review was conducted on the bases of Pubmed, Cinahl and PsicINFO data using as search terms: cuidados paliativos, UCI, percepciones, experiencias, conocimientos y enfermería and their alternatives in English (palliative care, ICU, perceptions, experiences, knowledge and nursing), and combined with AND and OR Boolean. Also, 3 journals in intensive care were reviewed. Twenty seven articles for review were selected, most of them qualitative studies (n=16). After analysis of the literature it has been identified that even though nurses perceive the need to respect the dignity of the patient, to provide care aimed to comfort and to encourage the inclusion of the family in patient care, there is a lack of knowledge of the end of life care in intensive care units' nurses. This review reveals that to achieve quality care at the end of life, is necessary to encourage the training of nurses in palliative care and foster their emotional support, to conduct an effective multidisciplinary work and the inclusion of nurses in decision making. Copyright © 2014 Elsevier España, S.L.U. y SEEIUC. All rights reserved.
Brooks, Laura Anne; Manias, Elizabeth; Nicholson, Patricia
Clinicians in the intensive care unit commonly face decisions involving withholding or withdrawing life-sustaining therapy, which present many clinical and ethical challenges. Communication and shared decision-making are key aspects relating to the transition from active treatment to end-of-life care. To explore the experiences and perspectives of nurses and physicians when initiating end-of-life care in the intensive care unit. The study was conducted in a 24-bed intensive care unit in Melbourne, Australia. An interpretative, qualitative inquiry was used, with focus groups as the data collection method. Intensive care nurses and physicians were recruited to participate in a discipline-specific focus group. Focus group discussions were audio-recorded, transcribed, and subjected to thematic data analysis. Five focus groups were conducted; 17 nurses and 11 physicians participated. The key aspects discussed included communication and shared decision-making. Themes related to communication included the timing of end-of-life care discussions and conducting difficult conversations. Implementation and multidisciplinary acceptance of end-of-life care plans and collaborative decisions involving patients and families were themes related to shared decision-making. Effective communication and decision-making practices regarding initiating end-of-life care in the intensive care unit are important. Multidisciplinary implementation and acceptance of end-of-life care plans in the intensive care unit need improvement. Clear organizational processes that support the introduction of nurse and physician end-of-life care leaders are essential to optimize outcomes for patients, family members, and clinicians. ©2017 American Association of Critical-Care Nurses.
Backes, Marli Terezinha Stein; Erdmann, Alacoque Lorenzini; Büscher, Andreas
to understand the meaning of the Adult Intensive Care Unit environment of care, experienced by professionals working in this unit, managers, patients, families and professional support services, as well as build a theoretical model about the Adult Intensive Care Unit environment of care. Grounded Theory, both for the collection and for data analysis. Based on theoretical sampling, we carried out 39 in-depth interviews semi-structured from three different Adult Intensive Care Units. built up the so-called substantive theory "Sustaining life in the complex environment of care in the Intensive Care Unit". It was bounded by eight categories: "caring and continuously monitoring the patient" and "using appropriate and differentiated technology" (causal conditions); "Providing a suitable environment" and "having relatives with concern" (context); "Mediating facilities and difficulties" (intervenienting conditions); "Organizing the environment and managing the dynamics of the unit" (strategy) and "finding it difficult to accept and deal with death" (consequences). confirmed the thesis that "the care environment in the Intensive Care Unit is a living environment, dynamic and complex that sustains the life of her hospitalized patients".
Marli Terezinha Stein Backes
Full Text Available OBJECTIVE: to understand the meaning of the Adult Intensive Care Unit environment of care, experienced by professionals working in this unit, managers, patients, families and professional support services, as well as build a theoretical model about the Adult Intensive Care Unit environment of care.METHOD: Grounded Theory, both for the collection and for data analysis. Based on theoretical sampling, we carried out 39 in-depth interviews semi-structured from three different Adult Intensive Care Units.RESULTS: built up the so-called substantive theory "Sustaining life in the complex environment of care in the Intensive Care Unit". It was bounded by eight categories: "caring and continuously monitoring the patient" and "using appropriate and differentiated technology" (causal conditions; "Providing a suitable environment" and "having relatives with concern" (context; "Mediating facilities and difficulties" (intervenienting conditions; "Organizing the environment and managing the dynamics of the unit" (strategy and "finding it difficult to accept and deal with death" (consequences.CONCLUSION: confirmed the thesis that "the care environment in the Intensive Care Unit is a living environment, dynamic and complex that sustains the life of her hospitalized patients".
Korha, E.A.; Hakverdioglu, G.; Ozlem, M.; Yurekli, I.; Gurbuz, A.; Alp, N.A
Objectives: To determine hospitalization durations and mortalities of elderly in the Cardiovascular Surgery Intensive Care Unit. Methods: The retrospective study was conducted in a Cardiovascular Surgery Intensive Care Unit in Turkey and comprised patient records from January 1 to December 31, 2011. Computerized epicrisis reports of 255, who had undergone a cardiac surgery were collected. The patients were grouped according to their ages, Group I aged 65-74 and Group II aged 75 and older. European society for Cardiac Operative Risk Evaluation scores of the two groups were compared using SPSS 17. Results: Overall, there were 80 (31.37%) females and 175 (68.62%) males. There were 138 (54.1%) patients in Group I and 117 (45.9%) in Group II. Regarding their hospitalization reasons, it was determined that 70 (27.5%) patients in Group I and 79 (30.9%) patients in Group II were treated with the diagnosis of coronary artery disease. The average hospitalization duration of patients in the intensive care unit was determined to be 11.57+-10.40 days. Regarding the EuroSCORE score intervals of patients, 132 (51.8%)had 3-5 and 225 (88.2%) patients were transferred to the Cardiovascular Surgery and then all of them were discharged; 5 (4.1%) had a mortal course; and 11 (7.7%) were transferred to the anaesthesia intensive care unit Conclusions: The general mortality rates are very low in the Cardiovascular Surgery Intensive Care Unit and the patients have a good prognosis. (author)
Alvarez Abril, A [National Technological University, Regional Bioengineering Institute, Mendoza (Argentina); Terron, A; Boschi, C [National Technological University, Regional Bioengineering Institute, Mendoza (Argentina); Gomez, M [National Technological University, La Rioja (Argentina)
This work is about the problem of noise in neonatal incubators and in the environment in the neonatal intensive care units. Its main objective is to analyse the impact of noise in hospitals of Mendoza and La Rioja. Methodology: The measures were taken in different moments in front of higher or lower severity level in the working environment. It is shown that noise produces severe damages and changes in the behaviour and the psychological status of the new born babies. Results: The noise recorded inside the incubators and the neonatal intensive care units together have many components but the noise of motors, opening and closing of access gates have been considered the most important ones. Values above 60 db and and up to 120 db in some cases were recorded, so the need to train the health staff in order to manage the new born babies, the equipment and the instruments associated with them very carefully is revealed.
From special care following surgery and from arteficial respiration of polio patients the modern and very special intensive medical care has developed. At the same time the provisional bedside radiology was improved to one branch of clinical radiology with special organisation and methods of investigation. Importance and urgency of radiological information are requiring close cooperation of all medical branches. Functions of these different groups have to be defined. The movable X-ray apparatus of 20 kV output is necessary for every intensive care unit. Hard beam technique for lung X-rays, scattered radiation grids and adequate positioning of the patient are important to get the same high quality pictures than from the radiological department.
From special care following surgery and from arteficial respiration of polio patients the modern and very special intensive medical care has developed. At the same time the provisional bedside radiology was improved to one branch of clinical radiology with special organisation and methods of investigation. Importance and urgency of radiological information are requiring close cooperation of all medical branches. Functions of these different groups have to be defined. The movable X-ray apparatus of 20 kV output is necessary for every intensive care unit. Hard beam technique for lung X-rays, scattered radiation grids and adequate positioning of the patient are important to get the same high quality pictures than from the radiological department. (orig.) [de
Lazignac, Coralie; Ricou, Bara; Dan, Liviu; Virgillito, Salvatore; Adam, Eric; Seyedi, Majid; Cicotti, Andrei; Azi, Amine; Damsa, Cristian
This paper discusses the importance of psychiatric guidelines and the position of the psychiatrist in the management of agitation in the intensive care unit. The use of psychiatric validated scales to assess agitation seems to ameliorate the quality of care in psychiatry, but also in intensive care. Psychiatric experts' recommendations for managing agitation are given, which is useful to create an open discussion with the intensivists. The use of sedative medication to protect the patient, staff and to prevent an escalation of violence remains a personal choice for each practitioner, depending on individual patient needs and context. In the treatment of agitated patients, an equilibrium needs to be found between the subjective dimension and the available data from evidence based medicine.
Alvarez Abril, A; Terron, A; Boschi, C; Gomez, M
This work is about the problem of noise in neonatal incubators and in the environment in the neonatal intensive care units. Its main objective is to analyse the impact of noise in hospitals of Mendoza and La Rioja. Methodology: The measures were taken in different moments in front of higher or lower severity level in the working environment. It is shown that noise produces severe damages and changes in the behaviour and the psychological status of the new born babies. Results: The noise recorded inside the incubators and the neonatal intensive care units together have many components but the noise of motors, opening and closing of access gates have been considered the most important ones. Values above 60 db and and up to 120 db in some cases were recorded, so the need to train the health staff in order to manage the new born babies, the equipment and the instruments associated with them very carefully is revealed
Medical progress and demographic changes will lead to increasing budgetary constraints in the health care system in the coming years. With respect to economic, medical, and ethical aspects, intensive care medicine has a particular role within the health system. Nonetheless, financial restriction will be inevitable in the near future. A literature review was performed. In an era of economic decline accompanied by widespread recognition that healthcare costs are on a consistent upward spiral, rationalization and rationing are unavoidable. Priorization models will play a pivotal role in allocation of resources. Individual ethics (respect for autonomy, nonmaleficence, beneficence) as well as justice are essential in daily practice. Economic thinking and acting as well as being ethically responsible are not mutually exclusive. On the contrary, acting in an ethically responsible manner will be of considerable significance given the pressure of increasing costs in intensive care medicine.
Bidabadi, Farimah Shirani; Yazdannik, Ahmadreza; Zargham-Boroujeni, Ali
Maintaining patient's dignity in intensive care units is difficult because of the unique conditions of both critically-ill patients and intensive care units. The aim of this study was to uncover the cultural factors that impeded maintaining patients' dignity in the cardiac surgery intensive care unit. The study was conducted using a critical ethnographic method proposed by Carspecken. Participants and research context: Participants included all physicians, nurses and staffs working in the study setting (two cardiac surgery intensive care units). Data collection methods included participant observations, formal and informal interviews, and documents assessment. In total, 200 hours of observation and 30 interviews were performed. Data were analyzed to uncover tacit cultural knowledge and to help healthcare providers to reconstruct the culture of their workplace. Ethical Consideration: Ethical approval for the study from Ethics committee of Isfahan University of Medical Sciences was obtained. The findings of the study fell into the following main themes: "Presence: the guarantee for giving enough attention to patients' self-esteem", "Instrumental and objectified attitudes", "Adherence to the human equality principle: value-action gap", "Paternalistic conduct", "Improper language", and "Non-interactive communication". The final assertion was "Reductionism as a major barrier to the maintaining of patient's dignity". The prevailing atmosphere in subculture of the CSICU was reductionism and paternalism. This key finding is part of the biomedical discourse. As a matter of fact, it is in contrast with dignified care because the latter necessitate holistic attitudes and approaches. Changing an ICU culture is not easy; but through increasing awareness and critical self-reflections, the nurses, physicians and other healthcare providers, may be able to reaffirm dignified care and cure in their therapeutic relationships.
Watson, J'ai; Kinstler, Angela; Vidonish, William P; Wagner, Michael; Lin, Li; Davis, Kermit G; Kotowski, Susan E; Daraiseh, Nancy M
Excessive exposure to noise places nurses at risk for safety events, near-misses, decreased job performance, and fatigue. Noise is particularly a concern in pediatric intensive care units, where highly skilled providers and vulnerable patients require a quiet environment to promote healing. To measure noise levels and noise duration on specialty pediatric intensive care units to explore sources of noise and its effects on the health of registered nurses. In a cross-sectional pilot study, levels and sources of noise in 3 different specialty pediatric intensive care units were assessed. Fifteen nurses were observed for 4-hour sessions during a 24-hour period. Sound pressure levels (noise) and heart rate were measured continuously, and stress ratings were recorded. Descriptive statistics were calculated for noise (level, source, location, and activity), heart rate, and stress. The Pearson correlation coefficient was calculated to analyze the relationship between heart rate and noise. Mean noise level was 71.9 (SD, 9.2) dBA. Mean heart rate was 85.2/min (SD, 15.8/min) and was significantly associated with noise, unit, within-unit location, nurse sources, and noise activities. The most frequent sources of noise were patients' rooms, care activities, and staff communications. Noise levels in pediatric intensive care units exceed recommended thresholds and require immediate attention through effective interventions. Although noise was not associated with stress, a significant correlation with increased heart rate indicates that noise may be associated with adverse health outcomes. ©2015 American Association of Critical-Care Nurses.
Kozub, Elizabeth; Hibanada-Laserna, Maribel; Harget, Gwen; Ecoff, Laurie
To accommodate a higher demand for critical care nurses, an orientation program in a surgical intensive care unit was revised and streamlined. Two theoretical models served as a foundation for the revision and resulted in clear clinical benchmarks for orientation progress evaluation. The purpose of the project was to integrate theoretical frameworks into practice to improve the unit orientation program. Performance improvement methods served as a framework for the revision, and outcomes were measured before and after implementation. The revised orientation program increased 1- and 2-year nurse retention and decreased turnover. Critical care knowledge increased after orientation for both the preintervention and postintervention groups. Incorporating a theoretical basis for orientation has been shown to be successful in increasing the number of nurses completing orientation and improving retention, turnover rates, and knowledge gained.
Benois, A; Raynaud, L; Coton, T; Petitjeans, F; Hassan, A; Ilah, A; Sergent, H; Grassin, F; Leberre, J
Prospective data on management and outcome of stroke in Africa is scarce. The purpose of this prospective descriptive study is to present epidemiologic, clinical and outcome data for a series of patients with hemorrhagic stroke in Djibouti. All patients admitted to the intensive care unit of the Bouffard Medical-Surgical Center in Djibouti for cerebral hemorrhage documented by CT-scan of the brain were recruited in this study. A total of 18 patients including 16 men were enrolled. The median patient age in this series was 51.5 years [range, 20-72]. The median duration of intensive care was 3 days [range, 1-38]. Mean Glasgow score at time of admission was 9 [range, 3-14]. Five patients were brought in by emergency medical airlift. The main risk factors for stroke were arterial hypertension, smoking, and regular khat use. Mechanical ventilation was performed in 10 patients with a survival rate of 40%. Six patients (33%) died in the intensive care unit. Hospital mortality within one month was 39% and mortality at 6 months was 44.4%. One-year survival for patients with a Glasgow score < or = 7 at the time of admission was 33%. Arterial hypertension, khat use, and smoking appeared to be major risk factors for male Djiboutians. Neurologic intensive care techniques provided hospital mortality rates similar to those reported in hospitals located in Western countries. Functional outcome in local survivors appeared to be good despite the absence of functional intensive care. These data argue against the passive, fatalistic approach to management of hemorrhagic stroke and for primary prevention of cardiovascular risk factors.
Romanò, Massimo; Bertona, Roberta; Zorzoli, Federica; Villani, Rosvaldo
Admissions to the intensive care unit at the end of life of patients with chronic non-malignant diseases are increasing. This involves the need for the development of palliative care culture and competence, also in the field of intensive cardiology. Palliative care should be implemented in the treatment of all patients with critical stages of disease, irrespective of prognosis, in order to improve the quality of care at the end of life.This review analyzes in detail the main clinical, ethical and communicational issues to move toward the introduction of basics of palliative care in cardiac intensive care units. It outlines the importance of shared decision-making with the patient and his family, with special attention to withholding/withdrawing of life-sustaining treatments, palliative sedation, main symptom control, patient and family psychological support.
Dighe, Manjiri P; Muckaden, Maryann A; Manerkar, Swati A; Duraisamy, Balaji P
Recent advances in medical care have improved the survival of newborn babies born with various problems. Despite this death in the neonatal intensive care unit (NICU) is an inevitable reality. For babies who are not going to "get better," the health care team still has a duty to alleviate the physical suffering of the baby and to support the family. Palliative care is a multidisciplinary approach to relieve the physical, psycho social, and spiritual suffering of patients and their families. P...
Paulo Antonio Chiavone
Full Text Available CONTEXT: The high-complexity features of intensive care unit services and the clinical situation of patients themselves render correct prognosis fundamentally important not only for patients, their families and physicians, but also for hospital administrators, fund-providers and controllers. Prognostic indices have been developed for estimating hospital mortality rates for hospitalized patients, based on demographic, physiological and clinical data. OBJECTIVE: The APACHE II system was applied within an intensive care unit to evaluate its ability to predict patient outcome; to compare illness severity with outcomes for clinical and surgical patients; and to compare the recorded result with the predicted death rate. DESIGN: Diagnostic test. SETTING: Clinical and surgical intensive care unit in a tertiary-care teaching hospital. PARTICIPANTS: The study involved 521 consecutive patients admitted to the intensive care unit from July 1998 to June 1999. MAIN MEASUREMENTS: APACHE II score, in-hospital mortality, receiver operating characteristic curve, decision matrices and linear regression analysis. RESULTS: The patients' mean age was 50 ± 19 years and the APACHE II score was 16.7 ± 7.3. There were 166 clinical patients (32%, 173 (33% post-elective surgery patients (33%, and 182 post-emergency surgery patients (35%, thus producing statistically similar proportions. The APACHE II scores for clinical patients (18.5 ± 7.8 were similar to those for non-elective surgery patients (18.6 ± 6.5 and both were greater than for elective surgery patients (13.0 ± 6.3 (p < 0.05. The higher this score was, the higher the mortality rate was (p < 0.05. The predicted death rate was 25.6% and the recorded death rate was 35.5%. Through the use of receiver operating curve analysis, good discrimination was found (area under the curve = 0.80. From the 2 x 2 decision matrix, 72.2% of patients were correctly classified (sensitivity = 35.1%; specificity = 92.6%. Linear
Sprung, Charles L; Artigas, Antonio; Kesecioglu, Jozef
on mortality and intensive care unit benefit, specifically for elderly patients. DESIGN:: Prospective, observational study of triage decisions from September 2003 until March 2005. SETTING:: Eleven intensive care units in seven European countries. PATIENTS:: All patients >18 yrs with an explicit request......RATIONALE:: Life and death triage decisions are made daily by intensive care unit physicians. Admission to an intensive care unit is denied when intensive care unit resources are constrained, especially for the elderly. OBJECTIVE:: To determine the effect of intensive care unit triage decisions...... care unit rejections than younger patients and have a higher mortality when admitted, the mortality benefit appears greater for the elderly. Physicians should consider changing their intensive care unit triage practices for the elderly....
Roche, Stephanie; Hall-Clifford, Rachel
Each year, thousands of Guatemalans receive non-emergent surgical care from short-term medical missions (STMMs) hosted by local non-governmental organizations (NGOs) and staffed by foreign visiting medical teams (VMTs). The purpose of this study was to explore the perspectives of individuals based in NGOs involved in the coordination of surgical missions to better understand how these missions articulate with the larger Guatemalan health care system. During the summers of 2011 and 2013, in-depth interviews were conducted with 25 representatives from 11 different Guatemalan NGOs with experience with surgical missions. Transcripts were analysed for major themes using an inductive qualitative data analysis process. NGOs made use of the formal health care system but were limited by several factors, including cost, issues of trust and current ministry of health policy. Participants viewed the government health care system as a potential resource and expressed a desire for more collaboration. The current practices of STMMs are not conducive to health system strengthening. The role of STMMs must be defined and widely understood by all stakeholders in order to improve patient safety and effectively utilise health resources. Priority should be placed on aligning the work of VMTs with that of the larger health care system.
Full Text Available The purpose of this paper is to define the role of environmental design in improving family integration with patient care in Intensive Care Units (ICUs. It argues that it is necessary to understand family needs, experience and behavioral responses in ICUs to develop effective models for family integration. With its two components—the “healing culture” promoting effective relationships between caregivers and care seekers, and the “environmental design” supporting the healing culture—a “healing environment of care” can be an effective family integration model. This paper presents evidence showing how environmental design may affect families in ICUs, and proposes design recommendations for creating a healing environment of care promoting family integration in ICUs.
Interventions to assess therapy ... and trauma intensive care unit (ICU) at Steve Biko Academic Hospital. ... of programme success, such as improving the quality of service by .... saving and extra quality assurance opportunity for the unit..
Manjiri P Dighe
Full Text Available Recent advances in medical care have improved the survival of newborn babies born with various problems. Despite this death in the neonatal intensive care unit (NICU is an inevitable reality. For babies who are not going to "get better," the health care team still has a duty to alleviate the physical suffering of the baby and to support the family. Palliative care is a multidisciplinary approach to relieve the physical, psycho social, and spiritual suffering of patients and their families. Palliative care provision in the Indian NICU settings is almost nonexistent at present. In this paper we attempt to "build a case" for palliative care in the Indian NICU setting.
Smith, Judith M; Van Aman, M Nancy; Schneiderhahn, Mary Elizabeth; Edelman, Robin; Ercole, Patrick M
Delirium is an acute brain dysfunction associated with poor outcomes in intensive care unit (ICU) patients. Critical care nurses play an important role in the prevention, detection, and management of delirium, but they must be able to accurately assess for it. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument is a reliable and valid method to assess for delirium, but research reveals most nurses need practice to use it proficiently. A pretest-posttest design was used to evaluate the success of a multimodal educational strategy (i.e., online learning module coupled with standardized patient simulation experience) on critical care nurses' knowledge and confidence to assess and manage delirium using the CAM-ICU. Participants (N = 34) showed a significant increase (p education. No statistical change in knowledge of delirium existed following the education. A multimodal educational strategy, which included simulation, significantly added confidence in critical care nurses' performance using the CAM-ICU. J Contin Nurs Educ. 2017;48(5):239-244. Copyright 2017, SLACK Incorporated.
Mikhael, Michel; Cleary, John P; Dhar, Vijay; Chen, Yanjun; Nguyen, Danh V; Chang, Anthony C
Objective The aim of this article is to examine characteristics of birth tourism (BT) neonates admitted to a neonatal intensive care unit (NICU). Methods This was a retrospective review over 3 years; BT cases were identified, and relevant perinatal, medical, social, and financial data were collected and compared with 100 randomly selected non-birth tourism neonates. Results A total of 46 BT neonates were identified. They were more likely to be born to older women (34 vs. 29 years; p impacts on families, health care system, and society. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Nørgaard, Betty; Johannessen, Helle; Fenger-Grøn, Jesper
: This PAR process was carried out from August 2011 to July 2013 and included participant observations, semi-structured interviews, multi sequential interviews, workshops, focus groups, group discussion, and a seminar. The theoretical framework of validity described by Herr and Anderson's three criteria......BACKGROUND: In neonatal intensive care units (NICUs) health care professionals typically give most of their attention to the infants and the mothers while many fathers feel uncertain and have an unmet need for support and guidance. This paper describes and discusses participatory action research...
Vasconcelos, Eduardo Motta de; Martino, Milva Maria Figueiredo De; França, Salomão Patrício de Souza
To analyze the existence of a relationship between burnout and depressive symptoms among intensive care unit nursing staff. A quantitative, descriptive, cross-sectional study with 91 intensive care nurses. Data collection used a sociodemographic questionnaire, the Maslach Burnout Inventory - Human Services Survey, and the Beck Depression Inventory - I. The Pearson test verified the correlation between the burnout dimension score and the total score from the Beck Depression Inventory. Fisher's exact test was used to analyze whether there is an association between the diseases. Burnout was presented by 14.29% of the nurses and 10.98% had symptoms of depression. The higher the level of emotional exhaustion and depersonalization, and the lower professional accomplishment, the greater the depressive symptoms. The association was significant between burnout and depressive symptoms. Nurses with burnout have a greater possibility of triggering depressive symptoms.
Noergaard, Betty; Ammentorp, Jette; Garne, Ester
BACKGROUND: Healthcare professionals in neonatal intensive care units (NICUs) tend to focus attention on the mothers and the newborn infants. Thus, fathers may find it difficult to establish an optimal father-child relationship and their stress may increase and persist during hospitalization...... and expect fathers to be involved, and support them to establish a father-child relationship, although they might become more stressed. IMPLICATIONS FOR RESEARCH: More adequate outcome measures are needed to determine the effect of interventions on paternal stress.This is an open-access article distributed....... PURPOSE: To investigate the impact of a more father-friendly NICU on paternal stress and their participation in childcare. METHODS: A quasiexperimental design was conducted on Danish-speaking fathers of newborn infants 28 or more weeks' gestational age. The Parental Stressor Scale: Neonatal Intensive Care...
Eduardo Motta de Vasconcelos
Full Text Available ABSTRACT Objective: To analyze the existence of a relationship between burnout and depressive symptoms among intensive care unit nursing staff. Method: A quantitative, descriptive, cross-sectional study with 91 intensive care nurses. Data collection used a sociodemographic questionnaire, the Maslach Burnout Inventory - Human Services Survey, and the Beck Depression Inventory - I. The Pearson test verified the correlation between the burnout dimension score and the total score from the Beck Depression Inventory. Fisher's exact test was used to analyze whether there is an association between the diseases. Results: Burnout was presented by 14.29% of the nurses and 10.98% had symptoms of depression. The higher the level of emotional exhaustion and depersonalization, and the lower professional accomplishment, the greater the depressive symptoms. The association was significant between burnout and depressive symptoms. Conclusion: Nurses with burnout have a greater possibility of triggering depressive symptoms.
Notz, K; Dubb, R; Kaltwasser, A; Hermes, C; Pfeffer, S
Treatment success in hospitals, particularly in intensive care units, is directly tied to quality of structure, process, and outcomes. Technological and medical advancements lead to ever more complex treatment situations with highly specialized tasks in intensive care nursing. Quality criteria that can be used to describe and correctly measure those highly complex multiprofessional situations have only been recently developed and put into practice.In this article, it will be shown how quality in multiprofessional teams can be definded and assessed in daily clinical practice. Core aspects are the choice of a nursing theory, quality assurance measures, and quality management. One possible option of quality assurance is the use of standard operating procedures (SOPs). Quality can ultimately only be achieved if professional groups think beyond their boundaries, minimize errors, and establish and live out instructions and SOPs.
Østby, Anne-Cathrine; Gubbels, Sophie; Baake, Gerben
Our aim was to determine the frequency of 12 common respiratory viruses in patients admitted to intensive care units with respiratory symptoms, evaluate the clinical characteristics and to compare the results to routine microbiological diagnostics. Throat swabs from 122 intensive care-patients >18...... years with acute respiratory symptoms were collected upon admission and analysed with multiplex real-time polymerase chain reaction, for 12 community respiratory viruses. Blood and respiratory tract specimens were analysed for bacteria and fungi upon clinicians' request. Clinical and paraclinical data...... were collected. Viruses were detected in 19 (16%) of the 122 study patients. Five virus-positive patients (26%) had possible clinically relevant bacteria or fungi co-detected. Patients with exacerbation in COPD were associated with a viral infection (p = 0.02). Other comorbidities, clinical...
Caiuby, Andrea Vannini Santesso; Andreoli, Paola Bruno de Araújo; Andreoli, Sergio Baxter
Post-traumatic stress disorder has been detected in patients after treatment in intensive care unit. The main goal of this study is to review the psychological aspects and therapeutic interventions on those patients after their treatment on intensive care unit. Thirty eight articles have been included. The prevalence of post-traumatic stress disorder has varied from 17% up to 30% and the incidence from 14% to 24%. The risk factors were: previous anxiety historic, depression or panic, having delusional traumatic memories (derived from psychic formations as dreams and delirium), belief effects, depressive behavior, stressing experiences and mechanical ventilation. High doses of opiates, symptoms caused by sedation or analgesia reduction and the use of lorazepam were related with the increase of delirium and delusional memory. The disorder sintomatology can be reduced with hydrocortisone administration, with daily sedation interruption. No other effectiveness psychological intervention study was found.
Silvia Helena Henriques Camelo
Full Text Available Objective. The aim in this study was to identify how Intensive Care Unit nurses perceive professional competences in thecare team. Methodology. Qualitative multiple case study with an exploratory focus. The sample consisted of 24 nurses from Intensive Care Units (ICU at two large hospitals. To collect the information, direct observation and - structured, non-structuredand participant - interviews were used. Results. Ninety-six percent of the participants were women, 79% were less than 40 years old, and 63% possessed less than five years of professional experience in ICU. Data analysis revealed three study categories: teamwork as a nursing management tool, improving teamwork, and interpersonal communication for teamwork. Conclusion. At the ICU where the nurses work, a teamwork strategy is observed, which demands cooperation and participation by other disciplines.
Nilsson, Krister; Ekström-Jodal, Barbro; Meretoja, Olli
The initiation and development of pediatric anesthesia and intensive care have much in common in the Scandinavian countries. The five countries had to initiate close relations and cooperation in all medical disciplines. The pediatric anesthesia subspecialty took its first steps after the Second...... World War. Relations for training and exchange of experiences between Scandinavian countries with centers in Europe and the USA were a prerequisite for development. Specialized pediatric practice was not a full-time position until during the 1950s, when the first pediatric anesthesia positions were...... created. Scandinavian anesthesia developed slowly. In contrast, Scandinavia pioneered both adult and certainly pediatric intensive care. The pioneers were heavily involved in the teaching and training of anesthetists and nurses. This was necessary to manage the rapidly increasing work. The polio epidemics...
Turkov, P N; Nikitin, V V; Antsupova, M A; Podkopaev, V N; Panfilova, R P; Ivanova, I N; Nesterova, L I
Urgency of the problem is defined by economical, regulatory and legislative acts, regional social and moral factors. There is critical situation in Russian Pediatric Healthcare system. This situation is due to inadequate funding, high medical technologies inaccessibility for some Russian children, their adverse health state. The article presents a retrospective analysis of intensive therapy and resuscitation outcomes with technical equipment and work environment assessment in the intensive care unit of Tushinskaya city pediatric clinic for the period from 2007 to 2011. Anaesthetic and emergency care quality and safety depend on several factors: permanent equipment improvement, comprehensive analysis of every fatal case and full implementation of "Anti-epidemic (prophylactic) actions plan" and "Program of monitoring compliance with the sanitary norms".
Vitner, Gad; Nadir, Erez; Feldman, Michael; Yurman, Shmuel
The aim of this paper is to present the process for approving and certifying a neonatal intensive care unit to ISO 9001 standards. The process started with the department head's decision to improve services quality before deciding to achieve ISO 9001 certification. Department processes were mapped and quality management mechanisms were developed. Process control and performance measurements were defined and implemented to monitor the daily work. A service satisfaction review was conducted to get feedback from families. In total, 28 processes and related work instructions were defined. Process yields showed service improvements. Family satisfaction improved. The paper is based on preparing only one neonatal intensive care unit to the ISO 9001 standard. The case study should act as an incentive for hospital managers aiming to improve service quality based on the ISO 9001 standard. ISO 9001 is becoming a recommended tool to improve clinical service quality.
Ajzenberg, Henry; Newman, Paula; Harris, Gail-Anne; Cranston, Marnie; Boyd, J Gordon
To reduce medication turnaround times during neurological emergencies, a multidisciplinary team developed a neurological emergency crash trolley in our intensive care unit. This trolley includes phenytoin, hypertonic saline and mannitol, as well as other equipment. The aim of this study was to assess whether the cart reduced turnaround times for these medications. In this retrospective cohort study, medication delivery times for two year epochs before and after its implementation were compared. Eligible patients were identified from our intensive care unit screening log. Adults who required emergent use of phenytoin, hypertonic saline or mannitol while in the intensive care unit were included. Groups were compared with nonparametric analyses. 33-bed general medical-surgical intensive care unit in an academic teaching hospital. Time to medication administration. In the pre-intervention group, there were 43 patients with 66 events. In the post-intervention group, there were 45 patients with 80 events. The median medication turnaround time was significantly reduced after implementation of the neurological emergency trolley (25 vs. 10minutes, p=0.003). There was no statistically significant difference in intensive care or 30-day survival between the two cohorts. The implementation of a novel neurological emergency crash trolley in our intensive care unit reduced medication turnaround times. Copyright © 2017 Elsevier Ltd. All rights reserved.
Introduction Competence of nurses is a complex combination of knowledge, function, skills, attitudes, and values. Delivering care for patients in the Intensive Cardiac Care Unit (ICCU) requires nurses’ competences. This study aimed to explain nurses’ competence in the ICCU. Methods This was a qualitative study in which purposive sampling with maximum variation was used. Data were collected through semi-structured interviews with 23 participants during 2012–2013. Interviews were recorded, transcribed verbatim, and analyzed by using the content-analysis method. Results The main categories were “clinical competence,” comprising subcategories of ‘routine care,’ ‘emergency care,’ ‘care according to patients’ needs,’ ‘care of non-coronary patients’, as well as “professional competence,” comprising ‘personal development,’ ‘teamwork,’ ‘professional ethics,’ and ‘efficacy of nursing education.’ Conclusion The finding of this study revealed dimensions of nursing competence in ICCU. Benefiting from competence leads to improved quality of patient care and satisfaction of patients and nurses and helps elevate nursing profession, improve nursing education, and clinical nursing. PMID:27382450
Marciniak, R.; Aronski, A.
760 patients suffering from acute pulmonary oedema were treated between 1980 and 1986 at the Institute of Anaesthesiology of the Medical Academy in Wroclaw. The radiological image of the pulmonary oedema was subdivided into three forms (hilar, hilar and perihilar, and hilar with massive plane-shaped infiltrates). In the treatment of acute pulmonary oedema in the intensive-care ward a thorough diagnostic programme is mandatory after the immediately necessary measures have been taken. (orig.) [de
Mehmet Sah Ipek
Aim: To determine the pattern of bloodstream infections (BSIs) and antimicrobial susceptibility of pathogens in a neonatal intensive care unit (NICU).Material and Method: Positive hemoculture of neonates diagnosed with nosocomial sepsis from March 2011 to March 2014 in the NICU of Diyarbakir Maternity and Children%u2019s Hospital, in the southeastern region of Anatolia, Turkey, were retrospectively reviewed. Results: A total of 148 pathogens were isolated in 142 neonates. The most common micr...
Machotka, O.; Maňák, J.; Kuběna, Aleš Antonín; Vlček, J.
Roč. 159, č. 4 (2015), s. 652-656 ISSN 1213-8118 Institutional support: RVO:67985556 Keywords : medical error * graph theory * graph coloring * drug administration * drug incompatibilities * applied combinatorics * decision theory * medical * medication safety * intensive care units Subject RIV: FN - Epidemiology, Contagious Diseases ; Clinical Immunology Impact factor: 0.924, year: 2015 http://library.utia.cas.cz/separaty/2014/E/kubena-0437509.pdf
Wauer, H J; Lorenz, B A; Kox, W J
Determination of Functional Residual Capacity (FRC) can be performed through washout methods, indicator gas dilution or bodyplethysmography. Some of these techniques have been adapted for use in intensive care patients whilst being mechanically ventilated. However, most measurement setups are bulky, cumbersome to use and their running costs are high. Hence FRC measurement has not become a routine method in intensive care although it offers considerable advantages in the management of ventilated patients such as the determination of "best PEEP", the detection of progressive alveolar collapse in the course of acute lung injury and during weaning from mechanical ventilation. Up to now most efforts to improve and simplify FRC measurement were made at the expense of accuracy. An ideal method ought to be accurate, easy to handle and cost-effective. It should supply not only FRC data but also information about intrapulmonary gas distribution and dead space. These demands can be met using modern data acquisition software. The pros and cons of all methods available for FRC measurement are discussed in view of their suitability for intensive care patients. A conventional nitrogen washout using emission spectroscopy for measurement of nitrogen concentration gives satisfying exact values for the determination of the parameters mentioned above. The measurement error can be lowered under 5% by special corrections for flow and nitrogen signal (delay and rise times, changes of gas viscosity). For flow measurement a normal pneumotachograph can be used. Using a laptop computer for data acquisition the bed-side monitor fulfills most of the demands in intensive care. It is then also possible to measure indices of intrapulmonary gas distribution such as Alveolar Mixing Efficiency and Lung Clearance Index.
Li, Y.; Albayrak, A.; Goossens, R.H.M.; Xiao, D.; Jakimowicz, J.J.
Because of high risk and instability of the patients in Intensive care unit(ICU), the design of ICU is very difficult. ICU design, auxiliary building design, lighting design, noise control and other aspects can also enhance its management. In this paper, we compare ICU design in China and Holland based on related standards. We also premeditate the indoor environment from planning perspective, analyze patients, their families, medical staff and space requirement to conduct research in ICU desi...
Seashore, J. H.
Nutritional support is an integral and essential part of the management of 5-10 percent of hospitalized children. Children in the intensive care unit are particularly likely to develop malnutrition because of the nature and duration of their illness, and their inability to eat by mouth. This article reviews the physiology of starvation and the development of malnutrition in children. A method of estimating the nutritional requirements of children is presented. The techniques of nutritional su...
Methods. The SA Surgical Outcomes Study (SASOS) was a 7-day national, multicentre, prospective, ...... L R Math ivha, T R Mokoena, S Monokoane, R Moreno, D F Morrell, ... stone Hospital: L Friedman, D Schmidt*, S Venter; Nelson Mandela.
A real clinical case reported to SENSAR is presented. A patient admitted to the surgical intensive care unit following a lung resection, suffered arterial hypotension. The nurse was asked to give the patient 1 mL of phenylephrine. A few seconds afterwards, the patient experienced a hypertensive crisis, which resolved spontaneously without damage. Thereafter, the nurse was interviewed and a dosing error was identified: she had mistakenly given the patient 1 mg of phenylephrine (1 mL) instead of 100 mcg (1 mL of the standard dilution, 1mg in 10 mL). The incident analysis revealed latent factors (event triggers) due to the lack of protocols and standard operating procedures, communication errors among team members (physician-nurse), suboptimal training, and underdeveloped safety culture. In order to preempt similar incidents in the future, the following actions were implemented in the surgical intensive care unit: a protocol for bolus and short lived infusions (del Dolor. Published by Elsevier España. All rights reserved.
Olper, L; Cabrini, L; Landoni, G; Rossodivita, A; Nobile, L; Monti, G; Alfieri, O; Zangrillo, A
Non-invasive ventilation (NIV) can prevent or treat postoperative acute respiratory failure. NIV after discharge from the Intensive Care Unit (ICU) has never been described in the setting of cardiac surgery. This study enrolled 85 patients who received NIV in the main ward as treatment for respiratory failure. The patients had the following conditions: atelectasis (45 patients), pleural effusion (20 patients), pulmonary congestion (13 patients), diaphragm hemiparesis (6 patients), pneumonia (4 patients) or a combination of these conditions. Eighty-three patients were discharged from the hospital in good condition and without need for further NIV treatment, while two died in-hospital. Four of the 85 patients had an immediate NIV failure, while eight patients had delayed NIV failure. Only one patient had a NIV-related complication represented by hypotension after NIV institution. In this patient, NIV was interrupted with no consequences. Major mistakes were mask malpositioning with excessive air leaks (7 patients), incorrect preparation of the circuit (one patient), and oxygen tube disconnection (one patient). Minor mistakes (sub-optimal positioning of the face mask without excessive air leaks) were noted by the respiratory therapists for all patients and were managed by slightly modifying the mask position. In our experience, postoperative NIV is feasible, safe and effective in treating postoperative acute respiratory failure when applied in the cardiac surgical ward, preserving intensive care unit beds for surgical activity. A respiratory therapy service managed the treatment in conjunction with ward nurses, while an anesthesiologist and a cardiologist served as consultants.
The field of critical care has changed markedly in recent years to accommodate a growing population of chronically critically ill patients. New administrative structures have evolved to include divisions, departments, and sections devoted exclusively to the practice of critical care medicine. On an individual level, the ability to manage complex multisystem critical illnesses and to introduce invasive monitoring devices defines the intensivist. On a systems level, critical care services managed by an intensivist-led multidisciplinary team are now recognized by their ability to efficiently utilize hospital resources and improve patient outcomes. Due to the numerous cost and quality issues related to the delivery of critical care medicine, intensive care unit physician staffing (IPS) has become a charged subject in recent years. Although the federal government has played a large role in regulating best practices by physicians, other third parties have entered the arena. Perhaps the most influential of these has been The Leapfrog Group, a consortium representing 130 employers and 65 Fortune 500 companies that purchase health care for their employees. This group has proposed specific regulatory guidelines for IPS that are purported to result in substantial cost containment and improved quality of care. This narrative review examines the impact of The Leapfrog Group's recommendations on critical care delivery in the United States. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Graf, J; Pump, S; Maas, W; Stüben, U
Safety is of extraordinary value in commercial aviation. Therefore, sophisticated and complex systems have been developed to ensure safe operation. Within this system, the pilots are of specific concern: they form the human-machine interface and have a special responsibility in controlling and monitoring all aircraft systems. In order to prepare pilots for their challenging task, specific selection of suitable candidates is crucial. In addition, for every commercial pilot regulatory requirements demand a certain number of simulator training sessions and check flights to be completed at prespecified intervals. In contrast, career choice for intensive care medicine most likely depends on personal reasons rather than eligibility or aptitude. In intensive care medicine, auditing, licensing, or mandatory training are largely nonexistent. Although knowledge of risk management and safety culture in aviation can be transferred to the intensive care unit, the diversity of corporate culture and tradition of leadership and training will represent a barrier for the direct transfer of standards or procedures. To accomplish this challenging task, the analysis of appropriate fields of action with regard to structural requirements and the process of change are essential.
Avila-Alvarez, A; Carbajal, R; Courtois, E; Pertega-Diaz, S; Muñiz-Garcia, J; Anand, K J S
Pain management and sedation is a priority in neonatal intensive care units. A study was designed with the aim of determining current clinical practice as regards sedation and analgesia in neonatal intensive care units in Spain, as well as to identify factors associated with the use of sedative and analgesic drugs. A multicenter, observational, longitudinal and prospective study. Thirty neonatal units participated and included 468 neonates. Of these, 198 (42,3%) received sedatives or analgesics. A total of 19 different drugs were used during the study period, and the most used was fentanyl. Only fentanyl, midazolam, morphine and paracetamol were used in at least 20% of the neonates who received sedatives and/or analgesics. In infusions, 14 different drug prescriptions were used, with the most frequent being fentanyl and the combination of fentanyl and midazolam. The variables associated with receiving sedation and/or analgesia were, to have required invasive ventilation (P3 (P=.023; OR=2.26), the existence of pain evaluation guides in the unit (Pneonates admitted to intensive care units receive sedatives or analgesics. There is significant variation between Spanish neonatal units as regards sedation and analgesia prescribing. Our results provide evidence on the "state of the art", and could serve as the basis of preparing clinical practice guidelines at a national level. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.
Full Text Available Neonatal mortality in India accounts for 50% of infant mortality, which has declined to 84/1000 live births. There is no prenatal care for over 50% of pregnant women, and over 80% deliver at home in unsafe and unsanitary conditions. Those women who do deliver in health facilities are unable to receive intensive neonatal care when necessary. Level I and Level II neonatal care is unavailable in most health facilities in India, and in most developing countries. There is a need in India for Level III care units also. The establishment of neonatal intensive care units (NICUs in India and developing countries would require space and location, finances, equipment, staff, protocols of care, and infection control measures. Neonatal mortality could be reduced by initially adding NICUs at a few key hospitals. The recommendation is for 30 NICU beds per million population. Each bed would require 50 square feet per cradle and proper climate control. Funds would have to be diverted from adult care. The largest expenses would be in equipment purchase, maintenance, and repair. Trained technicians would be required to operate and monitor the sophisticated ventilators and incubators. The nurse-patient ratio should be 1:1 and 1:2 for other infants. Training mothers to work in the NICUs would help ease the problems of trained nursing staff shortages. Protocols need not be highly technical; they could include the substitution of radiant warmers and room heaters for expensive incubators, the provision of breast milk, and the reduction of invasive procedures such as venipuncture and intubation. Nocosomial infections should be reduced by vacuum cleaning and wet mopping with a disinfectant twice a day, changing disinfectants periodically, maintaining mops to avoid infection, decontamination of linen, daily changing of tubing, and cleaning and sterilizing oxygen hoods and resuscitation equipment, and maintaining an iatrogenic infection record book, which could be used to
Hantel, Andrew; Wroblewski, Kristen; Balachandran, Jay S.; Chow, Selina; DeBoer, Rebecca; Fleming, Gini F.; Hahn, Olwen M.; Kline, Justin; Liu, Hongtao; Patel, Bhakti K.; Verma, Anshu; Witt, Leah J.; Fukui, Mayumi; Kumar, Aditi; Howell, Michael D.; Polite, Blase N.
Purpose: Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs. Methods: This was a retrospective case series of patients cared for in an academic medical center’s ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patient’s electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations. Results: Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05). Conclusion: Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care. PMID:27601514
Wolfswinkel, Erik M; Howell, Lori K; Fahradyan, Artur; Azadgoli, Beina; McComb, J Gordon; Urata, Mark M
Of U.S. craniofacial and neurosurgeons, 94 percent routinely admit patients to the intensive care unit following cranial vault remodeling for correction of sagittal synostosis. This study aims to examine the outcomes and cost of direct ward admission following primary cranial vault remodeling for sagittal synostosis. An institutional review board-approved retrospective review was undertaken of the records of all patients who underwent primary cranial vault remodeling for isolated sagittal craniosynostosis from 2009 to 2015 at a single pediatric hospital. Patient demographics, perioperative course, and outcomes were recorded. One hundred ten patients met inclusion criteria with absence of other major medical problems. Average age at operation was 6.7 months, with a mean follow-up of 19.8 months. Ninety-eight patients (89 percent) were admitted to a general ward for postoperative care, whereas the remaining 12 (11 percent) were admitted to the intensive care unit for preoperative or perioperative concerns. Among ward-admitted patients, there were four (3.6 percent) minor complications; however, there were no major adverse events, with none necessitating intensive care unit transfers from the ward and no mortalities. Average hospital stay was 3.7 days. The institution's financial difference in cost of intensive care unit stay versus ward bed was $5520 on average per bed per day. Omitting just one intensive care unit postoperative day stay for this patient cohort would reduce projected health care costs by a total of $540,960 for the study period. Despite the common practice of postoperative admission to the intensive care unit following cranial vault remodeling for sagittal craniosynostosis, the authors suggest that postoperative care be considered on an individual basis, with only a small percentage requiring a higher level of care. Therapeutic, III.
Drs. Marvella E. Ford and Nestor F. Esnaola were awarded a five-year NIH/NIMHD R01 grant to evaluate a patient navigation intervention to reduce barriers to surgical cancer care and improving surgical resection rates in African Americans with lung cancer.
Mullen, Antony; Drinkwater, Vincent; Lewin, Terry J
To implement and evaluate the care zoning model in an eight-bed psychiatric intensive care unit and, specifically, to examine the model's ability to improve the documentation and communication of clinical risk assessment and management. Care zoning guides nurses in assessing clinical risk and planning care within a mental health context. Concerns about the varying quality of clinical risk assessment prompted a trial of the care zoning model in a psychiatric intensive care unit within a regional mental health facility. The care zoning model assigns patients to one of 3 'zones' according to their clinical risk, encouraging nurses to document and implement targeted interventions required to manage those risks. An implementation trial framework was used for this research to refine, implement and evaluate the impact of the model on nurses' clinical practice within the psychiatric intensive care unit, predominantly as a quality improvement initiative. The model was trialled for three months using a pre- and postimplementation staff survey, a pretrial file audit and a weekly file audit. Informal staff feedback was also sought via surveys and regular staff meetings. This trial demonstrated improvement in the quality of mental state documentation, and clinical risk information was identified more accurately. There was limited improvement in the quality of care planning and the documentation of clinical interventions. Nurses' initial concerns over the introduction of the model shifted into overall acceptance and recognition of the benefits. The results of this trial demonstrate that the care zoning model was able to improve the consistency and quality of risk assessment information documented. Care planning and evaluation of associated outcomes showed less improvement. Care zoning remains a highly applicable model for the psychiatric intensive care unit environment and is a useful tool in guiding nurses to carry out routine patient risk assessments. © 2013 John Wiley & Sons
Ornelas-Aguirre, José Manuel; Zárate-Coronado, Olivia; Gaxiola-González, Fabiola; Neyoy-Sombra, Venigna
The World Health Organisation (WHO) has established a maximum noise level of 40 decibels (dB) for an intensive care unit. The aim of this study was to compare the noise levels in 2 different intensive care units at a tertiary care centre. Using a cross-sectional design study, an analysis was made of the maximum noise level was within the intensive coronary care unit and intensive care unit using a digital meter. A measurement was made in 4 different points of each room, with 5minute intervals, for a period of 60minutes 7:30, 14:30, and 20:30. The means of the observations were compared with descriptive statistics and Mann-Whitney U. An analysis with Kruskal-Wallis test was performed to the mean noise level. The noise observed in the intensive care unit had a mean of 64.77±3.33dB (P=.08), which was similar to that in the intensive coronary care unit, with a mean of 60.20±1.58dB (P=.129). Around 25% or more of the measurements exceeded the level recommended by the WHO by up to 20 points. Noise levels measured in intensive care wards exceed the maximum recommended level for a hospital. It is necessary to design and implement actions for greater participation of health personnel in the reduction of environmental noise. Copyright © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.
Harris, Carolyn B; Krauss, Melissa J; Coopersmith, Craig M; Avidan, Michael; Nast, Patricia A; Kollef, Marin H; Dunagan, W Claiborne; Fraser, Victoria J
To increase patient safety event reporting in three intensive care units (ICUs) using a new voluntary card-based event reporting system and to compare and evaluate observed differences in reporting among healthcare workers across ICUs. Prospective, single-center, interventional study. A medical ICU (19 beds), surgical ICU (24 beds), and cardiothoracic ICU (17 beds) at a 1,371-bed urban teaching hospital. Adult patients admitted to these three study ICUs. Use of a new, internally designed, card-based reporting program to solicit voluntary anonymous reporting of medical errors and patient safety concerns. During a 14-month period, 714 patient safety events were reported using a new card-based reporting system, reflecting a significant increase in reporting compared with pre-intervention Web-based reporting (20.4 reported events/1,000 patient days pre-intervention to 41.7 reported events/1,000 patient days postintervention; rate ratio, 2.05; 95% confidence interval, 1.79-2.34). Nurses submitted the majority of reports (nurses, 67.1%; physicians, 23.1%; other reporters, 9.5%); however, physicians experienced the greatest increase in reporting among their group (physicians, 43-fold; nurses, 1.7-fold; other reporters, 4.3-fold) relative to pre-intervention rates. There were significant differences in the reporting of harm by job description: 31.1% of reports from nurses, 36.2% from other staff, and 17.0% from physicians described events that did not reach/affect the patient (p = .001); and 33.9% of reports from physicians, 27.2% from nurses, and 13.0% from other staff described events that caused harm (p = .005). Overall reported patient safety events per 1,000 patient days differed by ICU (medical ICU = 55.5, cardiothoracic ICU = 25.3, surgical ICU = 40.2; p reporting system increased reporting significantly compared with pre-intervention Web-based reporting and revealed significant differences in reporting by healthcare worker and ICU. These differences may reveal
Pallás-Alonso, Carmen R; Losacco, Valentina; Maraschini, Alice
To compare, in a large representative sample of European neonatal intensive care units, the policies and practices regarding parental involvement and holding babies in the kangaroo care position as well as differences in the tasks mothers and fathers are allowed to carry out....
Quinn, Jill R; Schmitt, Madeline; Baggs, Judith Gedney; Norton, Sally A; Dombeck, Mary T; Sellers, Craig R
To support the process of effective family decision making, it is important to recognize and understand informal roles that various family members may play in the end-of-life decision-making process. To describe some informal roles consistently enacted by family members involved in the process of end-of-life decision making in intensive care units. Ethnographic study. Data were collected via participant observation with field notes and semistructured interviews on 4 intensive care units in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical, a surgical, a burn and trauma, and a cardiovascular intensive care unit. Health care clinicians, patients, and family members. Informal roles for family members consistently observed were primary caregiver, primary decision maker, family spokesperson, out-of-towner, patient's wishes expert, protector, vulnerable member, and health care expert. The identified informal roles were part of families' decision-making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision making within the family system and between the family and health care domains. These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these informal roles of family members can help clinicians recognize and understand the functions of these roles in families' decision making at the end of life and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes.
Mitchell, Sarah; Dale, Jeremy
The majority of children and young people who die in the United Kingdom have pre-existing life-limiting illness. Currently, most such deaths occur in hospital, most frequently within the intensive care environment. To explore the experiences of senior medical and nursing staff regarding the challenges associated with Advance Care Planning in relation to children and young people with life-limiting illnesses in the Paediatric Intensive Care Unit environment and opportunities for improvement. Qualitative one-to-one, semi-structured interviews were conducted with Paediatric Intensive Care Unit consultants and senior nurses, to gain rich, contextual data. Thematic content analysis was carried out. UK tertiary referral centre Paediatric Intensive Care Unit. Eight Paediatric Intensive Care Unit consultants and six senior nurses participated. Four main themes emerged: recognition of an illness as 'life-limiting'; Advance Care Planning as a multi-disciplinary, structured process; the value of Advance Care Planning and adverse consequences of inadequate Advance Care Planning. Potential benefits of Advance Care Planning include providing the opportunity to make decisions regarding end-of-life care in a timely fashion and in partnership with patients, where possible, and their families. Barriers to the process include the recognition of the life-limiting nature of an illness and gaining consensus of medical opinion. Organisational improvements towards earlier recognition of life-limiting illness and subsequent Advance Care Planning were recommended, including education and training, as well as the need for wider societal debate. Advance Care Planning for children and young people with life-limiting conditions has the potential to improve care for patients and their families, providing the opportunity to make decisions based on clear information at an appropriate time, and avoid potentially harmful intensive clinical interventions at the end of life. © The Author(s) 2015.
Full Text Available In parallel to technological advances in late twentieth century, medical diagnostics and therapeutic options greatly improved. A surge of evidence-based research in intensive care medicine provided additional opportunities and the “best” medical practice has been changing rapidly. However, the primary focus of Hippocrates: “Primum non nocere” (first do no harm is often neglected at the bedside. It became apparent that lesser intervention in the ICU may actually mean more for the patient. Multiple examples of the concept “when less is more in the ICU” are described here in an ABC format. Critical care providers have an obligation to keenly and closely follow the results of new investigative studies and to carefully incorporate those into our practice. However, they have to be sensitive to individual circumstances, patient and family preferences, and avoidance of harm.
Smith, Thomas J
This paper reports a comparative study of occupancy and patient care quality in four types of intensive care units in a children's hospital,: an Infant Care Center (ICC), a Medical/Surgical (Med/Surg) unit, a Neonatal Intensive Care Unit (NICU), and a Pediatric Intensive Care Unit (PICU), each featuring a mix of multi-bed and private room (PR) patient care environments. The project is prompted by interest by the project sponsor in a pre-occupancy analysis, before the units are upgraded to exclusive PR designs. Methods comprised, for each unit: (1) observations of ergonomic design features; (2) task activity analyses of job performance of selected staff; and (3) use of a survey to collect perceptions by unit nursing and house staff (HS) of indicators of occupancy and patient care quality. (1) the five most common task activities are interaction with patients, charting, and interaction with equipment, co-workers and family members; (2) job satisfaction, patient care, work environment, job, patient care team interaction, and general occupancy quality rankings by ICC and/or NICU respondents are significantly higher than those by other staff respondents; and (3) ergonomic design shortcomings noted are excess noise, problems with equipment, and work environment, job-related health, and patient care quality issues.
Coombs, Maureen A
Although anticipatory grief is a much-debated and critiqued bereavement concept, it does offer a way of understanding and exploring expected loss that may be helpful in certain situations. In end-of-life care in adult intensive care units, families often act as proxy decision makers for patients in the transition from curative treatment efforts to planned treatment withdrawal. Despite there being a developed evidence base to inform care of families at this time, few of the clinical studies that provided this evidence were underpinned by bereavement theory. Focusing on end-of-life intensive care practices, this paper integrates work on anticipatory grief and family interventions to present a family-centred framework of care. Through this it is argued that the complex needs of families must be more comprehensively understood by doctors and nurses and that interventions must be more systematically planned to improve quality end-of-life care for families in this setting.
Vergales, Jeffrey; Addison, Nancy; Vendittelli, Analise; Nicholson, Evelyn; Carver, D Jeannean; Stemland, Christopher; Hoke, Tracey; Gangemi, James
The goal was to develop and implement a comprehensive, primarily face-to-face handoff process that begins in the operating room and concludes at the bedside in the intensive care unit (ICU) for pediatric patients undergoing congenital heart surgery. Involving all stakeholders in the planning phase, the framework of the handoff system encompassed a combination of a formalized handoff tool, focused process steps that occurred prior to patient arrival in the ICU, and an emphasis on face-to-face communication at the conclusion of the handoff. The final process was evaluated by the use of observer checklists to examine quality metrics and timing for all patients admitted to the ICU following cardiac surgery. The process was found to improve how various providers view the efficiency of handoff, the ease of asking questions at each step, and the overall capability to improve patient care regardless of overall surgical complexity. © 2014 by the American College of Medical Quality.
Shamim, Faisal; Rizwan, Muhammad; Aziz, Adil
A suicide bomb blast in 2013 at a distant city of Pakistan killed 84 and wounded more than 150 people. Some patients were transferred to our tertiary care hospital because of extreme load on medical services there. This patient arrived at the Aga Khan Hospital, 2 days after the bomb blast injury and underwent an orthopedic procedure. Next day, he developed sudden tachypnea, desaturation, and circulatory collapse. After initial cardiopulmonary resuscitation, he was immediately transferred to surgical intensive care unit. Based on history, echocardiography findings and patient parameters, a clinical diagnosis of massive pulmonary embolism was made and immediate thrombolytic therapy with alteplase was started. The immediate improvement in hemodynamic status was evident following 2 hours of alteplase infusion. This case also highlights the aggressiveness of resuscitation, decision making in initiating thrombolytic therapy on clinical grounds, importance of deep venous thrombosis prophylaxis, and exhaustion of health resources due to blast related mass destruction.
Trimmel, H; Herzer, G; Schöchl, H; Voelckel, W G
Traumatic brain injury (TBI) and hemorrhagic shock due to uncontrolled bleeding are the major causes of death after severe trauma. Mortality rates are threefold higher in patients suffering from multiple injuries and additionally TBI. Factors known to impair outcome after TBI, namely hypotension, hypoxia, hypercapnia, acidosis, coagulopathy and hypothermia are aggravated by the extent and severity of extracerebral injuries. The mainstays of TBI intensive care may be, at least temporarily, contradictory to the trauma care concept for multiple trauma patients. In particular, achieving normotension in uncontrolled bleeding situations, maintenance of normocapnia in traumatic lung injury and thromboembolic prophylaxis are prone to discussion. Due to an ongoing uncertainty about the definition of normotensive blood pressure values, a cerebral perfusion pressure-guided cardiovascular management is of key importance. In contrast, there is no doubt that early goal directed coagulation management improves outcome in patients with TBI and multiple trauma. The timing of subsequent surgical interventions must be based on the development of TBI pathology; therefore, intensive care of multiple trauma patients with TBI requires an ongoing and close cooperation between intensivists and trauma surgeons in order to individualize patient care.
van Pul, C.; Joshi, R.; Dijkman, W.; van de Mortel, H.; Mohns, T.; Andriessen, P.; Chen, Wei; Carlos Augusto, Juan; Seoane, Fernando; Lehocki, Fedor; Wolf, Klaus-Henderik; Arends, Johan; Ungureanu, Constantin; Wichert, Reiner
An international trend in intensive care is the shift from open, bay area intensive care units towards single-patient room care, since this is considered optimal for patient healing and family privacy. However, in the intensive care setting, an increasing number of devices and parameters are being
Cardoso, Teresa; Fonseca, Teresa; Pereira, Sofia; Lencastre, Luís
The objective of the present study was to evaluate the opinion of Portuguese intensive care physicians regarding 'do-not-resuscitate' (DNR) orders and decisions to withhold/withdraw treatment. A questionnaire was sent to all physicians working on a full-time basis in all intensive care units (ICUs) registered with the Portuguese Intensive Care Society. A total of 266 questionnaires were sent and 175 (66%) were returned. Physicians from 79% of the ICUs participated. All participants stated that DNR orders are applied in their units, and 98.3% stated that decisions to withhold treatment and 95.4% stated that decisions to withdraw treatment are also applied. About three quarters indicated that only the medical group makes these decisions. Fewer than 15% of the responders stated that they involve nurses, 9% involve patients and fewer than 11% involve patients' relatives in end-of-life decisions. Physicians with more than 10 years of clinical experience more frequently indicated that they involve nurses in these decisions (P atheist doctors more frequently involve patients' relatives in decisions to withhold/withdraw treatment (P religious beliefs of the respondents influences the way in which these decisions are made.
Wang, Wen-Ling; Feng, Jui-Ying; Wang, Chi-Jen; Chen, Jing-Huei
This study aimed to develop a family-centered care survey for Chinese adult intensive care units and to establish the survey's psychometric properties. Family-centered care (FCC) is widely recognized as an ideal model of care. Few studies have explored FCC perceptions among family members of adult critical care patients in Asian countries, and no Chinese FCC measurement has been developed. An English version of the 3-factor family-centered care survey for adult intensive care units (FCCS-AICU) was translated into Chinese using a modified back translation procedure. Based on the literature review, two additional concepts, information and empowerment, were added to the Chinese FCCS-AICU. The psychometric properties of the Chinese FCCS-AICU were determined with 249 family members from a medical center in Taiwan and were tested for construct and convergent validity, and internal consistency. Both the monolingual and bilingual equivalence tests of the English and Chinese versions of the 3-factor FCCS-AICU were supported. Exploratory factor analysis supported the 5-factor structure of the Chinese FCCS-AICU with a total explained variance of 58.34%. The Chinese FCCS-AICU was correlated with the Chinese Critical Care Family Needs Inventory. Internal consistency, determined by Cronbach's α, for the overall scale was .94. The Chinese FCCS-AICU is a valid and reliable tool for measuring perceptions of FCC by family members of adult intensive care patients within Chinese-speaking communities. Copyright © 2015 Elsevier Inc. All rights reserved.
Keller, E.; Yonekawa, Y.; Imhof, H.G.; Tanaka, M.; Valavanis, Anton
We studied the impact of emergency neurosurgery and intensive care on the outcome for patients with severe intracerebral haemorrhage after endovascular treatment of brain arteriovenous malformations (AVMs). We reviewed the case notes of 18 patients with severe haemorrhage after embolisation of a brain AVM between 1986 and 2001. During this period the treatment changed: before 1993, these patients were not surgically treated, and they died, while after 1994, all patients underwent emergency surgery. We established a standardised protocol for emergency treatment and intensive care in May 1998, and emergency surgery was performed as soon as possible after the onset of symptoms of haemorrhage. Postoperative intensive care was according to a standardised regime. During these 15 years, 24 out of 605 patients undergoing 1066 interventions had a haemorrhage during or after the procedure, of which 18 were severe (3% of patients, 1.7% of interventions). All patients had a severe clinical deficit (mean Glasgow coma scale 4.2); eight had uni- or bilateral mydriasis. From 1989 to April 1998 four (31%) of 13 patients died, one (7.5%) remained in a vegetative state and eight (61.5%) made a good recovery. All five patients treated between 1998 and 2001 had a favourable outcome. The mean time from onset of the symptoms of haemorrhage to reaching the operation room was 129 min between 1989 and 1998 and 24 min between 1998 and 2001. Standardised emergency treatment and intensive care with early resuscitation, minimal radiological exploration before rapid surgery improved the outcome. A short time between the onset of the symptoms of haemorrhage and evacuation of the haematoma may be the most important factor for a favourable outcome. (orig.)
de Prost, N; Bosc, R; Brun-Buisson, C; Chosidow, O; Decousser, J-W; Dhonneur, G; Lepeule, R; Rahmouni, A; Sbidian, E; Amathieu, R
Necrotizing fasciitis (NF) are rare and severe soft tissue infections associated with a high mortality rate. In order to assess the management of NF in French-speaking intensive care units (ICUs), we conducted a survey endorsed by the French Society of Anesthesia and Intensive Care (SFAR). Online self-administered survey. A link to an online survey was sent by email to 4620 anesthesiologists and/or intensivists and was available online from January to February 2014. One hundred and seventy-five physicians (3.8%) who worked in 135 ICUs filled out the online survey. Among respondents, 42% reported having managed up to two patients with NF during the previous year; 59% and 72% of respondents reported not having a surgical and a medical specialist consultant, respectively. A delayed access to the operating room (OR) of more than 6hours was reported in 31% of cases and access to the OR was reported not to be routinely considered as a priority in 13% of cases. Only 17% of respondents reported that time to transfer to the OR was never a cause for delayed surgery. The main causes for delayed surgery were: delayed diagnosis (45%), delayed validation of surgical intervention (37%), and difficulty of access to the OR (8%). Finally, 83% of respondents estimated that creating dedicated multidisciplinary teams for managing NFs could lead to improving outcomes. This survey illustrates the heterogeneous management of NF in French-speaking ICUs and points out several logistical aspects that should be improved to reduce the time to the first surgical debridement. Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.
Santos Edilson Floriano dos
Full Text Available There are various strategies to improve the effectiveness of antibiotics in hospitals. In general, the implementation of guidelines for appropriate antibiotic therapy and the participation of infectious disease (ID physicians deserve considerable attention. This study was a prospective ecological time-series study that evaluates the effectiveness of the ID physician's opinion to rationalize and control the use of antibiotics in medical-surgical intensive care units (ICU, and the impact of their intervention on treatment expenditures. There was significant change in the pattern of use of antimicrobials, this pattern approximating that of a medical-surgical ICU that participates in the ICARE (Intensive Care Antimicrobial Resistance Epidemiology Project. For example, there was a significant increase in the consumption of antimicrobials of the ampicillin group (Relative Risk [RR]=3.39; 95% CI: 2.34-4.91 and antipseudomonal penicillins (RR=2.89; 95% CI: 1.70-4.92. On the other hand, there was a significant reduction in the consumption of 3rd/4th generation cephalosporins (RR=0.66; 95% CI: 0.57-0.77 and carbapenems (RR=0.43; 95% CI: 0.33-0.56. On average, for every patient-day antibiotic expense was reduced 37.2% during calendar year 2001, when compared with 2000. The ID specialists' opinion and the adoption of guidelines for empirical antibiotic therapy of hospital-acquired pneumonia contributed to a reduction in the use of antimicrobials in medical-surgical ICU. However, further studies that have more control over confounding variables are needed to help determine the relevance of these discoveries.
Edilson Floriano dos Santos
Full Text Available There are various strategies to improve the effectiveness of antibiotics in hospitals. In general, the implementation of guidelines for appropriate antibiotic therapy and the participation of infectious disease (ID physicians deserve considerable attention. This study was a prospective ecological time-series study that evaluates the effectiveness of the ID physician's opinion to rationalize and control the use of antibiotics in medical-surgical intensive care units (ICU, and the impact of their intervention on treatment expenditures. There was significant change in the pattern of use of antimicrobials, this pattern approximating that of a medical-surgical ICU that participates in the ICARE (Intensive Care Antimicrobial Resistance Epidemiology Project. For example, there was a significant increase in the consumption of antimicrobials of the ampicillin group (Relative Risk [RR]=3.39; 95% CI: 2.34-4.91 and antipseudomonal penicillins (RR=2.89; 95% CI: 1.70-4.92. On the other hand, there was a significant reduction in the consumption of 3rd/4th generation cephalosporins (RR=0.66; 95% CI: 0.57-0.77 and carbapenems (RR=0.43; 95% CI: 0.33-0.56. On average, for every patient-day antibiotic expense was reduced 37.2% during calendar year 2001, when compared with 2000. The ID specialists' opinion and the adoption of guidelines for empirical antibiotic therapy of hospital-acquired pneumonia contributed to a reduction in the use of antimicrobials in medical-surgical ICU. However, further studies that have more control over confounding variables are needed to help determine the relevance of these discoveries.
Green, C A; Logie, R H; Gilhooly, K J; Ross, D G; Ronald, A
The clinician in an intensive therapy unit is presented regularly with a range of information about the current physiological state of the patients under care. This information typically comes from a variety of sources and in a variety of formats. A more integrated form of display incorporating several physiological parameters may be helpful therefore. Three experiments are reported that explored the potential use of analogue, polygon diagrams to display physiological data from patients undergoing intensive therapy. Experiment 1 demonstrated that information can be extracted readily from such diagrams comprising 8- or 10-sided polygons, but with an advantage for simpler polygons and for information displayed at the top of the diagram. Experiment 2 showed that colour coding removed these biases for simpler polygons and the top of the diagram, together with speeding the processing time. Experiment 3 used polygons displaying patterns of physiological data that were consistent with typical conditions observed in the intensive care unit. It was found that physicians can readily learn to recognize these patterns and to diagnose both the nature and severity of the patient's physiological state. These polygon diagrams appear to have some considerable potential for use in providing on-line summary information of a patient's physiological state.
Mattsson, Janet Yvonne; Arman, Maria; Castren, Maaret; Forsner, Maria
When children are critically ill, parents still strive to be present and participate in the care of their child. Pediatric intensive care differs from other realms of pediatric care as the nature of care is technically advanced and rather obstructing than encouraging parental involvement or closeness, either physically or emotionally, with the critically ill child. The aim of this study was to elucidate the meaning of caring in the pediatric intensive care unit from the perspective of parents. The design of this study followed Benner's interpretive phenomenological method. Eleven parents of seven children participated in observations and interviews. The following aspects of caring were illustrated in the themes arising from the findings: being a bridge to the child on the edge, building a sheltered atmosphere, meeting the child's needs, and adapting the environment for family life. The overall impression is that the phenomenon of caring is experienced exclusively when it is directed toward the exposed child. The conclusion drawn is that caring is present when providing expert physical care combined with fulfilling emotional needs and supporting continuing daily parental care for the child in an inviting environment. © The Author(s) 2013.
Sewchand, W.; Drzymala, R.E.; Amin, P.P.; Salcman, M.; Salazar, O.M.
A bedside lead cubicle was designed to minimize the radiation exposure of intensive care unit staff during routine interstitial brain irradiation by removable, high intensity iridium-192. The cubicle shields the patient without restricting intensive care routines. The design specifications were confirmed by exposure measurements around the shield with an implanted anthropomorphic phantom simulating the patient situation. The cubicle reduces the exposure rate around an implant patient by as much as 90%, with the exposure level not exceeding 0.1 mR/hour/mg of radium-equivalent 192 Ir. Evaluation of data accumulated for the past 3 years has shown that the exposure levels of individual attending nurses are 0.12 to 0.36 mR/mg of radium-equivalent 192 Ir per 12-hour shift. The corresponding range for entire nursing teams varies between 0.18 and 0.26. A radiation control index (exposure per mg of radium-equivalent 192 Ir per nurse-hour) is thus defined for individual nurses and nursing teams; this index is a significant guide to the planning of nurse rotations for brain implant patients with various 192 Ir loads. The bedside shield reduces exposure from 192 Ir implants by a factor of about 20, as expected, and the exposure from the lower energy radioisotope iodine-125 is barely detectable
Langlotz, Curtis P.; Cleff, Bridget; Even-Shoshan, Orit; Bozzo, Mary T.; Redfern, Regina O.; Brikman, Inna; Seshadri, Sridhar B.; Horii, Steven C.; Kundel, Harold L.
Our purpose is to determine the incremental costs (or savings) due to the introduction of picture archiving and communication systems (PACS) and computed radiology (CR) in a medical intensive care unit (MICU). Our economic analysis consists of three measurement methods. The first method is an assessment of the direct costs to the radiology department, implemented in a spreadsheet model. The second method consists of a series of brief observational studies to measure potential changes in personnel costs that might not be reflected in administrative claims. The third method (results not reported here) is a multivariate modeling technique which estimates the independent effect of PACS/CR on the cost of care (estimated from administrative claims data), while controlling for clinical case- mix variables. Our direct cost model shows no cost savings to the radiology department after the introduction of PACS in the medical intensive care unit. Savings in film supplies and film library personnel are offset by increases in capital equipment costs and PACS operation personnel. The results of observational studies to date demonstrate significant savings in clinician film-search time, but no significant change in technologist time or lost films. Our model suggests that direct radiology costs will increase after the limited introduction of PACS/CR in the MICU. Our observational studies show a small but significant effect on clinician film search time by the introduction of PACS/CR in the MICU, but no significant effect on other variables. The projected costs of a hospital-wide PACS are currently under study.
Almeida, Alessandro de Moura; Albuquerque, Ligia Carvalho; Bitencourt, Almir Galvão Vieira; Rolim, Carlos Eduardo Cerqueira; Godinho, Tiana Mascarenhas; Liberato, Maurício Valverde; Oliveira Filho, Fernando Cezar Cabral; Azevedo, Ana Bárbara Galvão de; Neves, Ana Paula Soares da Silva; Martins, Marcelo de Jesus; Silva, João Paulo Maciel; Jesuíno, Paulo André; Souza Filho, Sydney Agareno de
There are deficiencies on Intensive Medicine (IM) teaching in most of medical undergraduate schools. Those deficiencies may imply damages on their clinical competence. The objective of this study was to analyze current status of IM teaching and the medical undergraduate student interest in this speciality. A cross-sectional study was performed in 2005. We applied a self-reported questionnaire to enrolled students between the sixth and the last semesters of two medical schools from Salvador-Bahia. The questionnaire contained questions about students' interest and knowledge on IM, and opinion on IM teaching in their schools. We studied 570 students. Most of them (57.5%) had never realized a clerkship in intensive care unit (ICU) despite classifying its usefulness as high (mean of 4.14 ± 1.05, in a scale from 1 to 5). IM interest was high or very high in 53.7% of sample. Almost all students (97%) thought that IM topics should be more explored at their curriculum. Only 42.1% reported to be able to assess a critical care patient and this assurance was higher among students with previous clerkship in ICU (p < 0.001). Shock, cardiopulmonary resuscitation and sepsis were the most interesting topics in ICU for students' opinion. This study revealed a high interest in IM among medical undergraduate students. However, most had never practice a clerkship in ICU, demonstrating to be an important factor on undergraduate student performance faced to a critical care patient.
Korhan, Esra Akn; Yönt, Gülendam Hakverdioğlu; Erdemir, Firdevs; Müller-Staub, Maria
The purpose of this study was to determine intensive care unit nurses diagnostic abilities and diagnoses that they provide. A vignette study was performed. The vignette contained a patient's history, treatment, and signs/symptoms of 18 nursing diagnoses based on NANDA-I as the criterion standard. Turkish intensive care unit nurses (N = 45) stated nursing diagnoses described by patient data in the vignette. The resulting nursing diagnoses were grouped into Gordon's Functional Health Patterns, and descriptive analyses were performed. One-way analysis of variance was used to detect possible differences in diagnostic abilities based on nurses' education levels. Nurses identified 14 nursing diagnoses. Four of the predetermined psychosocial nursing diagnoses were not identified. The highest percentage of diagnoses was risk for impaired skin integrity (62.2%) and impaired oral mucous membrane (60.0%). The lowest number of diagnoses was impaired verbal communication (2.2%). A statistically significant difference was found between the educational level of nurses and their abilities to determine nursing diagnoses (P < .05). The findings are important for nursing education. They demonstrate the need to focus on patients as complete human beings, covering not only biological aspects but also cultural and social values, as well as emotional and spiritual care needs.
Spooner, Amy J; Aitken, Leanne M; Corley, Amanda; Chaboyer, Wendy
Despite increasing demand for structured processes to guide clinical handover, nursing handover tools are limited in the intensive care unit. The study aim was to identify key items to include in a minimum dataset for intensive care nursing team leader shift-to-shift handover. This focus group study was conducted in a 21-bed medical/surgical intensive care unit in Australia. Senior registered nurses involved in team leader handovers were recruited. Focus groups were conducted using a nominal group technique to generate and prioritise minimum dataset items. Nurses were presented with content from previous team leader handovers and asked to select which content items to include in a minimum dataset. Participant responses were summarised as frequencies and percentages. Seventeen senior nurses participated in three focus groups. Participants agreed that ISBAR (Identify-Situation-Background-Assessment-Recommendations) was a useful tool to guide clinical handover. Items recommended to be included in the minimum dataset (≥65% agreement) included Identify (name, age, days in intensive care), Situation (diagnosis, surgical procedure), Background (significant event(s), management of significant event(s)) and Recommendations (patient plan for next shift, tasks to follow up for next shift). Overall, 30 of the 67 (45%) items in the Assessment category were considered important to include in the minimum dataset and focused on relevant observations and treatment within each body system. Other non-ISBAR items considered important to include related to the ICU (admissions to ICU, staffing/skill mix, theatre cases) and patients (infectious status, site of infection, end of life plan). Items were further categorised into those to include in all handovers and those to discuss only when relevant to the patient. The findings suggest a minimum dataset for intensive care nursing team leader shift-to-shift handover should contain items within ISBAR along with unit and patient specific
Wasserfallen, Jean-Blaise; Bütschi, Anne-Joëlle; Muff, Patrik; Biollaz, Jérôme; Schaller, Marie-Denise; Pannatier, André; Revelly, Jean-Pierre; Chiolero, René
To assess whether formatting the medical order sheet has an effect on the accuracy and security of antibiotics prescription. Prospective assessment of antibiotics prescription over time, before and after the intervention, in comparison with a control ward. The medical and surgical intensive care unit (ICU) of a university hospital. All patients hospitalized in the medical or surgical ICU between February 1 and April 30, 1997, and July 1 and August 31, 2000, for whom antibiotics were prescribed. Formatting of the medical order sheet in the surgical ICU in 1998. Compliance with the American Society of Hospital Pharmacists' criteria for prescription safety was measured. The proportion of safe orders increased in both units, but the increase was 4.6 times greater in the surgical ICU (66% vs. 74% in the medical ICU and 48% vs. 74% in the surgical ICU). For unsafe orders, the proportion of ambiguous orders decreased by half in the medical ICU (9% vs. 17%) and nearly disappeared in the surgical ICU (1% vs. 30%). The only missing criterion remaining in the surgical ICU was the drug dose unit, which could not be preformatted. The aim of antibiotics prescription (either prophylactic or therapeutic) was indicated only in 51% of the order sheets. Formatting of the order sheet markedly increased security of antibiotics prescription. These findings must be confirmed in other settings and with different drug classes. Formatting the medical order sheet decreases the potential for prescribing errors before full computerized prescription is available.
Hjort Jakobsen, Dorthe; Rud, Kirsten; Kehlet, Henrik
guidelines based on the principles of fast-track surgery-i.e. patient information, surgical stress reduction, effective analgesia, early mobilisation and rapid return to normal eating. Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN...
Ríos Risquez, M I; Godoy Fernández, C; Peñalver Hernández, F; Alonso Tovar, A R; López Alcaraz, F; López Romera, A; Garnés González, S; Salmerón Saura, E; López Real, M D; Ruiz Sánchez, R; Simón Domingo, P; Manzanera Nicolás, J L; Menchón Almagro, M A; Liébanas Bellón, R
To assess and compare the burnout level between Intensive Care Unit and Emergency Unit, and study its association with the sociodemographic and work characteristics of the professionals surveyed. Cross-sectional, descriptive study. Emplacement. Intensive Care Unit of the university hospital Morales Meseguer, Murcia-Spain. STUDIED SAMPLE: 97 nursing professionals: 55 professionals belong to the Emergency Department, and 42 professionals belong to the Intensive Care Department. Two evaluation tools were used: a sociodemographic and work survey, and the Maslach Burnout Inventory, 1986. Quantitative variables expressed as mean +/- SD compared with the Student's T test and qualitative variables compared with the chi2 test. SPSS 12.0(c). The comparative analysis of the burnout dimensions shows that emotional exhaustion level is significantly higher in the intensive care service than in the emergency one (25.45 +/- 11.15 vs 22.09 +/- 10.99) p burnout dimensions do not show significant differences between both departments. The masculine gender obtains a higher score in the depersonalization dimension of burnout (10.12 +/- 5.38) than female one (6.7 +/- 5.21) p burnout levels are moderate to high among the nursing professionals studied. A total of 5.15% of the sample studied achieves a high score in the three dimensions of the burnout syndrome. The intensive care professionals are the most vulnerable to suffering high levels of emotional exhaustion, and the masculine gender is more susceptible to depersonalization attitudes.
Cuzco Cabellos, C; Guasch Pomés, N
Assess whether the use of the nursing care plans improves outcomes of nursing care to patients admitted to the intensive care unit (ICU). The study was conducted in a University Hospital of Barcelona in Spain, using a pre- and post-study design. A total of 61 patient records were analysed in the pre-intervention group. A care plan was applied to 55 patients in the post-intervention group. Specific quality indicators in a medical intensive care unit to assess the clinical practice of nursing were used. Fisher's exact test was used to compare the degree of association between quality indicators in the two groups. A total of 116 records of 121 patients were evaluated: 61 pre-intervention and 55 post-intervention. Fisher test: The filling of nursing records, p=.0003. Checking cardiorespiratory arrest equipment, p <.001. Central vascular catheter related bacteraemia (B-CVC) p=.622. Ventilator associated pneumonia (VAP) p=.1000. Elevation of the head of the bed more than 30° p=.049, and the pain management in non-sedated patients p=.082. The implementation of nursing care plans in patients admitted to the intensive care area may contribute to improvement in the outcomes of nursing care. Copyright © 2015 Elsevier España, S.L.U. y SEEIUC. All rights reserved.
Albaqawi, Hamdan M; Butcon, Vincent R; Molina, Roger R
To examine awareness of holistic patient care by staff nurses in the intensive care units of hospitals in the city of Hail, Saudi Arabia. Methods: A quantitative correlational study design was used to investigate relationships between intensive care nurse's awareness of holistic practices and nurses' latest performance review. Intensive care staff nurses (n=99) from 4 public sector hospitals in Hail were surveyed on their awareness of variables across 5 holistic domains: physiological, sociocultural, psychological, developmental, and spiritual. Data were collected between October and December 2015 using written survey, and performance evaluations obtained from the hospital administrations. Results were statistically analyzed and compared (numerical, percentage, Pearson's correlation, Chronbach's alpha). Results: The ICU staff nurses in Hail City were aware of the secular aspects of holistic care, and the majority had very good performance evaluations. There were no demographic trends regarding holistic awareness and nurse performance. Further, awareness of holistic care was not associated with nurse performance. Conclusion: A caring-enhancement workshop and a mentoring program for non-Saudi nurses may increase holistic care awareness and enhance its practice in the ICUs.
Karanikola, Maria N K; Papathanassoglou, Elizabeth D E; Mpouzika, Meropi; Lemonidou, Chrysoula
Burnout symptoms in Greek intensive care unit (ICU) nurses have not been explored adequately. The aim of this descriptive, correlational study was to investigate the prevalence and intensity of burnout symptoms in Greek ICU nursing personnel and any potential associations with professional satisfaction, as well as with demographic, educational, and vocational characteristics. Findings showed that the overall burnout level reported by Greek ICU nursing personnel was at a moderate to high degree. The most pronounced symptom of burnout was depersonalization, whereas emotional exhaustion was found to be a strong predictor of job satisfaction. This is a factor connected with the nurses' intention to quit the job. It appears that work factors have a more powerful influence over the development of burnout in comparison to personality traits.
Full Text Available Introduction: Stroke is the second most common cause of death and major cause of disability worldwide. About a quarter of stroke patients are dead within a month, about a third by 6 months, and a half by 1 year. Although the most substantial advance in stroke has been the routine management of patients in stroke care units, intensive care unit has remained the choice for stroke patients’ care in developing countries. This study explores the mortality of stroke patients in intensive care unit setting in tertiary care neurological centre in a developing country. Methods: We collected data of stroke patients admitted in our ICU from August 2009 to Aug 2010 and analyzed. Results: Total 44 (10.25% patients were admitted for acute stroke. Age ranged from 17-93 years. Low GCS (Glasgow Coma Scale, uncontrolled hypertension and aspiration pneumonia were common indications for admission in ICU. Total 23 (52.3% patients had hemorrhagic stroke and 21(47.7% patients had ischemic stroke. 13 (29.54% patients of stroke died within 7 days, 9 (69.23% patients of hemorrhagic stroke died within 6 days, and 4 patients (30.76% of ischemic stroke died within 7 days. 6 (13.63% patients left hospital against medical advice. All of these patients had ischemic stroke. Conclusions: Stroke mortality in intensive care unit remains high despite of care in tertiary neurological center in resource poor settings. Stroke care unit, which would also help dissemination of knowledge of stroke management, is an option for improved outcome in developing countries Keywords: intensive care unit; mortality; stroke; stroke care unit.
Ramírez-Puerta, M R; Fernández-Fernández, R; Frías-Pareja, J C; Yuste-Ossorio, M E; Narbona-Galdó, S; Peñas-Maldonado, L
To analyze the readability of informed consent documents (IC) used in an intensive care department and in the Andalusian Healthcare System (AHS). A descriptive study was carried out. The Intensive Care Unit of a tertiary Hospital, and the AHS. A review and analysis was made of the existing 14 IC models in the Intensive Care Unit and of another 14 IC models offered by the AHS, using the following readability scores: Flesch, Sentence complexity, LEGIN, Fernández-Huerta, Szigriszt and INFLESZ. Twenty-four IC (85.7%) failed to satisfy some of the indexes, while three (10.7%) did not satisfy any of them. Four documents (14.3%) satisfied all the indexes analyzed, and therefore are easy to understand. Flesch score: satisfied by one of the ICU IC (7.1%) and by three of the AHS documents (21.4%). Sentence complexity score: satisfied by 11 of the ICU IC (78.6%) and by 13 of the AHS documents (92.8%). Fernández-Huerta score: satisfied by four of the ICU IC (28.6%) and by 13 of the AHS documents (92.8%). Szigriszt score: satisfied by two of the ICU IC (14.3%) and by 11 of the AHS documents (64.3%). INFLESZ score: satisfied by two of the ICU IC (14.3%) and by 10 of the AHS documents (71.4%). The documents analyzed are generally difficult to read and understand by most people, and do not satisfy the basic purpose for which they were drafted. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.
Ng, K J; Yii, M K
Comparative surgical audit to monitor quality of care should be performed with a risk-adjusted scoring system rather than using crude morbidity and mortality rates. A validated and widely applied risk adjusted scoring system, P-POSSUM (Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality) methodology, was applied to a prospective series of predominantly general surgical patients at the Sarawak General Hospital, Kuching over a six months period. The patients were grouped into four risk groups. The observed mortality rates were not significantly different from predicted rates, showing that the quality of surgical care was at par with typical western series. The simplicity and advantages of this scoring system over other auditing tools are discussed. The P-POSSUM methodology could form the basis of local comparative surgical audit for assessment and maintenance of quality care.
Savel, Richard H; Cohen, Wess; Borgia, Dena; Simon, Ronald J
The primary purpose of this narrative is to elucidate the numerous significant changes that occur at the intensive care unit (ICU) level as a medical center pursues becoming a Level I trauma center. Specifically, we will focus on the following important areas: (1) leadership and strategy issues behind the decision to move forward with becoming a trauma center; (2) preparation needed to take a highly functioning surgical ICU and align it for the inevitable changes that happen as trauma go-live occurs; (3) intensivist staffing changes; (4) roles for and training of advanced practice practitioners; (5) graduate medical education issues; (6) optimizing interactions with closely related services; (7) nursing, staffing, and training issues; (8) bed allocation issues; and (9) reconciling the advantages of a "unified adult critical care service" with the realities of the central relationship between trauma and surgical critical care.
Richard H Savel
Full Text Available The primary purpose of this narrative is to elucidate the numerous significant changes that occur at the intensive care unit (ICU level as a medical center pursues becoming a Level I trauma center. Specifically, we will focus on the following important areas: (1 leadership and strategy issues behind the decision to move forward with becoming a trauma center; (2 preparation needed to take a highly functioning surgical ICU and align it for the inevitable changes that happen as trauma go-live occurs; (3 intensivist staffing changes; (4 roles for and training of advanced practice practitioners; (5 graduate medical education issues; (6 optimizing interactions with closely related services; (7 nursing, staffing, and training issues; (8 bed allocation issues; and (9 reconciling the advantages of a “unified adult critical care service” with the realities of the central relationship between trauma and surgical critical care.
Vlayen, Annemie; Verelst, Sandra; Bekkering, Geertruida E; Schrooten, Ward; Hellings, Johan; Claes, Neree
Adverse events are unintended patient injuries or complications that arise from health care management resulting in death, disability or prolonged hospital stay. Adverse events that require critical care are a considerable financial burden to the health care system, but also their global impact on patients and society is probably underestimated. The objectives of this systematic review were to synthesize the best available evidence regarding the estimates of the incidence and preventability of adverse events that necessitate intensive care admission, to determine the type and consequences [mortality, length of intensive care unit (ICU) stay and costs] of these adverse events. MEDLINE (from 1966 to present), EMBASE (from 1974 to present) and CENTRAL (version 1-2010) were searched for studies reporting on unplanned admissions on ICUs. Several other sources were searched for additional studies. Only quantitative studies that used chart review for the detection of adverse events requiring intensive care admission were considered for eligibility. For the purposes of this systematic review, ICUs were defined as specialized hospital facilities which provide continuous monitoring and intensive care for acutely ill patients. Studies that were published in the English, Dutch, German, French or Spanish language were eligible for inclusion. Two reviewers independently extracted data and assessed the methodological quality of the included studies. A total of 27 studies were reviewed. Meta-analysis of the data was not appropriate because of methodological and statistical heterogeneity between studies; therefore, results are presented in a descriptive way. The percentage of surgical and medical adverse events that required ICU admission ranged from 1.1% to 37.2%. ICU readmissions varied from 0% to 18.3%. Preventability of the adverse events varied from 17% to 76.5%. Preventable adverse events are further synthesized by type of event. Consequences of the adverse events included a
Weinreich, Mark; Herman, Jennifer; Dickason, Stephanie; Mayo, Helen
This paper is a synthesis of the available literature on occupational therapy interventions performed in the adult intensive care unit (ICU). The databases of Ovid MEDLINE, Embase, the Cochrane Library, ClinicalTrials.gov and CINAHL databases were systematically searched from inception through August 2016 for studies of adults who received occupational therapy interventions in the ICU. Of 1,938 citations reviewed, 10 studies met inclusion criteria. Only one study explicitly discussed occupational therapy interventions performed and only one study specifically tested the efficacy of occupational therapy. Future research is needed to clarify the specific interventions and role of occupational therapy in the ICU and the efficacy of these interventions.
Eddelien, Heidi Shil; Hoffmeyer, Henrik Westy; Lund, Eva Charlotte Løbner
Glucocorticoids (GC) are used for intensive care unit (ICU) patients on several indications. We present a patient who was admitted to the ICU due to severe respiratory failure caused by bronchospasm requiring mechanical ventilation and treated with methylprednisolone 240 mg/day in addition...... to antibiotics and bronchiolytics. When the sedation was lifted on day 10, the patient was awake but quadriplegic. Blood samples revealed elevated muscle enzymes, electromyography showed myopathy, and a muscle biopsy was performed. Glucocorticoid-induced myopathy was suspected, GC treatment was tapered...
Aasen, S.E.; Johansson, A.; Cristensen, T.
In this study the magnetic flux density in and around the infant incubators of a neonatal intensive care unit were registered and mapped. The mean 50 Hz magnetic flux densities in an incubator was typically in the region 0.2 - l μT, with maximum values around 1.5μT. The field levels are quite varying dependent on type of incubator, position in the incubator, position of the electronic surveillance and treatment equipment and the position of the 220 V main plugs. 8 refs., 21 figs., 2 tabs
Jantsch, H.; Winkler, M.; Pichler, W.; Mauritz, W.; Lechner, G.; Vienna Univ.
In 55 intensive-care patients an additional tangential view of the chest was taken to demonstrate or exclude a pneumothorax in patients with sudden deterioration of gas exchange and negative ap-chest x-ray, if there was a suspicion of pneumothorax or a confirmed small pneumothorax in the ap-view. In 14 of 42 cases (33.3%) with negative or suspected ap-chest x-ray the tangential view revealed a pneumothorax. 6 of these 14 pneumothoraces were under tension. In 7 out of 11 patients (63.6%) with small pneumothorax, the tangential view showed additionally a tensionpneumothorax. (orig.) [de
Galanski, M.; Hartenauer, U.; Krumme, B.
Pneumothorax is the most severe manifestation of pulmonary barotrauma which occurs in mechanical ventilation. Diagnosis of pneumothorax in intensive care radiology is of particular difficulty. Chest radiographs in supine position show a variety of signs which may be helpful but are not conclusive. There are different techniques for verification of ventrally located pneumothorax. 45 0 tangential radiographs of the hemithorax in question are most conclusive for demonstration of extrapulmonary air located inside the pleural cavity. This 45 0 technique is easy to carry out without changing the patients position. (orig.) [de
Paes, B; Mitchell, A; Hunsberger, M; Blatz, S; Watts, J; Dent, P; Sinclair, J; Southwell, D
Advances in technology have improved the survival rates of infants of low birth weight. Increasing service commitments together with cutbacks in Canadian training positions have caused concerns about medical staffing in neonatal intensive care units (NICUs) in Ontario. To determine whether an imbalance exists between the supply of medical personnel and the demand for health care services, in July 1985 we surveyed the medical directors, head nurses and staff physicians of nine tertiary level NICUs and the directors of five postgraduate pediatric residency programs. On the basis of current guidelines recommending an ideal neonatologist:patient ratio of 1:6 (assuming an adequate number of support personnel) most of the NICUs were understaffed. Concern about the heavy work pattern and resulting lifestyle implications has made Canadian graduates reluctant to enter this subspecialty. We propose strategies to correct staffing shortages in the context of rapidly increasing workloads resulting from a continuing cutback of pediatric residency positions and restrictions on immigration of foreign trainees.
Full Text Available The present prospective study was carried out in the Paediatric Intensive Care Unit (PICU of a tertiary care teaching hospital in Mumbai. The objective was to determine the incidence, risk factors, mortality and organisms responsible for urinary catheter related infections (UCRI. Colonization and/or bacteriuria was labelled as urinary catheter related infection (UCRI. Forty-four patients with 51 urinary catheters were studied. Incidence of UCRI was 47.06%. Age, female sex and immunocompromised status did not increase the risk of UCRI. Duration of catheter in-situ and duration of stay in the PICU were associated with higher risk of UCRI. The mortality was not increased by UCRI. Commonest organism isolated in UCRI was E. coli, which had maximum susceptibility to nitrofurantoin and amikacin.
Elaine Cantarella Lima
Full Text Available ABSTRACT Objective: The goal of this study is to analyze nurses’ leadership in intensive care units at hospitals in the state of São Paulo, Brazil, in the face of positive and negative critical incidents. Method: Exploratory, descriptive study, conducted with 24 nurses by using the Critical Incident Technique as a methodological benchmark. Results: Results were grouped into 61 critical incidents distributed into categories. Researchers came to the conclusion that leadership-related situations interfere with IC nurses’ behaviors. Among these situations they found: difficulty in the communication process; conflicts in the daily exercise of nurses’ activities; people management; and the setting of high quality care targets. Final considerations: Researchers identified a mixed leadership model, leading them to the conclusion that nurses’ knowledge and practice of contemporary leadership theories/styles are crucial because they facilitate the communication process, focusing on behavioral aspects and beliefs, in addition to valuing flexibility. This positively impacts the organization’s results.
Maastrup, Ragnhild; Bojesen, Susanne Nordby; Kronborg, Hanne
Background: The incidence of breastfeeding of preterm infants is affected by the support provided at the hospital and in the neonatal intensive care unit (NICU). However, policies and guidelines promoting breastfeeding vary both nationally and internationally. Objectives: The aim of this survey...... was to describe breastfeeding support in Danish NICUs, where approximately 98% of mothers initiate lactation. Methods: A national survey of all 19 Danish NICUs was conducted in 2009. Four NICUs were at designated Baby-Friendly hospitals, and 5 had a lactation consultant. In all NICUs, it was possible for some...... parents to stay overnight; 2 units had short restrictions on parents' presence. Five NICUs had integrated postpartum care for mothers. Breastfeeding policies, written guidelines, and systematic breastfeeding training for the staff were common in most NICUs. Seventeen NICUs recommended starting breast milk...
Oosterhouse, Kimberly J; Vincent, Catherine; Foreman, Marquis D; Gruss, Valerie A; Corte, Colleen; Berger, Barbara
Delirium, the most frequent complication of hospitalized older adults, particularly in intensive care units (ICUs), can result in increased mortality rates and length of stay. Nurses are neither consistently identifying nor managing delirium in these patients. The purpose of this study was to explore ICU nurses' identification of delirium, actions they would take for patients with signs or symptoms of delirium, and beliefs about delirium assessment and management. In this cross-sectional study using qualitative descriptive methods guided by the theory of planned behavior, 30 ICU nurses' responses to patient vignettes depicting different delirium subtypes were explored. Descriptive and content analyses revealed that nurses did not consistently identify delirium; their actions varied in different vignettes. Nurses believed that they needed adequate staffing, balanced workload, interprofessional collaboration, and established policy and protocols to identify and manage delirium successfully. Research is needed to determine if implementing these changes increases recognition and decreases consequences of delirium. ©2016 American Association of Critical-Care Nurses.
Van den Bulcke, Bo; Vyt, Andre; Vanheule, Stijn; Hoste, Eric; Decruyenaere, Johan; Benoit, Dominique
This article describes a study that evaluated the quality of teamwork in a surgical intensive care unit and assessed whether teamwork could be improved significantly through a tailor-made intervention. The quality of teamwork prior to and after the intervention was assessed using the Interprofessional Practice and Education Quality Scales (IPEQS) using the PROSE online diagnostics and documenting system, which assesses three domains of teamwork: organisational factors, care processes, and team members' attitudes and beliefs. Furthermore, team members evaluated strengths and weaknesses of the teamwork through open-ended questions. Information gathered by means of the open questions was used to design a tailor-made 12-week intervention consisting of (1) optimising the existing weekly interdisciplinary meetings with collaborative decision-making and clear communication of goal-oriented actions, including the psychosocial aspects of care; and (2) organising and supporting the effective exchange of information over time between all professions involved. It was found that the intervention had a significant impact on organisational factors and care processes related to interprofessional teamwork for the total group and within all subgroups, despite baseline differences between the subgroups in interprofessional teamwork. In conclusion, teamwork, and more particularly the organisational aspects of interprofessional collaboration and processes of care, can be improved by a tailor-made intervention that takes into account the professional needs of healthcare workers.
Matlakala, M C; Bezuidenhout, M C; Botha, A D H
To illustrate the need for and suggest strategies that will enhance sustainable management of a large intensive care unit (ICU). The challenges faced by intensive care nursing in South Africa are well documented. However, there appear to be no strategies available to assist nurses to manage large ICUs or for ICU managers to deal with problems as they arise. Data sources to illustrate the need for strategies were challenges described by ICU managers in the management of large ICUs. A purposive sample of managers was included in individual interviews during compilation of evidence regarding the challenges experienced in the management of large ICUs. The challenges were presented at the Critical Care Society of Southern Africa Congress held on 28 August to 2 September 2012 in Sun City North-West province, South Africa. Five strategies are suggested for the challenges identified: divide the units into sections; develop a highly skilled and effective nursing workforce to ensure delivery of quality nursing care; create a culture to retain an effective ICU nursing team; manage assets; and determine the needs of ICU nurses. ICUs need measures to drive the desired strategies into actions to continuously improve the management of the unit. Future research should be aimed at investigating the effectiveness of the strategies identified. This research highlights issues relating to large ICUs and the strategies will assist ICU managers to deal with problems related to large unit sizes, shortage of trained ICU nurses, use of agency nurses, shortage of equipment and supplies and stressors in the ICU. The article will make a contribution to the body of nursing literature on management of ICUs. © 2014 John Wiley & Sons Ltd.
Chuang, Chien-Huai; Tseng, Pei-Chi; Lin, Chun-Yu; Lin, Kuan-Han; Chen, Yen-Yuan
Burnout has been described as a prolonged response to chronic emotional and interpersonal stress on the job that is often the result of a period of expending excessive effort at work while having too little recovery time. Healthcare workers who work in a stressful medical environment, especially in an intensive care unit (ICU), may be particularly susceptible to burnout. In healthcare workers, burnout may affect their well-being and the quality of professional care they provide and can, therefore, be detrimental to patient safety. The objectives of this study were: to determine the prevalence of burnout in the ICU setting; and to identify factors associated with burnout in ICU professionals. The original articles for observational studies were retrieved from PubMed, MEDLINE, and Web of Science in June 2016 using the following MeSH terms: "burnout" and "intensive care unit". Articles that were published in English between January 1996 and June 2016 were eligible for inclusion. Two reviewers evaluated the abstracts identified using our search criteria prior to full text review. To be included in the final analysis, studies were required to have employed an observational study design and examined the associations between any risk factors and burnout in the ICU setting. Overall, 203 full text articles were identified in the electronic databases after the exclusion of duplicate articles. After the initial review, 25 studies fulfilled the inclusion criteria. The prevalence of burnout in ICU professionals in the included studies ranged from 6% to 47%. The following factors were reported to be associated with burnout: age, sex, marital status, personality traits, work experience in an ICU, work environment, workload and shift work, ethical issues, and end-of-life decision-making. The impact of the identified factors on burnout remains poorly understood. Nevertheless, this review presents important information, suggesting that ICU professionals may suffer from a high level
Huffines, Meredith; Johnson, Karen L; Smitz Naranjo, Linda L; Lissauer, Matthew E; Fishel, Marmie Ann-Michelle; D'Angelo Howes, Susan M; Pannullo, Diane; Ralls, Mindy; Smith, Ruth
Background Survey data revealed that families of patients in a surgical intensive care unit were not satisfied with their participation in decision making or with how well the multidisciplinary team worked together. Objectives To develop and implement an evidence-based communication algorithm and evaluate its effect in improving satisfaction among patients' families. Methods A multidisciplinary team developed an algorithm that included bundles of communication interventions at 24, 72, and 96 hours after admission to the unit. The algorithm included clinical triggers, which if present escalated the algorithm. A pre-post design using process improvement methods was used to compare families' satisfaction scores before and after implementation of the algorithm. Results Satisfaction scores for participation in decision making (45% vs 68%; z = -2.62, P = .009) and how well the health care team worked together (64% vs 83%; z = -2.10, P = .04) improved significantly after implementation. Conclusions Use of an evidence-based structured communication algorithm may be a way to improve satisfaction of families of intensive care patients with their participation in decision making and their perception of how well the unit's team works together.
Doede, Megan; Trinkoff, Alison M; Gurses, Ayse P
Neonatal intensive care units (NICUs) remain one of the few areas in hospitals that still use an open bay (OPBY) design for patient stays greater than 24 hr, housing multiple infants, staff, and families in one large room. This creates high noise levels, contributes to the spread of infection, and affords families little privacy. These problems have given rise to the single-family room NICU. This represents a significant change in the care environment for nurses. This literature review answers the question: When compared to OPBY layout, how does a single family room layout impact neonatal nurses' work? Thirteen studies published between 2006 and 2015 were located. Many studies reported both positive and negative effects on nurses' work and were therefore sorted by their cited advantages and disadvantages. Advantages included improved quality of the physical environment; improved quality of patient care; improved parent interaction; and improvements in nurse job satisfaction, stress, and burnout. Disadvantages included decreased interaction among the NICU patient care team, increased nurse workload, decreased visibility on the unit, and difficult interactions with family. This review suggests that single-family room NICUs introduce a complex situation in which trade-offs occur for nurses, most prominently the trade-off between visibility and privacy. Additionally, the literature is clear on what elements of nurses' work are impacted, but how the built environment influences these elements, and how these elements interact during nurses' work, is not as well understood. The current level of research and directions for future research are also discussed.
Full Text Available Introduction: The patients’ families in intensive care units (ICUs experience excessive stress which may disrupt their performance in daily life. Empathy is basic to the nursing role and has been found to be associated with improved patient outcomes and greater satisfaction with care in patient and his/her family. However, few studies have investigated the nursing empathy with ICU patients. This study aimed to assess nursing empathy and its relationship with the needs, from the perspective of families of patients in ICU.Methods: In this cross-sectional study, 418 subjects were selected among families of patients admitted to ICUs in Tabriz, Iran, by convenience sampling, from May to August 2012. Data were collected through Barrett-Lennard Relationship inventory (BLRI empathy scale and Critical Care Family Needs Intervention (CCFNI inventories and were analyzed using descriptive and inferential statistical tests. Results: Findings showed that most of the nurses had high level of empathy to the patients (38.8%. There was also statistically significant relationship between nurses’ empathy and needs of patients’ families (p < 0.001. Conclusion: In this study we found that by increasing the nurse’s empathy skills, we would be able to improve providing family needs. Through empathic communication, nurses can encourage family members to participate in planning for the care of their patients. However, further studies are necessary to confirm the results.
Baeza-Bacab, Manuel Antonio
Here, two papers are presented, which constitute the first reports of surgical procedures in Mexican children performed at the 19 th century. The two publications refer to surgical operations for the extraction of bladder stones. At that time, there was no anesthesia, so part of the description alludes to the suffering of the patients and the operative difficulties. The first case, is referred to as a lithotomy in a 17-year-old girl, performed by surgeon José Victoriano Guerrero in Guadalajara in 1822. The publication is not an academic report, but a pamphlet written as a gift to Emperor Augustin I to celebrate his ascension to the throne. The second work, is a lateral lithotomy in a 5-year-old boy, published by Dr. Luis Jecker in the first issue of the Periódico de la Academia de Medicina de Mégico in 1836. Copyright: © 2018 Permanyer.
Lei, Jin'e; Han, Shaoshan; Wu, Wenjing; Wang, Xue; Xu, Jiru; Han, Lei
Extensively drug-resistant Acinetobacter baumannii (XDRAB) is a great threat in intensive care units (ICUs). The aim of this study was to describe an XDRAB outbreak which was cross-transmitted in the ICU and respiratory intensive care unit (RICU) in a tertiary care hospital from January-March 2013. Patient and environmental surveillances were performed. Isolates were tested for antimicrobial susceptibility. Genotypes were analyzed by multilocus sequence typing (MLST). A series of enhanced strategies were implemented to control the outbreak. A total of 11 patients were infected by XDRAB strains during this outbreak. Three patients in the ICU were found positive for XDRAB at the onset of the outbreak. Thereafter, infections were detected in 6 patients in the RICU, followed by reappearance of this strain in the ICU in 2 patients. All A baumannii strains isolated from patients and the environment were extensively drug resistant. MLST revealed them as ST368. After 3 rounds of environmental screening and cleaning, the laminar flow system connecting the ICU and RICU was found as the source of transmission. Successful control of this outbreak was achieved through multifaceted intervention measures. This study suggested the importance of thorough surveillance and disinfection of the environment, including concealed devices, in preventing the transmission of an outbreak. Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Maher, Kevin O; Chang, Anthony C; Shin, Andrew; Hunt, Juliette; Wong, Hector R
The word innovation is derived from the Latin noun innovatus, meaning renewal or change. Although companies such as Google and Apple are nearly synonymous with innovation, virtually all sectors in our current lives are imbued with yearn for innovation. This has led to organizational focus on innovative strategies as well as recruitment of chief innovation officers and teams in a myriad of organizations. At times, however, the word innovation seems like an overused cliché, as there are now more than 5,000 books in print with the word "innovation" in the title. More recently, innovation has garnered significant attention in health care. The future of health care is expected to innovate on a large scale in order to deliver sustained value for an overall transformative care. To date, there are no published reports on the state of the art in innovation in pediatric health care and in particular, pediatric cardiac intensive care. This report will address the issue of innovation in pediatric medicine with relevance to cardiac intensive care and delineate possible future directions and strategies in pediatric cardiac intensive care. © The Author(s) 2015.
Cochran, Amalia; Davis, Lynn; Morris, Stephen E; Saffle, Jeffrey R
Aggressive glycemic management in critically ill patients with acute burn injury or life-threatening soft-tissue infections has not been thoroughly evaluated. An intensive insulin protocol with target glucose values of less than 120 mg/dl was implemented in October 2005 in our regional Burn-Trauma intensive care unit. We reviewed our initial experience with this protocol to evaluate the safety and efficacy of aggressive glycemic control in these patient groups. Patients were placed on the intensive insulin protocol based upon the need for glycemic management during their hospitalization for burn or soft-tissue disease. Patient information prospectively collected while on protocol included all measured blood glucose values, total daily insulin use, and incidence of hypoglycemic episodes, defined as serum glucose patients (17 burns, 13 soft-tissue infections) were placed on the intensive insulin protocol during the first 16 months of use. The mean daily blood glucose level for burn patients was 115.9 mg/dl and for soft-tissue disease patients was 119.5 mg/dl. There was a 5% incidence of hypoglycemic episodes per protocol day. All hypoglycemic episodes were treated by holding the insulin infusion, and no episode had known adverse effects. Hyperglycemia in critically ill patients with burns and extensive soft-tissue disease can be effectively managed with an insulin protocol that targets blood glucose values of less than 120 mg/dl with minimal incidence of hypoglycemia. A multicenter prospective randomized trial would provide the ideal forum for evaluating clinical outcome benefits of using an intensive insulin protocol.
Tripathy, Swagata; Routray, Pragyan K; Mishra, Jagdish C
Intensive Care Unit (ICU) nurses have a vital role in the implementation of end of life (EOL) care. There is limited data on the attitude of ICU nurses toward EOL and palliation. This study aimed to investigate knowledge, attitude, and beliefs of intensive care nurses in eastern India toward EOL. A self-administered questionnaire was distributed to delegates in two regional critical care nurses' training programs. Of 178 questionnaires distributed, 138 completed, with a response rate of 75.5*. About half (48.5*) had more than 1 year ICU experience. A majority (81.9*) agreed that nurses should be involved in and initiate (62.3*) EOL discussions. Terms "EOL care or palliative care in ICU" were new for 19.6*; 21* and 55.8* disagreed with allowing peaceful death in terminal patients and unrestricted family visits, respectively. Work experience was associated with wanting unrestricted family visitation, discontinuing monitoring and investigations at EOL, equating withholding and withdrawal of treatment, and being a part of EOL team discussions ( P = 0.005, 0.01, 0.01, and 0.001), respectively. Religiousness was associated with a greater desire to initiate EOL discussions ( P = 0.001). Greater emphasis on palliative care in critical care curriculum may improve awareness among critical care nurses.
Full Text Available Objectives: The objective of this study was to describe the care practices of nursing staff caring older people with dementia in a surgical ward. Methods: The data were collected from nursing staff (n = 191 working in surgical wards in one district area in Finland during October to November 2015. Data were collected using a structured questionnaire and analyzed statistically. The instrument consists of a total number of 141 items and four dimensions. The dimensions were as follows: background information (12 of items, specific characteristics of older people with dementia in a surgical ward (24 of items, specific characteristics of their care in a surgical ward (66 of items and use of physical restraints and alternative models for use of restraints for people with dementia (39 of items. Results: The questions which measure the nursing staff’s own assessment of care practices when caring for people with dementia in surgical wards were selected: counseling people with dementia, reaction when a surgical patient with dementia displays challenging behavior and use of alternative approach instead of physical restraints. Most commonly the nursing staff pay attention to patient’s state of alertness before counseling older people with dementia. Instead of using restraints, nursing staff gave painkillers for the patient and tried to draw patients’ attention elsewhere. The nursing staff with longer work experience estimate that they can handle the patients’ challenging behavior. They react by doing nothing more often than others. They pretend not to hear, see or notice anything. Conclusion: The findings of this study can be applied in nursing practice and in future studies focusing on the care practices among older people with dementia in acute care environment. The results can be used while developing patient treatments process in surgical ward to meet future needs.
Melles, M; Freudenthal, A; de Ridder, H
This study investigates how future informatics applications can support and challenge intensive care nurses (ICU nurses) to grow and learn continuously. To this end a research-and-design tool is introduced which is based on a model of the nursing process that starts from the idea that a nurse fulfills three different roles: the role of practitioner (using information immediately to base actions upon), the role of scholar (using information later on to learn from) and the role of human (coping with stress and dealing with emotions). In this paper the focus is on the scholar role. Twenty-eight intensive care staff members from six different hospitals were asked to recount an imposing experience from the perspective of each role. Regarding the scholar role, the participants mentioned 77 learning strategies they adopt for individual as well as organizational learning. Individual learning concerned reflection on former patient cases, reflection on current patient cases to anticipate a change in the patient's condition and reflection on personal behavior and decisions. Organizational learning concerned reflection on former patient cases. Examples of specific strategies were formal team evaluations focused on procedure and understanding the perspective of team members, being present at autopsies, and giving feedback on the nursing skills of colleagues. Based on these strategies design implications are defined for future nursing informatics applications, which will be presented.
Mohammad Hasan Kargar Maher
Full Text Available IntroductionChildren with severe asthma attack are a challenging group of patients who could be difficult to treat and leading to significant morbidity and mortality. Asthma attack severity is qualitatively estimated as mild, moderate and severe attacks and respiratory failure based on conditions such as respiration status, feeling of dyspnea, and the degree of unconsciousness. part of which are subjective rather than objective. We investigated clinical findings as predictors of severe attack and probable requirement for Pediatric Intensive Care Unit (PICU admission.Materials and MethodsIn a cross sectional and analytical study 120 patients with asthma attack were enrolled from April 2010 to April 2014 (80 admitted in the ward and 40 in pediatric intensive care unit. Predictors of PICU admission were investigated regarding to initial heart rate(HR, respiratory rate (RR, Arterial Oxygen Saturation(SaO2 and PaCo2 and clinically evident cyanosis.ResultsInitial heart rate(p-value=0.02, respiratory rate (p-value=0.03, Arterial Oxygen Saturation(p-value=0.02 and PaCo2(p-value=0.03 and clinically evident cyanosis were significantly different in two groups(Ward admitted and PICU admittedConclusion There was a significant correlation between initial vital sign and blood gas analysis suggesting usefulness of these factors as predictors of severe asthma attack and subsequent clinical course.
Full Text Available Toxic epidermal necrolysis (TEN is a serious adverse drug reaction with high lethality, which usually requires intensive-medical care. A 44-year-old man developed generalized exanthema with increasing exfoliation and mucosal involvement after taking allopurinol, ibuprofen, and etoricoxib. The clinical diagnosis of TEN was histologically confirmed. Prednisolone therapy with 3 mg/kg body weight (BW was not able to prevent further progress to finally 80% of the body surface, and infliximab 5 mg/kg BW was given as a single dose. This prevented further progression of the TEN. Despite marked improvement in skin findings, the ICU stay was prolonged by a complex analgosedation, transient kidney failure, volume management, positioning therapy, and vegetatively impeded weaning. Moreover, there was colonization with multiresistant bacteria (MRSA and VRE. Nonetheless, the patient could be restored to health and was released after four weeks. Infliximab seems to be effective in the treatment of TEN, especially in cases of rapid progression. Moreover, patients with TEN are difficult to handle in intensive-medical care, whereby attention should especially be paid to sufficient pain therapy, and the positioning of the patient is a particular challenge.
Beil, M; Sviri, S; de la Guardia, V; Stav, I; Ben-Chetrit, E; van Heerden, P V
Variable mortality rates have been reported for patients with rheumatic diseases admitted to an intensive care unit (ICU). Due to the absence of appropriate control groups in previous studies, it is not known whether the presence of a rheumatic disease constitutes a risk factor. Moreover, the accuracy of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score for predicting outcome in this group of patients has been questioned. The primary goal of this study was to compare outcome of patients with rheumatic diseases admitted to a medical ICU to those of controls. The records of all patients admitted between 1 April 2003 and 30 June 2014 (n=4020) were screened for the presence of a rheumatic disease during admission (n=138). The diagnosis of a rheumatic disease was by standard criteria for these conditions. An age- and gender-matched control group of patients without a rheumatic disease was extracted from the patient population in the database during the same period (n=831). Mortality in ICU, in hospital and after 180 days did not differ significantly between patients with and without rheumatic diseases. There was no difference in the performance of the APACHE II score for predicting outcome in patients with rheumatic diseases and controls. This score, as well as a requirement for the use of inotropes or vasopressors, accurately predicted hospital mortality in the group of patients with rheumatic diseases. In conclusion, patients with a rheumatic condition admitted to intensive care do not do significantly worse than patients without such a disease.
Kramer, Bree; Joshi, Prashant; Heard, Christopher
Patients and staff may experience adverse effects from exposure to noise. This study assessed noise levels in the pediatric intensive care unit and evaluated family and staff opinion of noise. Noise levels were recorded using a NoisePro DLX. The microphone was 1 m from the patient's head. The noise level was averaged each minute and levels above 70 and 80 dBA were recorded. The maximum, minimum, and average decibel levels were calculated and peak noise level great than 100 dBA was also recorded. A parent questionnaire concerning their evaluation of noisiness of the bedside was completed. The bedside nurse also completed a questionnaire. The average maximum dB for all patients was 82.2. The average minimum dB was 50.9. The average daily bedside noise level was 62.9 dBA. The average % time where the noise level was higher than 70 dBA was 2.2%. The average percent of time that the noise level was higher than 80 dBA was 0.1%. Patients experienced an average of 115 min/d where peak noise was greater than 100 dBA. The parents and staff identified the monitors as the major contribution to noise. Patients experienced levels of noise greater than 80 dBA. Patients experience peak noise levels in excess of 100 dB during their pediatric intensive care unit stay. Copyright © 2016 Elsevier Inc. All rights reserved.
Trubuhovich, R V
In taking 1960 as the foundation year for the practice of intensive care medicine in New Zealand, this paper briefly looks into the previous two centuries for some interventions in life-threatening conditions. With the help of descriptions in early 19th century journals and books by perceptive observers, the author focuses on some beliefs and practices of the Maori people during pre-European and later times, as well as aspects of medical treatment in New Zealand for early settlers and their descendents. Dr Laurie Gluckman's book Tangiwai has proved a valuable resource for New Zealand's medical history prior to 1860, while the recent publication of his findings from the examination of coroners' records for Auckland, 1841 to 1864, has been helpful. Drowning is highlighted as a common cause of accidental death, and consideration is given to alcohol as a factor. Following the 1893 foundation of the New Zealand Medical Journal, a limited number of its papers which are historically relevant to today's intensive care are explored: topics include tetanus, laryngeal diphtheria, direct cardiac massage, traumatic shock, thiopentone management for fitting and the ventilatory failure due to poliomyelitis.
The purpose of the study was to present recommendations, relevant to the management of neonates and infants aged 0-1 years, treated in intensive care settings. They include general principles and recommendations for pain and sedation assessment, sedation and pain management and advice on the use of pharmacological strategies. The bolus (on demand) administration of sedative agents should be avoided because of increased risk of cardiovascular depression and/or neurological complications. Midazolam administration time should be limited to 72 hours because of tachyphylaxis, and the possibility of development of a withdrawal syndrome and neurological complications (grade A, LOE 1b). The level of sedation and pain should be regularly assessed and documented, using presented scales; the COMFORT scale is preferred. Opioids, given in continuous infusion, are the drugs of choice for neonatal sedation. To avoid withdrawal syndrome, the total doses and time of administration of sedative agents should be limited. Methadone is a drug of choice in the treatment of a withdrawal (Grade B, LOE 2). Intravenous ketamine is recommended, when short-term sedation/anaesthesia is required (Grade C, LOE 3) for painful and/or stressful intensive care procedures. (Grade C, LOE 2). Muscle relaxants should be used for endotracheal intubation and in the situations when mechanical ventilation is not possible due to maximal respiratory effort of the patient.
Full Text Available Tanyong Pipanmekaporn,1 Nahathai Wongpakaran,2 Sirirat Mueankwan,3 Piyawat Dendumrongkul,2 Kaweesak Chittawatanarat,3 Nantiya Khongpheng,3 Nongnut Duangsoy31Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 2Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 3Division of Surgical Critical Care and Trauma, Department of Surgery, Chiang Mai University Hospital, Chiang Mai, ThailandPurpose: The purpose of this study was to determine the validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU, when compared to the diagnoses made by delirium experts.Patients and methods: This was a cross-sectional study conducted in both surgical intensive care and subintensive care units in Thailand between February–June 2011. Seventy patients aged 60 years or older who had been admitted to the units were enrolled into the study within the first 48 hours of admission. Each patient was randomly assessed as to whether they had delirium by a nurse using the Thai version of the CAM-ICU algorithm (Thai CAM-ICU or by a delirium expert using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.Results: The prevalence of delirium was found to be 18.6% (n=13 by the delirium experts. The sensitivity of the Thai CAM-ICU’s algorithms was found to be 92.3% (95% confidence interval [CI] =64.0%-99.8%, while the specificity was 94.7% (95% CI =85.4%-98.9%. The instrument displayed good interrater reliability (Cohen’s κ=0.81; 95% CI =0.64-0.99. The time taken to complete the Thai CAM-ICU was 1 minute (interquatile range, 1-2 minutes.Conclusion: The Thai CAM-ICU demonstrated good validity, reliability, and ease of use when diagnosing delirium in a surgical intensive care unit setting. The use of this diagnostic tool should be encouraged for daily, routine use, so as to promote the early detection
Samokhvalov, I M; Zavrazhnov, A A; Fakhrutdinov, A M; Sychev, M I
The results of rendering of the medical care (the first aid, qualified and specialized) obtained in 172 servicemen with neck injuries who stayed in Republic of Chechnya during the period from 09.08.1999 to 28.07.2000 were analyzed. Basing on the results of analysis and experience of casualties' treatment the authors discuss the problems of sequence and volume of surgical care in this group of casualties with reference to available medical evacuation system, surgical tactics at the stage of specialized care. They also consider the peculiarities of operative treatment of the casualties with neck injuries.
Stickney, Carolyn A; Ziniel, Sonja I; Brett, Molly S; Truog, Robert D
To compare the experiences and attitudes of healthcare providers and parents regarding parental participation in morning rounds, in particular to evaluate for differences in perception of parental comprehension of rounds content and parental comfort with attendance, and to identify subgroups of parents who are more likely to report comfort with attending rounds. Cross-sectional survey of 100 parents and 131 healthcare providers in a tertiary care pediatric medical/surgical intensive care unit. Descriptive statistics were used to analyze survey responses; univariate and multivariate analyses were performed to compare parent and healthcare provider responses. Of parents, 92% reported a desire to attend rounds, and 54% of healthcare providers reported a preference for parental presence. There were significant discrepancies in perception of understanding between the 2 groups, with healthcare providers much less likely to perceive that parents understood both the format (30% vs 73%, P parents. Analysis of parent surveys did not reveal characteristics correlated with increased comfort or desire to attend rounds. A majority of parents wish to participate in morning rounds, whereas healthcare provider opinions are mixed. Important discrepancies exist between parent and healthcare provider perceptions of parental comfort and comprehension on rounds, which may be important in facilitating parental presence. Copyright © 2014 Mosby, Inc. All rights reserved.
Full Text Available To survey the recent medical literature reporting effects of intensive care unit (ICU design on patients’ and family members’ well-being, safety and functionality. Features of ICU design linked to the needs of patients and their family are single-rooms, privacy, quiet surrounding, exposure to daylight, views of nature, prevention of infection, a family area and open visiting hours. Other features such as safety, working procedures, ergonomics and logistics have a direct impact on the patient care and the nursing and medical personnel. An organization structured on the needs of the patient and their family is mandatory in designing a new intensive care. The main aims in the design of a new department should be patient centered care, safety, functionality, innovation and a future-proof concept.
Full Text Available JUSTIFICATIVA E OBJETIVOS: Define-se iatrogenia ou afecções iatrogênicas como decorrentes da intervenção médica, correta ou não e justificada ou não, da qual resultam conseqüências prejudiciais ao paciente. Os cuidados em Medicina Intensiva apresentam desafios substanciais com relação à segurança do paciente. O objetivo deste artigo foi apresentar uma breve revisão da literatura sobre a iatrogenia em seus conceitos e termos básicos e suas taxas de prevalência em Medicina Intensiva. CONTEÚDO: A Medicina Intensiva fornece subsídios que melhoram a morbidade e a mortalidade, mas que também se associam a riscos significativos de eventos adversos e erros graves; as iatrogenias podem ser diminuídos com monitoração adequada ou podem ser rotuladas como agravante esperado, idiopatia e se perpetuarem no anonimato CONCLUSÕES: É fundamental reconhecer a necessidade do constante aprendizado, reciclagem e consciência da susceptibilidade ao erro; neste contexto, o respeito pelo ser humano deve nortear a conduta profissional.BACKGROUND AND OBJECTIVES: Iatrogenic conditions was due of the medical, correctly intervention or not, justified or not, which harmful consequences to the patient. The cares in Intensive Care Medicine present substantial challenges with relation to the security of the patient. The objective of this article is to make one brief revision of literature on the iatrogenic in its concepts and basic terms and its taxes prevalence in Intensive Care Medicine. CONTENTS: Intensive Care Medicine supplies subsidies that improve the morbidity and mortality, but that also the significant risks of adverse events and serious errors associate. The Iatrogenic can be minimized with the adequate monitorization or can be friction as waited aggravation, idiopathic and if to perpetuate in the anonymity. CONCLUSIONS: It is basic to recognize the necessity of the constant learning and recycling and conscience of the susceptibilities to the
Implementación de un programa de uso regulado de antibióticos en 2 unidades de cuidado intensivo medico-quirúrgico en un hospital universitario de tercer nivel en Colombia Implementation of a regulated antibiotic use program in two medical-surgical intensive units care in a third level mayor teaching hospital in Colombia
Christian José Pallares
impact of a Program of Regulated Use of Antibiotics in adherence, antibiotic use and bacterial resistance in two medical-surgical Intensive Units Care (ICU´s in a third level mayor teaching hospital in Colombia. Materials and Methods: Prospective observational study of intervention that examines two time periods in two ICU: pre-intervention (august/2008 to February/2009 and post-intervention (march to September/2009. The study was carried out in the Hospital Universitario del Valle Evaristo García E.S.E. (H.U.V. We evaluated adherence to the antibiotic therapy guidelines established by Hospital Epidemiology, antibiotic use measured by Defined Daily Doses and monthly incidence of infection by ESBL producer E.coli and K.pneumoniae, P.aeruginosa fluoroquinolone and four generation cephalosporin resistant, oxacilin resistant S.aureus and multidrug resistant A.baumannii. Results: The adherence to the antibiotic guidelines of antibiotic use was greater to 80% for the both ICU during the intervention period. Antibiotic use was significantly reduced for meropenem (ICU1 p=0,009/ICU2 p=0,000, vancomycin (ICU1-ICU2 p=0,018, ceftriaxone (ICU1 p=0,015/ICU2 p=0,018, ciprofloxacin (ICU1 p=0,027/ICU2 p=0,018, and increased the used of piperacilin/tazobactam (ICU2 p=0,017, and cefepime (ICU1 p=0,028/ICU2 p=0,004. The incidences of infection by ESBL producer E.coli and K.pneumoniae (ICU1 83%/ ICU2 78%, ciprofloxacin resistant and four generation cephalosporin resistant P.aeruginosa (ICU1 87%/ ICU2 82% and (ICU1 83%/ICU2 76% ware also reduced. Conclusions: The implementation of a Program of Regulated Use of Antibiotics reduces antibiotics use and resistant micro-organism specific infection rate in the Hospital Universitario del Valle´s ICU.
Dellenmark-Blom, Michaela; Wigert, Helena
A descriptive study of parents' experiences with neonatal home care following initial care in the neonatal intensive care unit. As survival rates improve among premature and critically ill infants with an increased risk of morbidity, parents' responsibilities for neonatal care grow in scope and degree under the banner of family-centred care. Concurrent with medical advances, new questions arise about the role of parents and the experience of being provided neonatal care at home. An interview study with a phenomenological hermeneutic approach. Parents from a Swedish neonatal (n = 22) home care setting were extensively interviewed within one year of discharge. Data were collected during 2011-2012. The main theme of the findings is that parents experience neonatal home care as an inner emotional journey, from having a child to being a parent. This finding derives from three themes: the parents' experience of leaving the hospital milieu in favour of establishing independent parenthood, maturing as a parent and processing experiences during the period of neonatal intensive care. This study suggests that neonatal home care is experienced as a care structure adjusted to incorporate parents' needs following discharge from a neonatal intensive care unit. Neonatal home care appears to bridge the gap between hospital and home, supporting the family's adaptation to life in the home setting. Parents become empowered to be primary caregivers, having nurse consultants serving the needs of the whole family. Neonatal home care may therefore be understood as the implementation of family-centred care during the transition from NICU to home. © 2013 John Wiley & Sons Ltd.
textabstractThe aim of this thesis – the EMPATHIC studies – was to develop and implement validated parent satisfaction questionnaires for pediatric and neonatal intensive care units. Part I presents the general introduction, which justifies the construction, validation, and utilization of parent satisfaction instruments. Part II provides a review about the few existing parent and family satisfaction instruments. A theoretical framework incorporating family-centered care, parental needs and ex...
Full Text Available Health care professionals working in Intensive Care Units (ICUs are exposed to high levels of stress-provoking stimuli. Some may unconsciously employ negative coping skill s which may contribute to burnout and negatively affect patient care. We chose to explore ways of facilitating and encouraging self-reflective practice in an effort to increase empathic traits and enhance communication. A narrative medicine series, which included six sessions that were focused on different narrative approaches, was organized for staff of an academic teaching hospital. Totally, 132 interdisciplinary ICU staff attended the sessions. They were generally open to exploring the selected approaches and discussing their reflections within the interdisciplinary environment. The narrative medicine series provided tools for health care professionals to enhance self-reflective skills utilizing a team-based learning approach. The anticipated outcomes were improved self-care, increased empathy and communication skills, enhanced team functioning, which all contribute to better patient care at the bedside.
Alfieri, Emanuela; Ferrini, Anna Chiara; Gianfrancesco, Francesca; Lise, Gianluca; Messana, Giovanni; Tirelli, Lorenzo; Lorenzo, Ana; Sarli, Leopoldo
Since the recent introduction of the Case/Care Manager's professional figure, it is quite difficult to identify properly his/her own particular features, which could be mainly be found revising mainly in American studies. Therefore, the present study intended to identify the Case/Care Manager's skills and professional profile in an Intensive Care Unit experience, taking into consideration the staff's activities, perception and expectations towards the Case/Care Manager. In particular, it has been compared the experience of an Intensive Care Units where the Case/Care Manager's profile is operational to a different Unit where a Case/Care Manager is not yet in force. a Levati's model was used to map the Case/Care Manager's skills, involving each unit whole working staff, executives and caregivers through semi-structured interviews. It has been taken into consideration the Anaesthesia Unit and Emergency Unit of Cesena's healthcare organisation (AUSL of Romagna) and a Cardiology Intensive Care Unit of Piacenza's healthcare organisation, where the Case/Care Manager's profile has not been experimented yet. Firstly, it a data collection in each healthcare organization has been organised. Subsequently, semi-structured interviews to doctors, unit nurses, caregivers, nurses' coordinators and medical staff have been used to compare each healthcare system. The interviewees' described their expectations in relation to the Case/Care Manager working in a critical area. Then, every data collected during interviews has been organised to map a Case/Care Manager's essential professional profile to work in a critical area together with medical staff. Piacenza's O.U. critical area experience reported a major demand for patients' and patient's families' assistance. On the other hand, the very same aspects seem to have been better achieved in Cesena's O.U., where a Case/Care Manager's recent introduction has actually helped to overcome the void in organising systems. a Case/Care Manager
Diniz, Denise Para; Marques, Daniella Aparecida; Blay, Sérgio Luis; Schor, Nestor
Several studies point out that pathophysiological changes related to stress may influence renal function and are associated with disease onset and evolution. However, we have not found any studies about the influence of stress on renal function and acute kidney injury. To evaluate the association between stressful life events and acute kidney injury diagnosis, specifying the most stressful classes of events for these patients in the past 12 months. Case-control study. The study was carried out at Hospital São Paulo, in Universidade Federal de São Paulo and at Hospital dos Servidores do Estado de São Paulo, in Brazil. Patients with acute kidney injury and no chronic disease, admitted to the intensive or semi-intensive care units were included. Controls included patients in the same intensive care units with other acute diseases, except for the acute kidney injury, and also with no chronic disease. Out of the 579 patients initially identified, 475 answered to the Social Readjustment Rating Scale (SRRS) questionnaire and 398 were paired by age and gender (199 cases and 199 controls). The rate of stressful life events was statistically similar between cases and controls. The logistic regression analysis to detect associated effects of the independent variables to the stressful events showed that: increasing age and economic classes A and B in one of the hospitals (Hospital São Paulo - UNIFESP) increased the chance of a stressful life event (SLE). This study did not show association between the Acute Kidney Injury Group with a higher frequency of stressful life events, but that old age, higher income, and type of clinical center were associated.
Full Text Available Abstract Background Medication administration errors in patient care have been shown to be frequent and serious. Such errors are particularly prevalent in highly technical specialties such as the intensive care unit (ICU. In Ethiopia, the prevalence of medication administration errors in the ICU is not studied. Objective To assess medication administration errors in the intensive care unit of Jimma University Specialized Hospital (JUSH, Southwest Ethiopia. Methods Prospective observation based cross-sectional study was conducted in the ICU of JUSH from February 7 to March 24, 2011. All medication interventions administered by the nurses to all patients admitted to the ICU during the study period were included in the study. Data were collected by directly observing drug administration by the nurses supplemented with review of medication charts. Data was edited, coded and entered in to SPSS for windows version 16.0. Descriptive statistics was used to measure the magnitude and type of the problem under study. Results Prevalence of medication administration errors in the ICU of JUSH was 621 (51.8%. Common administration errors were attributed to wrong timing (30.3%, omission due to unavailability (29.0% and missed doses (18.3% among others. Errors associated with antibiotics took the lion's share in medication administration errors (36.7%. Conclusion Medication errors at the administration phase were highly prevalent in the ICU of Jimma University Specialized Hospital. Supervision to the nurses administering medications by more experienced ICU nurses or other relevant professionals in regular intervals is helpful in ensuring that medication errors don’t occur as frequently as observed in this study.
Schlünder, C; Houben, F; Hartwig, S; Theisohn, M; Roth, B
In pediatric intensive care, analgesia and sedation has become increasingly important for newborns as well as prematures in recent years. However, its importance is frequently not well recognized and sedation is confounded with analgesia. In our intensive-care unit (ICU), fentanyl and midazolam have proved to be useful. In newborn and premature infants, fentanyl alone has been sufficient because of its analgesic and sedative action. In a study on 20 newborns and prematures suffering from severe respiratory problems as compared with a historical group that did not receive fentanyl, we could show that in subjects receiving fentanyl, considerably less treatment with sedatives and other analgesics was necessary. Cardiopulmonary tolerance was satisfactory. The highest bilirubin values were reached about 1 day earlier and were slightly higher than those measured in the control group, but oral nutrition could be initiated sooner. In small infants, additional midazolam was given after cardiac surgery. During the first 72 h, we found a correlation between serum levels of midazolam and the depth of sedation; however, after 72 h of medication, the dose had to be raised because of an increase in metabolic clearance. During the concomitant administration of midazolam and fentanyl, significantly less midazolam was needed to achieve appropriate analog-sedation. Prior to the administration of analgesics and sedatives, care should be taken to ensure that circulatory conditions are stable and that there is no hypovolemia, and the drugs must be given slowly during several minutes. Especially in a pediatric ICU, light and noise should be diminished and contact between the parents and the child should be encouraged, even when the child is undergoing mechanical ventilation.
Kvande, Monica; Delmar, Charlotte; Lykkeslet, Else
Aim To explore the phenomenon of assessing changes in patients' conditions in intensive care units from the perspectives of experienced intensive care nurses. Background Providing safe care for patients in intensive care units requires an awareness and perception of the signs that indicate changes...... in a patient's condition. Nurses in intensive care units play an essential role in preventing the deterioration of a patient's condition and in improving patient outcomes. Design and methods This hermeneutic phenomenological study conducted close observations and in-depth interviews with 11 intensive care...... nurses. The nurses' experience ranged from 7 to 28 years in the intensive care unit. Data were collected at two intensive care units in two Norwegian university hospitals. The analysis was performed using the reflective methods of van Manen. Findings An overarching theme of ‘sensitive situational...
Williams, Kristen G; Patel, Kayla T; Stausmire, Julie M; Bridges, Christy; Mathis, Mary W; Barkin, Jennifer L
The relationship between maternal mental health and infant development has been established in the literature. The Neonatal Intensive Care Unit (NICU) is a particularly challenging environment for new mothers as several natural processes are disrupted. The objective of this study is to elucidate protective factors and environmental deficits associated with the NICU. The experiences of forty-six ( n = 46) mothers of infants admitted to a Level III NICU in the Midwestern United States, who responded to a related open-ended question, were analyzed thematically. Five themes related to the NICU environment emerged as being either stressful or helpful: (1) amount and quality of communication with medical staff, (2) bedside manner of medical staff, (3) feeling alienated from infant's care, (4) support from other NICU mothers and families, and (5) NICU Physical Environment and Regulations. There is a need for medical staff training on awareness, communication, empathy, and other behaviors that might improve maternal (and parental) experiences in the NICU. The physical environment, including rules and regulations of the NICU, should be reexamined with family comfort in mind in addition to the clinical care of the infant.
Decembrino, L; Perrini, S; Stronati, M
Nosocomial infections are one of the major causes of morbidity and mortality in the newborn intensive care unit (NICU). They result in prolonged hospital stays and increased hospital costs. Neonates are susceptible hosts because of prematurity of organ systems, immaturity of immune system, low birth weight and the use of invasive devices. Most infections are endemic others can occur during outbreaks. As advances in medical technology improve mortality in the tiniest of infants, it is imperative that health care providers identify effective interventions to minimize the risks of nosocomial infections in the NICU. Recommended infection control and prevention strategies are: hand washing promotion, decreased use of invasive procedures, limited antitibiotic exposure, environmental hygiene. In this context infection surveillance is the first step to recognize and analyze problems, to effectively target infection control measures and feedback. Any suspicion of an outbreak should lead to a review of general infection control procedures to prevent the spread of the pathogens as quickly as possible. A multidisciplinary approach can be an effective means of developing a plan of action to apply prolonged and strict adherence to isolation precautions', to detect potential reservoirs or source of infections, to educate every member of the patient care team and to review NICU protocols.
Morrison, Wynne E; Haas, Ellen C; Shaffner, Donald H; Garrett, Elizabeth S; Fackler, James C
To measure and describe hospital noise and determine whether noise can be correlated with nursing stress measured by questionnaire, salivary amylase, and heart rate. Cohort observational study. Tertiary care center pediatric intensive care unit. Registered nurses working in the unit. None. Eleven nurse volunteers were recruited. An audiogram, questionnaire data, salivary amylase, and heart rate were collected in a quiet room. Each nurse was observed for a 3-hr period during patient care. Heart rate and sound level were recorded continuously; saliva samples and stress/annoyance ratings were collected every 30 mins. Variables assessed as potential confounders were years of nursing experience, caffeine intake, patients' Pediatric Risk of Mortality Score, shift assignment, and room assignment. Data were analyzed by random effects multiple linear regression using Stata 6.0. The average daytime sound level was 61 dB(A), nighttime 59 dB(A). Higher average sound levels significantly predicted higher heart rates (p =.014). Other significant predictors of tachycardia were higher caffeine intake, less nursing experience, and daytime shift. Ninety percent of the variability in heart rate was explained by the regression equation. Amylase measurements showed a large variability and were not significantly affected by noise levels. Higher average sound levels were also predictive of greater subjective stress (p =.021) and annoyance (p =.016). In this small study, noise was shown to correlate with several measures of stress including tachycardia and annoyance ratings. Further studies of interventions to reduce noise are essential.
The severely ill infant or child who requires admission to a pediatric intensive care unit (PICU) often presents with a complex set of problems necessitating multiple and frequent management decisions. Diagnostic imaging plays an important role, not only in the initial assessment of the patient's condition and establishing a diagnosis, but also in monitoring the patient's progress and the effects of interventional therapeutic measures. Bedside studies obtained using portable equipment are often limited but can provide much useful information when a careful and detailed approach is utilized in producing the radiograph and interpreting the examination. This article reviews some of the basic principles of radiographic interpretation and details some of the diagnostic points which, when promptly recognized, can lead to a better understanding of the patient's condition and thus to improved patient care and management. While chest radiography is stressed, studies of other regions including the upper airway, abdomen, skull, and extremities are discussed. A brief consideration of the expanding role of new modality imaging (i.e., ultrasound, CT) is also included. Multiple illustrative examples of common and uncommon problems are shown
Brown, Kyla N; Leigh, Jeanna Parsons; Kamran, Hasham; Bagshaw, Sean M; Fowler, Rob A; Dodek, Peter M; Turgeon, Alexis F; Forster, Alan J; Lamontagne, Francois; Soo, Andrea; Stelfox, Henry T
Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks. This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients. A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p notes; mean agreement of patient issues was 42% [95% CI 31-53%]. Qualitative analyses identified eight themes related to focus (central point - e.g., problem list), structure (organization, - e.g., note-taking style), and purpose (intention - e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority. Important gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.
Bonnefoy-Cudraz, Eric; Bueno, Hector; Casella, Gianni
, the recommended management structure, the optimal number of staff, the need for specially trained cardiologists and cardiovascular nurses, the desired equipment and architecture, and the interaction with other departments in the hospital and other intensive cardiovascular care units in the region...
J.M. Latour (Jos)
textabstractThe aim of this thesis – the EMPATHIC studies – was to develop and implement validated parent satisfaction questionnaires for pediatric and neonatal intensive care units. Part I presents the general introduction, which justifies the construction, validation, and utilization of
Bagley, Kimberly A; Dunn, Sarah E; Chuang, Eliseu Y; Dorr, Victoria J; Thompson, Julie A; Smith, Sophia K
A community hospital combined its medical and surgical patients with cancer on one unit, which resulted in nurses not trained in oncology caring for this patient population. The Oncology Intensives Initiative (ONCii) involved the (a) design and implementation of a daylong didactic boot camp class and a four-hour simulation session and (b) the examination of nurses' worries, attitudes, self-efficacy, and perception of interdisciplinary teamwork. A two-group, pre-/post-test design was implemented. Group 1 consisted of nurses who attended the didactic boot camp classes alone, whereas group 2 was comprised of nurses who attended the didactic boot camp classes and the simulation sessions. Results of data analysis showed a decrease in worries and an increase in positive attitudes toward chemotherapy administration in both groups, as well as an increase in self-efficacy among members of group 2.
Rosenthal, Victor D; Guzman, Sandra; Safdar, Nasia
Hand hygiene is a fundamental measure for the control of nosocomial infection. However, sustained compliance with hand hygiene in health care workers is poor. We attempted to enhance compliance with hand hygiene by implementing education, training, and performance feedback. We measured nosocomial infections in parallel. We monitored the overall compliance with hand hygiene during routine patient care in intensive care units (ICUs); 1 medical surgical ICU and 1 coronary ICU, of 1 hospital in Buenos Aires, Argentina, before and during implementation of a hand hygiene education, training, and performance feedback program. Observational surveys were done twice a week from September 2000 to May 2002. Nosocomial infections in the ICUs were identified using the National Nosocomial Infections Surveillance (NNIS) criteria, with prospective surveillance. We observed 4347 opportunities for hand hygiene in both ICUs. Compliance improved progressively (handwashing adherence, 23.1% (268/1160) to 64.5% (2056/3187) (RR, 2.79; 95% CI: 2.46-3.17; P nosocomial infection in both ICUs decreased from 47.55 per 1000 patient-days (104/2187) to 27.93 per 1000 patient days (207/7409) RR, 0.59; 95% CI: 0.46-0.74, P hand hygiene, coinciding with a reduction in nosocomial infection rates in the ICUs.
Full Text Available Background. The role of the pharmacist has evolved over the last 2 decades beyond traditional functions such as stock control and dispensing.Â Objectives. To describe the functions performed by a clinical pharmacist while based in a surgical and trauma intensive care unit of a teaching hospital.Â Methods. An operational research study that included indications of programme success was conducted. Interventions to assess therapy and achieve definite outcomes to satisfy patientsâ€™ medicine needs were documented for 51 patients over a study period of 8 weeks.Results. A total of 181 interventions were suggested by the pharmacist, with 127 (70% accepted and implemented by the medical and nursing staff of the unit. The most frequent interventions were related to: untreated medical conditions (15.5%, appropriate therapy or course (13.8%, investigations indicated or outstanding (12.2%, and inappropriate doses and dosing frequency (11%. Interventions were also made regularly to address system errors or non-compliance and factors hindering therapeutic effect. Of the 250 h the pharmacist spent in the ward, most time was used for pharmaceutical care (28% and ward rounds (21% with members of the multidisciplinary team.Conclusions. The study results demonstrated that a clinical pharmacistâ€™s contribution to patient care at ward level resulted in improved monitoring of pharmacotherapy. Medicine-related problems were identified and addressed.
Taysa Costa da Silva
Full Text Available Objective: To verify the main measures of care for the newborn in the neonatal intensive care unit. Method: This is an integrative review, in which, it is possible to identify, analyze and synthesize research results with the inclusion of experimental and non-experimental studies. A total of 133 articles were collected. After reading titles, exclusion criteria and reading resumes, 10 were left, in which the sample was composed. Results: The selected publications were placed in 3 thematic categories: The importance of knowledge in nursing care, to the internal NB in NICU; Nursing evaluation and care used for pain relief in NB; Main factors and adverse events that may lead to the hospitalization of the newborn and the increase of morbidity and mortality in an NICU. Conclusion: The analysis of the aforementioned study exposes the importance and main nursing care that can be administered in newborns in a NICU, so that the reduction of neonatal mortality can be provided. Descriptors: Neonatal Intensive Care Unit; Nursing care; Newborn.
Youth gang violence has continued its upward trend nationwide. It was once thought that gangs convened only in selected areas, which left churches, schools, and hospitals as "neutral" territory. Unfortunately, this is a fallacy. The results of gang violence pour into hospitals and into intensive care units regularly. The media portrays California as having a gang violence problem; however, throughout the United States, gang violence has risen more than 35% in the past year. Youth gang violence continues to rise dramatically with more and more of our youth deciding to join gangs each day. Sadly, every state has gangs, and the problem is getting much worse in areas that would never have thought about gangs a year ago. These "new generation" of gang members is younger, much more violent, and staying in the gang longer. Gangs are not just an urban problem. Gang activity is a suburban and rural problem too. There are more than 25 500 gangs in the United States, with a total gang membership of 850 000. Ninety-four percent of gang members are male and 6% are female. The ethnic composition nationwide includes 47% Latino, 31% African American, 13% White, 7% Asian, and 2% "mixed," according to the Office of Juvenile Justice and Delinquency Prevention of the U.S. Department of Justice. As a result of the ongoing proliferation of youth street gangs in our communities, it is imperative that critical care nurses and others involved with the direct care become educated about how to identify gang members, their activities, and understand their motivations. Such education and knowledge will help provide solutions to families and the youth themselves, help eradicate the problem of gang violence, and keep health care professionals safe.
Full Text Available The premature birth and the hospitalization in a neonatal intensive care unit (NICU are potential risk factors for the development and behavior of the newborn, as has been shown in recent studies. Premature birth of an infant is a distressing event for the family. Several feelings are experienced by parents during hospitalization of their baby in the NICU. Feelings of guilt, rejection, stress and anxiety are common. Also the attachment processes have the potential to be disrupted or delayed as a result of the initial separation of the premature newborn and the mother after the admission to the NICU. Added to these difficulties, there is the distortion of infant’s “ideal image”, created by the family, in contrast with the real image of the preterm. This relationship-based family-centered approach, the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP, promotes the idea that infants and their families are collaborators in developing an individualized program to maximize physical, mental, and emotional growth and health and to improve long-term outcomes for the high risk newborns. The presence of parents in NICUs and their involvement caring their babies, in a family centered care philosophy, is vital to improve the outcome of their infants and the relationships within each family. Proceedings of the 11th International Workshop on Neonatology and Satellite Meetings · Cagliari (Italy · October 26th-31st, 2015 · From the womb to the adultGuest Editors: Vassilios Fanos (Cagliari, Italy, Michele Mussap (Genoa, Italy, Antonio Del Vecchio (Bari, Italy, Bo Sun (Shanghai, China, Dorret I. Boomsma (Amsterdam, the Netherlands, Gavino Faa (Cagliari, Italy, Antonio Giordano (Philadelphia, USA
Mar 23, 2017 ... aDepartamet of Pediatric Surgery, Hospital Teresa Herrera, Complejo Hospitalario. Universitario de A ... Advances in anesthesia, neonatal intensive, surgical, and cardiac care have ... First, these patients are at risk of airway ...
Stokes, Matthew A R; Guest, Glenn D; Mamadi, Perista; Seta, Westin; Yaubihi, Noel; Karawiga, Grace; Naidi, Billy; Watters, David A K
Timely access to emergency and essential surgical care (EESC) and anaesthesia in low- and middle-income countries (LMICs) prevents premature death, minimises lifelong disability and reduces their economic impact on families and communities. Papua New Guinea is one of the poorest countries in the Pacific region, and provides much of its surgical care at a district hospital level. We aimed to evaluate the surgical capacity of a district hospital in PNG and estimate the effectiveness of surgical interventions provided. We performed a prospective study to calculate the number of DALYs averted for 465 patients treated with surgical care over a 3-month period (Sep-Nov 2013) in Alotau Hospital, Milne Bay Province, PNG (pop 210,000). Data were also collected on infrastructure, workforce, interventions provided and equipment available using the World Health Organization's Integrated Management of Emergency and Essential Surgical Care Toolkit, a survey to assess EESC and surgical capacity. We also performed a retrospective one-year audit of surgical, obstetric and anaesthetic care to provide context with regards to annual disease burden treated and surgical activity. EESC was provided by 11 Surgeons/Anaesthetists/Obstetricians (SAO) providers, equating to 5.7 per 100,000 population (including 4 nurse anaesthetists). They performed 783/100,000 procedures annually. Over the 3-month prospective study period, 4954 DALYs were averted by 465 surgical interventions, 52 % of which were elective. This equates to 18,330 DALYs averted annually or, approximately 18 % of the published but estimated disease burden in the Province in the 2013 Global Burden of Disease Study. The overall peri-operative mortality rate was 1.29 %, with 0.41 % for elective procedures and 2.25 % for emergencies. Much of the burden of surgical disease in Papua New Guinea presenting to Alotau General Hospital serving Milne Bay Province can be effectively treated by a small team providing emergency and
Martin, A E; D'Agostino, J A; Passarella, M; Lorch, S A
Nurses provide parental support and education in the neonatal intensive care unit (NICU), but it is unknown if satisfaction and expectations about nursing care differ between racial groups. A prospective cohort was constructed of families with a premature infant presenting to primary care between 1 January 2010 and 1 January 2013 (N=249, 52% white, 42% black). Responses to questions about satisfaction with the NICU were analyzed in ATLAS.ti using the standard qualitative methodology. One hundred and twenty (48%) parents commented on nursing. Fifty-seven percent of the comments were positive, with black parents more negative (58%) compared with white parents (33%). Black parents were most dissatisfied with how nurses supported them, wanting compassionate and respectful communication. White parents were most dissatisfied with inconsistent nursing care and lack of education about their child. Racial differences were found in satisfaction and expectations with neonatal nursing care. Accounting for these differences will improve parental engagement during the NICU stay.
Belli, M A
The purpose of the study was to examine the experiences, feelings and expectation of mothers of high risk newborns. The population was a group of 20 mothers of high risk newborns of three hospitals in the City of São Paulo. Interview with the mothers was the method of data collection containing opened and structured questions. It was verified that most of the mothers had none or only a little interaction with the newborn after delivery; the eye contact was the most referred during the staying of the newborn in the Intensive Care Unity; all of them demonstrated interest in participating in the care of the newborn and expressed the need of information concerning to the health status of the newborn, the Intensive Care Unity environment and the hospital team. Several were the feelings expressed and the motives that indicated the needs of the mothers.
Hadad, Alejandro J.; Evin, Diego A.; Drozdowicz, Bartolomé; Chiotti, Omar
This paper proposes a scheme for the analysis of time-stamped series data from multiple monitoring devices of intensive care units, using Temporal Abstraction concepts. This scheme is oriented to obtain a description of the patient state evolution in an unsupervised way. The case of study is based on a dataset clinically classified with Pulmonary Edema. For this dataset a trends based Temporal Abstraction mechanism is proposed, by means of a Behaviours Base of time-stamped series and then used in a classification step. Combining this approach with the introduction of expert knowledge, using Fuzzy Logic, and multivariate analysis by means of Self-Organizing Maps, a states characterization model is obtained. This model is feasible of being extended to different patients groups and states. The proposed scheme allows to obtain intermediate states descriptions through which it is passing the patient and that could be used to anticipate alert situations.
Ratzer, Mette; Brink, Ole; Knudsen, Linda
Aims: This study aimed to estimate the prevalence of severe Posttraumatic Stress Disorder (PTSD) symptoms and to identify factors associated with PTSD in survivors of intensive care unit (ICU) treatment following traumatic injury. Methods: Fifty-two patients who were admitted to an ICU through...... the emergency ward following traumatic injury were prospectively followed. Information on injury severity and ICU treatment were obtained through medical records. Demographic information and measures of acute stress symptoms, experienced social support, coping style, sense of coherence (SOC) and locus...... of control were assessed within one-month post-accident (T1). At the six months follow-up (T2), PTSD was assessed with the Harvard Trauma Questionnaire (HTQ). Results: In the six months follow-up, 10 respondents (19.2%) had HTQ total scores reaching a level suggestive of PTSD (N = 52), and 11 respondents (21...
Ana Paula Cezar Machado
Full Text Available Abstract Pediatric patients, especially those admitted to the neonatal intensive care unit (ICU, are highly vulnerable to medication errors. This study aimed to measure the prescription error rate in a university hospital neonatal ICU and to identify susceptible patients, types of errors, and the medicines involved. The variables related to medicines prescribed were compared to the Neofax prescription protocol. The study enrolled 150 newborns and analyzed 489 prescription order forms, with 1,491 medication items, corresponding to 46 drugs. Prescription error rate was 43.5%. Errors were found in dosage, intervals, diluents, and infusion time, distributed across 7 therapeutic classes. Errors were more frequent in preterm newborns. Diluent and dosing were the most frequent sources of errors. The therapeutic classes most involved in errors were antimicrobial agents and drugs that act on the nervous and cardiovascular systems.
Østergaard, Kija Lin; Brandrup, Morten
-ended dry-erase whiteboard (make-up-your-own-sentences). In conclusion the primary feature in the two subjects is to optimize communication/collaboration and information between ICU and general wards in the transition. To make it a long term solution the content of such a support would need involvement...... of the end-users in the design process (Participatory Design). Hence these two findings, this review is setting the stage for further research on how electronic whiteboards can support the initial follow up when patients are transferred from an ICU to a general ward.......This paper is reviewing the existing literature on Intensive Care Unit (ICU) Outreach, in-hospital follow up 24 hours after the transition to a general ward from an ICU. It also touches upon the use of Electronic Whiteboards in a hospital setting and how the electronic whiteboards might support...
Tat, Tiberiu; Li, Huming; Constantinescu, Catalin-Sorin; Onaciu, Anca; Chira, Sergiu; Osan, Ciprian; Pasca, Sergiu; Petrushev, Bobe; Moisoiu, Vlad; Micu, Wilhelm-Thomas; Berce, Cristian; Tranca, Sebastian; Dima, Delia; Berindan-Neagoe, Ioana; Shen, Jianliang; Tomuleasa, Ciprian; Qian, Liren
Chimeric antigen receptor-modified T cells (CAR-T cells) and donor lymphocyte infusion (DLI) are important protocols in lymphocyte engineering. CAR-T cells have emerged as a new modality for cancer immunotherapy due to their potential efficacy against hematological malignancies. These genetically modified receptors contain an antigen-binding moiety, a hinge region, a transmembrane domain, and an intracellular costimulatory domain resulting in lymphocyte T cell activation subsequent to antigen binding. In present-day medicine, four generations of CAR-T cells are described depending on the intracellular signaling domain number of T cell receptors. DLI represents a form of adoptive therapy used after hematopoietic stem cell transplant for its anti-tumor and anti-infectious properties. This article covers the current status of CAR-T cells and DLI research in the intensive care unit (ICU) patient, including the efficacy, toxicity, side effects and treatment. PMID:29662667
With the ever-increasing availability of aggressive medical treatment and technical support, neonatologists are offered an increasing ability to prolong life. While "end-of-life" decisions within NICUs have been studied internationally, there is limited data available for Ireland. Through the auspices of the Irish Faculty of Paediatrics 2002 Neonatal Mortality Ouestionnaire, decisions made around the time of death in Irish Neonatal Intensive Care Units were examined. The overall response rate to the questionnaire was 96% (n=25). One hundred and eighty seven deaths were reported for 2002. Information pertaining to the mode of death was available in 53% of cases. Seventy seven percent of those paediatricians who answered this question, reported either withdrawing or withholding treatment in babies thought to have a hopeless outcome, with the greatest proportion of these deaths occurring in premature infants (n=30) and babies with congenital defects (n=40).
Krag, M; Perner, A; Wetterslev, J
BACKGROUND: Stress ulcer prophylaxis (SUP) may decrease the incidence of gastrointestinal bleeding in patients in the intensive care unit (ICU), but the risk of infection may be increased. In this study, we aimed to describe SUP practices in adult ICUs. We hypothesised that patient selection...... for SUP varies both within and between countries. METHODS: Adult ICUs were invited to participate in the survey. We registered country, type of hospital, type and size of ICU, preferred SUP agent, presence of local guideline, reported indications for SUP, criteria for discontinuing SUP, and concerns about...... adverse effects. Fisher's exact test was used to assess differences between groups. RESULTS: Ninety-seven adult ICUs in 11 countries participated (eight European). All but one ICU used SUP, and 64% (62/97) reported having a guideline for the use of SUP. Proton pump inhibitors were the most common SUP...
Paulo Caceres Guido
Full Text Available Background Amikacin treatment requires close monitoring of blood concentrations to increase the probability that levels achieved are both effective and safe. Aims We described population pharmacokinetics parameters of amikacin in newborns from a Neonatal Intensive Care Unit with suspected or documented sepsis. Methods A nonlinear mixed-effect model approach was used to analyse the data. Results Twenty seven neonates were enrolled. Final parameter estimates were: Ke(h-1=0.232x(CR Exp-0.85; V(mL/kg=497. Conclusion Weight and serum creatinine are associated with neonatal amikacin volume of distribution and elimination constant rate, respectively. The presence of sepsis may decrease amikacin elimination, although this observation should be further explored. These results could help to individualize amikacin dosage for neonates.
Jensen, Hanne Irene
be interdisciplinary, but the literature shows that this is not always the case. Research on end-of-life issues in Danish ICUs is limited. Aim The aims of this thesis were to • Examine Danish practices regarding end-of-life decisions in the ICU. • Examine the opinions of nurses and physicians who work in Danish ICUs...... and decision-making. Hypotheses • Nurses, intensivists, and primary physicians have different experiences of interdisciplinary collaboration regarding end-of-life decision-making in the ICU. • Specific interventions targeting end-of-life decision-making in the ICU, such as interdisciplinary audits......Background When making end-of-life decisions in intensive care units, the different staff groups have different roles in the decision-making process and may not always assess the situation identically. Practice recommendations for withholding or withdrawing therapy state that decisions should...
Cartagena, A M; Jog, M; Young, G B
The syndrome of involuntary craniofacial lingual movements in the setting of acute intensive care-acquired quadriplegia (critical illness neuromyopathy) following sepsis-associated encephalopathy has not been previously described. We suggest a localization and treatment for this disabling condition. Three patients (2 female) from our center were quadriplegic from critical illness neuromyopathy when they developed involuntary craniofacial lingual movements following sepsis-associated encephalopathy. Extensive investigations failed to identify an etiology for the abnormal movements. Movements were of large amplitude, of moderate speed, and semi-rhythmic in the jaw, tongue, and palate, persistent and extremely bothersome to all patients. Injection with Botulinum toxin type A was very beneficial. Involuntary craniofacial lingual movements in the setting of flaccid quadriplegia following sepsis-associated encephalopathy are consistent with focal craniofacial brainstem myoclonus and constitutes a new syndrome. Botulinum toxin type A treatment maybe helpful in treatment.
Lorenzini, Elisiane; Lorenzini, Elisiane; da Costa, Tatiane Costa; da Silva, Eveline Franco
This study was aimed to identify the knowledge of the nursing team of a Neonatal Intensive Care Unit (NICU) on infection control, identijfying the factors that facilitate or hinder the prevention and control of Healthcare Associated Infections (HICAI). A descriptive study using a qualitative research method conducted with three nurses and 15 nurse technicians, who work in a NICU of a charitable organization, in southern Brazil. It became evident that the nursing staff had great knowledge about the factors that facilitate the prevention and control of HCAI in NICU, the most important factor being proper hand hygiene. Among the factors that hinder infection prevention and control are to overcrowding and excessive workload. The efficient performance of the nursing staff is an important part of the strategy for prevention and control of HCAI.
Kühn, Jan; Brendle, Christian; Stollenwerk, André; Schweigler, Martin; Kowalewski, Stefan; Janisch, Thorsten; Rossaint, Rolf; Leonhardt, Steffen; Walter, Marian; Kopp, Rüdger
This paper presents a decentralized safety concept for networked intensive care setups, for which a decentralized network of sensors and actuators is realized by embedded microcontroller nodes. It is evaluated for up to eleven medical devices in a setup for automated acute respiratory distress syndrome (ARDS) therapy. In this contribution we highlight a blood pump supervision as exemplary safety measure, which allows a reliable bubble detection in an extracorporeal blood circulation. The approach is validated with data of animal experiments including 35 bubbles with a size between 0.05 and 0.3 ml. All 18 bubbles with a size down to 0.15 ml are successfully detected. By using hidden Markov models (HMMs) as statistical method the number of necessary sensors can be reduced by two pressure sensors.
Krag, M; Perner, A; Wetterslev, J
BACKGROUND: In this statistical analysis plan, we aim to provide details of the pre-defined statistical analyses of the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial. The aim of the SUP-ICU trial is to assess benefits and harms of stress ulcer prophylaxis with a proton pump......-year mortality, and a health economic analysis. Two formal interim analyses will be performed. The statistical analyses will be conducted according to the outlined pre-defined statistical analysis plan. The primary analysis will be a logistic regression analysis adjusted for stratification variables...... comparing the two intervention groups in the intention-to-treat population. In a secondary analysis, we will additionally adjust the primary outcome for potential random differences in baseline characteristics. The conclusion will be based on the intention-to-treat population. CONCLUSION: Stress ulcer...
Hadad, Alejandro J; Evin, Diego A; Drozdowicz, Bartolome; Chiotti, Omar
This paper proposes a scheme for the analysis of time-stamped series data from multiple monitoring devices of intensive care units, using Temporal Abstraction concepts. This scheme is oriented to obtain a description of the patient state evolution in an unsupervised way. The case of study is based on a dataset clinically classified with Pulmonary Edema. For this dataset a trends based Temporal Abstraction mechanism is proposed, by means of a Behaviours Base of time-stamped series and then used in a classification step. Combining this approach with the introduction of expert knowledge, using Fuzzy Logic, and multivariate analysis by means of Self-Organizing Maps, a states characterization model is obtained. This model is feasible of being extended to different patients groups and states. The proposed scheme allows to obtain intermediate states descriptions through which it is passing the patient and that could be used to anticipate alert situations
Schmitt, D. V.
Full Text Available Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, DGTHG and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF. The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the
Gunst, Jan; Van den Berghe, Greet
Abnormal blood glucose levels are common during critical illness and are associated with outcomes that correspond to a J-shaped curve, the lowest risk associated with normoglycemia. Three proof-of-concept randomized-controlled-trials performed in the surgical, medical, and pediatric intensive care units of the Leuven University Hospital in Belgium demonstrated that maintaining strict age-adjusted normal fasting levels of glycemia (80-110 mg/dl in adults, 70-100 mg/dl in children, 50-80 mg/dl in infants) with intensive insulin therapy reduced morbidity and mortality as compared with tolerating stress hyperglycemia as a potentially beneficial response. Recently, concern has risen about the safety of this intervention, as a multicenter adult study reported an, as yet unexplained, increased mortality with targeting normoglycemia as compared with an intermediate blood glucose level of around 140 mg/dl. This apparent contradiction may be explained by several methodological differences among studies, comprising, among others, different glucose target ranges in the control groups, different feeding policies, and variable accuracy of tools used for glucose measurement and insulin infusion. Hence, efficacy and safety of intensive insulin therapy may be affected by patient-related and ICU setting-related variables. Therefore, no single optimal blood glucose target range for ICU patients can be advocated. It appears safe not to embark on targeting "age-normal" levels in intensive care units (ICUs) that are not equipped to accurately and frequently measure blood glucose, and have not acquired extensive experience with intravenous insulin administration using a customized guideline. A simple fallback position could be to control blood glucose levels as close to normal as possible without evoking unacceptable blood glucose fluctuations, hypoglycemia, and hypokalemia.
Epidemiologic, comparative study of patients that entered to the Unit of Intensive Cares of the Quito Oncological Hospital SOLCA from January August 2005. There were determined the incidences of infections according to diagnostic, type of patient clinical, surgical or pediatric. The statistics tests used where percentages, Ji square, average, standard deviation and descriptive analysis. The clinical histories of all the patients of ICU were revised, the sheet of gathering data was filled. The Microbiology Service. A number of 331 patients entered to the unit including post surgical, clinical with different diagnostic; and pediatric surgical or clinical. Of these 19,63% (n: 64) were infected or were infected during their hospitalization. For the analysis they were contained in surgical 21% (13), clinical 71% (46) and pediatrics 8% (5). Their average age was of 51,33 years D S 21,9; the predominant sex was the feminine 60,9% (n:35). The demurrage average was of 7 days. The surgical patients where classified according to the surgery type in abdominal, thoracic, neurosurgery and other (head and neck or traumatology), significance didn't exist relating them with the surgery type, surgical time and infectious focus; the mortality in these patients was of 21,4% (n:3). The clinical patients where chose in relation with the association or not of chemotherapy and the presence of the infectious focus founding a 39,14% (n:18) of infection in those patients that didn't receive chemotherapy and 60,86% (n:28) with infectious focuses in the patients that received chemotherapy; the mortality in these patients were of 32,6%. In the pediatrics patients with infectious focuses severe, antibiotic extensive therapy didn't settle down direct relationship with the infection. The mortality was of 60%. The more frequent pathogens where Escherichia Coli with 19,2% Candida Albicans and other candida 14,6%, Staphylococcus aureus 8,2% , epidermidis 6,4%, Klebsiella pneumoniae 8,2%, oxytoca 2
Venn, R M; Bradshaw, C J; Spencer, R; Brealey, D; Caudwell, E; Naughton, C; Vedio, A; Singer, M; Feneck, R; Treacher, D; Willatts, S M; Grounds, R M
Dexmedetomidine, a highly selective and potent alpha2-adrenergic agonist, has a potentially useful role as a sedative agent in patients requiring intensive care. As part of a larger European multicentre trial, a total of 119 postoperative cardiac and general surgical patients requiring ventilation and sedation in an intensive care unit were enrolled in four centres in the United Kingdom. One hundred and five patients were randomly allocated to receive either dexmedetomidine or placebo with rescue sedation and analgesia provided by midazolam and morphine, respectively. Compared with the control group, intubated patients receiving dexmedetomidine required 80% less midazolam [mean 4.9 (5.8) microg.kg-1.h-1 vs. 23.7 (27.5) microg.kg-1.h-1, p < 0.0001], and 50% less morphine [11.2 (13.4) microg.kg-1.h-1 vs. 21.5 (19.4) microg.kg-1.h-1,p = 0.0006]. Cardiovascular effects and adverse events could be predicted from the known properties of alpha-2 agonists. In conclusion, dexmedetomidine is a useful agent for the provision of postoperative analgesia and sedation.
Guerra, Tatiana Lopes de Souza; Mendonça, Simone Sotero; Marshall, Norma Guimarães
To evaluate the incidence of constipation in critical patients on enteral nutrition in a hospital intensive care unit and to correlate this incidence with the variables found for critical patients. The present investigation was a retrospective analytical study conducted in the intensive care unit of Hospital Regional da Asa Norte (DF) via the analysis of medical records of patients admitted during the period from January to December 2011. Data on the incidence of constipation and enteral nutritional support, gastrointestinal changes, stool frequency, ventilatory support, and outcomes were collected and analyzed. The initial sample consisted of 127 patients admitted to the unit during the period from January to December 2011. Eighty-four patients were excluded, and the final sample consisted of 43 patients. The incidence of constipation, defined as no bowel movement during the first 4 days of hospitalization, was 72% (n=31). The patients were divided into a control group and a constipated group. The group of constipated patients reached the caloric target, on average, at 6.5 days, and the control group reached the caloric target in 5.6 days (p=0.51). Constipation was not associated with the length of hospital stay, suspension of nutritional support, or outcome of hospitalization. There was an association between evacuation during hospitalization and a longer duration of hospitalization for a subgroup of patients who did not evacuate during the entire period (p=0.009). The incidence of constipation in the unit studied was 72%. Only the absence of evacuation during hospitalization was associated with longer hospital stays. Constipation was not associated with the length of hospital stay, suspension of nutritional support, or outcome of hospitalization.
Full Text Available Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED of 15 hospitals in the Paris (France area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83-91 were included in the study. 94% of participants completed follow-up (n = 2495. 12.4% (n = 329 of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717 and 50.7% (n = 1264. At six months, 57.5% (n = 1433 of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear.ClinicalTrials.gov NCT00912600.
Reinikainen, M; Uusaro, A; Ruokonen, E; Niskanen, M
In the general population, mortality from acute myocardial infarctions, strokes and respiratory causes is increased in winter. The winter climate in Finland is harsh. The aim of this study was to find out whether there are seasonal variations in mortality rates in Finnish intensive care units (ICUs). We analysed data on 31,040 patients treated in 18 Finnish ICUs. We measured severity of illness with acute physiology and chronic health evaluation II (APACHE II) scores and intensity of care with therapeutic intervention scoring system (TISS) scores. We assessed mortality rates in different months and seasons and used logistic regression analysis to test the independent effect of various seasons on hospital mortality. We defined 'winter' as the period from December to February, inclusive. The crude hospital mortality rate was 17.9% in winter and 16.4% in non-winter, P = 0.003. Even after adjustment for case mix, winter season was an independent risk factor for increased hospital mortality (adjusted odds ratio 1.13, 95% confidence interval 1.04-1.22, P = 0.005). In particular, the risk of respiratory failure was increased in winter. Crude hospital mortality was increased during the main holiday season in July. However, the severity of illness-adjusted risk of death was not higher in July than in other months. An increase in the mean daily TISS score was an independent predictor of increased hospital mortality. Severity of illness-adjusted hospital mortality for Finnish ICU patients is higher in winter than in other seasons.
Garnier, M; Quesnel, C; Fulgencio, J-P; Degrain, M; Carteaux, G; Bonnet, F; Similowski, T; Demoule, A
Independent bench studies using specific ventilation scenarios allow testing of the performance of ventilators in conditions similar to clinical settings. The aims of this study were to determine the accuracy of the latest generation ventilators to deliver chosen parameters in various typical conditions and to provide clinicians with a comprehensive report on their performance. Thirteen modern intensive care unit ventilators were evaluated on the ASL5000 test lung with and without leakage for: (i) accuracy to deliver exact tidal volume (VT) and PEEP in assist-control ventilation (ACV); (ii) performance of trigger and pressurization in pressure support ventilation (PSV); and (iii) quality of non-invasive ventilation algorithms. In ACV, only six ventilators delivered an accurate VT and nine an accurate PEEP. Eleven devices failed to compensate VT and four the PEEP in leakage conditions. Inspiratory delays differed significantly among ventilators in invasive PSV (range 75-149 ms, P=0.03) and non-invasive PSV (range 78-165 ms, Pventilation algorithms efficiently prevented the decrease in pressurization capacities and PEEP levels induced by leaks in, respectively, 10 and 12 out of the 13 ventilators. We observed real heterogeneity of performance amongst the latest generation of intensive care unit ventilators. Although non-invasive ventilation algorithms appear to maintain adequate pressurization efficiently in the case of leakage, basic functions, such as delivered VT in ACV and pressurization in PSV, are often less reliable than the values displayed by the device suggest. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Bauer, M; Bach, A
Managed care, i.e., the integration of health insurance and delivery of care under the direction of one organization, is gaining importance in the USA health market. The initial effects consisted of a decrease in insurance premiums, a very attractive feature for employers. Managed care promises to contain expenditures for health care. Given the shrinking public resources in Germany, managed care seems attractive for the German health system, too. In this review the development of managed care, the principal elements, forms of organisation and practical tools are outlined. The regulation of the delivery of care by means of controlling and financial incentives threatens the autonomy of physicians: the physician must act as a "double agent", caring for the interest for the individual patient and being restricted by the contract with the managed care organisation. Cost containment by managed care was achieved by reducing the fees for physicians and hospitals (and partly by restricting care for patients). Only a fraction of this cost reduction was handed over to the enrollee or employer, and most of the money was returned with profit to the shareholders of the managed care organisations. The preeminent role of primary care physicians as gatekeepers of the health network led to a reduced demand for specialist services in general and for university hospitals and anesthesiologists in particular. The paradigm of managed care, i.e., to guide the patient and the care giver through the health care system in order to achieve cost-effective and high quality care, seems very attractive. The stress on cost minimization by any means in the daily practice of managed care makes it doubtful if managed care should be an option for the German health system, in particular because there are a number of restrictions on it in German law.
Delaney, Lori J; Currie, Marian J; Huang, Hsin-Chia Carol; Lopez, Violeta; Litton, Edward; Van Haren, Frank
The intensive care unit (ICU) environment exposes patients to noise levels that may result in substantial sleep disruption. There is a need to accurately describe the intensity pattern and source of noise in the ICU in order to develop effective sound abatement strategies. The objectives of this study were to determine nocturnal noise levels and their variability and the related sources of noise within an Australian tertiary ICU. An observational cross-sectional study was conducted in a 24-bed open-plan ICU. Sound levels were recorded overnight during three nights at 5-s epochs using Extech (SDL 600) sound monitors. Noise sources were concurrently logged by two research assistants. The mean recorded ambient noise level in the ICU was 52.85 decibels (dB) (standard deviation (SD) 5.89), with a maximum noise recording at 98.3 dB (A). All recorded measurements exceeded the WHO recommendations. Noise variability per minute ranged from 9.9 to 44 dB (A), with peak noise levels >70 dB (A) occurring 10 times/hour (SD 11.4). Staff were identified as the most common source accounting for 35% of all noise. Mean noise levels in single-patient rooms compared with open-bed areas were 53.5 vs 53 dB ( p = 0.37), respectively. Mean noise levels exceeded those recommended by the WHO resulting in an acoustical intensity of 193 times greater than the recommended and demonstrated a high degree of unpredictable variability, with the primary noise sources coming from staff conversations. The lack of protective effects of single rooms and the contributing effects that staffs have on noise levels are important factors when considering sound abatement strategies.
Iurkevich, V V; Fidarov, E Z; Bauér, V A
Experience of organization of the surgical care in the military hospital to 438 wounded in extremities during armed conflict in Republic of Chechnya is generalized. Maximum reduction of stages of medical evacuation of the wounded in extremities, approaching of the qualified and urgent specialized surgical care directly to the region of battle actions, use of opportunities for it one-moment rendering corresponded to principles of the modern military-medical doctrine. Due to realization of the requirements of the doctrine life of many wounded ++ was saved, terms of treatment, medical and social rehabilitation are reduced. Besides lethality, treatment cost and numbers of transferring to the reserve from the Armed Forces were reduced.
Antcliffe, David; Jiménez, Beatriz; Veselkov, Kirill; Holmes, Elaine; Gordon, Anthony C
Clinical features and investigations lack predictive value when diagnosing pneumonia, especially when patients are ventilated and when patients develop ventilator associated pneumonia (VAP). New tools to aid diagnosis are important to improve outcomes. This pilot study examines the potential for metabolic profiling to aid the diagnosis in critical care. In this prospective observational study ventilated patients with brain injuries or pneumonia were recruited in the intensive care unit and serum samples were collected soon after the start of ventilation. Metabolic profiles were produced using 1D 1 H NMR spectra. Metabolic data were compared using multivariate statistical techniques including Principal Component Analysis (PCA) and Orthogonal Partial Least Squares Discriminant Analysis (OPLS-DA). We recruited 15 patients with pneumonia and 26 with brain injuries, seven of whom went on to develop VAP. Comparison of metabolic profiles using OPLS-DA differentiated those with pneumonia from those with brain injuries (R 2 Y=0.91, Q 2 Y=0.28, p=0.02) and those with VAP from those without (R 2 Y=0.94, Q 2 Y=0.27, p=0.05). Metabolites that differentiated patients with pneumonia included lipid species, amino acids and glycoproteins. Metabolic profiling shows promise to aid in the diagnosis of pneumonia in ventilated patients and may allow a more timely diagnosis and better use of antibiotics. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.
Blakeman, Thomas; Rodriquez, Dario; Petro, Michael; Branson, Richard
Devices may forgo US military air worthiness and safety testing in an attempt to expedite the availability of critical assets such as mechanical ventilators with a waiver for one-time use in extenuating circumstances. We evaluated two Intensive Care Unit (ICU) level ventilators: Drager Evita XL and Puritan Bennett (PB) 840 in an altitude chamber at sea level and altitudes of 8,000 and 16,000 feet. Altitude affected delivered tidal volumes (VTs) in volume control mode (VCV) and Pressure Regulated Volume Controlled (PRVC) mode at altitude with the Evita XL but the differences were not considered clinically important with the PB 840. Sixty-seven percent of the V T s were outside the ASTM standard of ± 10% of set V T with the Evita XL at altitude. The PB 840 did not deliver V T s that were larger than the ASTM standard up to an altitude of 16,000 feet while the majority of the delivered V T s with the Därger XL were greater than the ASTM standard. This could present a patient safety issue. Caregivers must be aware of the capabilities and limitations of ICU ventilators when utilized in a hypobaric environment in order to provide safe care. Copyright © 2017 Air Medical Journal Associates. All rights reserved.
Argentero, Piergiorgio; Dell'Olivo, Bianca
Burnout phenomenon emerges from a constellation of factors which cannot be described in terms of cause-effect relationships. This study investigated levels of burnout in nurses working in Critical Care Units with a systemic approach, giving evidence of relation between nurses staff burnout and psychosocial workplace factors. The purpose of this study was to examine the relationship between job burnout in emergency and intensive care nurse with specific areas of work life in their organizations, using Maslach and Leiter work life model . A cross-sectional survey was designed using the Italian version of the "Organizational Checkup System" in a sample of 180 Italian nurses. Results showed that high burnout levels were strongly related to high demands, low control, low fairness, lack of social support, and individual disagreement on values in the workplace. High professional efficacy levels were instead correlated to professional reward and leadership involvement. The article concludes by suggesting the possible areas for intervention in order to prevent job burnout and building job engagement.
Sussmane, Jeffrey B; Torbati, Dan; Gitlow, Howard S
Our goal was to measure the quality of care provided in the Pediatric Intensive Care Unit (PICU) during Therapeutic Apheresis (TA). We described the care as a step by step process. We designed a flow chart to carefully document each step of the process. We then defined each step with a unique clinical indictor (CI) that represented the exact task we felt provided quality care. These CIs were studied and modified for 1 year. We measured our performance in this process by the number of times we accomplished the CI vs. the total number of CIs that were to be performed. The degree of compliance, with these clinical indicators, was analyzed and used as a metric for quality by calculating how close the process is running exactly as planned or "in control." The Apheresis Process was in control (compliance) for 47% of the indicators, as measured in the aggregate for the first observational year. We then applied the theory of Total Quality Management (TQM) through our Design, Measure, Analyze, Improve, and Control (DMAIC) model. We were able to improve the process and bring it into control by increasing the compliance to > 99.74%, in the aggregate, for the third and fourth quarter of the second year. We have implemented TQM to increase compliance, thus control, of a highly complex and multidisciplinary Pediatric Intensive Care therapy. We have shown a reproducible and scalable measure of quality for a complex clinical process in the PICU, without additional capital expenditure. Copyright © 2011 Wiley-Liss, Inc.
I reflected on the training I had on an extraordinary treatment for profound respiratory failure. The result of training enabled us to successfully treat a young female with the influenza A virus with extracorporeal membrane oxygenation (ECMO). I report the positive outcome that occurred, while continuing to run a busy general intensive care unit (ICU). She was the first of six patients who were all successfully treated with ECMO. Ten trained and experienced critical care nurses and two doctors attended the ECMO training course provided by the national centre in the UK. Five patients had already received ECMO therapy in the Scottish specialist unit (over the period of 8 years). As our Scottish specialist unit purchased exactly the same equipment as the national centre, it was easier for the multidisciplinary team to utilize their new-found knowledge and treat future patients with ECMO. With the predicted swine flu (H1N1) pandemic and the subsequent demand for critical care beds, funding was obtained to facilitate ECMO training. The potential need for increased provision of ECMO therapies was highlighted by recent events in Australia and New Zealand. Their most recent winter produced 68 patients requiring ECMO, whereas the previous year had manifested only three. Using our new equipment and adapted protocols from the national centre, we used these new skills to treat our first patient in October 2009. Johns' reflective practice tool was used to evaluate the care provided. Our patient was on ECMO for 9 days. She went on to make a remarkable recovery and was discharged from the ICU 1 week after ECMO was discontinued. She was discharged to the cardiothoracic high-dependency unit, where she was successfully rehabilitated. We were able to successfully treat a young lady, while providing the care for all other patients. This was a complex treatment, one that uses many resources including time and finance. Now that we have all the equipment, the necessary training and the
Ory, Jérôme; Raybaud, Evelyne; Chabanne, Russell; Cosserant, Bernard; Faure, Jean Sébastien; Guérin, Renaud; Calvet, Laure; Pereira, Bruno; Mourgues, Charline; Guelon, Dominique; Traore, Ousmane
The quality of oral care is important in limiting the emergence of ventilator-associated pneumonia (VAP) in intubated patients. Our main objective was to measure the quality improvement in oral care following the implementation of a new oral care protocol. We also monitored VAP rates. This was a cohort study of patients in 5 adult ICUs covering different specialties. During period 1, caregivers used a foam stick for oral care and during period 2 a stick and tooth brushing with aspiration. Oral chlorhexidine was used during both periods. The caregivers rated improvement in oral health on the basis of 4 criteria (tongue, mucous membranes, gingivae, and teeth). Caregiver satisfaction was also assessed. The incidence of VAP was monitored. A total of 2,030 intubated patients admitted to intensive care units benefited from oral care. The patient populations during the 2 periods were similar with regard to demographic data and VAP potential risk factors. Oral health was significantly better from the third day of oral care in period 2 onward (period 1, 6.4 ± 2.1; period 2, 5.6 ± 1.8; P = .043). Caregivers found the period 2 protocol easier to implement and more effective. VAP rates decreased significantly between the 2 periods (period 1, 12.8%; period 2, 8.5%; P = .002). Our study showed that the implementation of a simple strategy improved the quality of oral care of patients in intensive care units, and decreased VAP rates. Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
O'Neill, Catherine S; Yaqoob, Maryam; Faraj, Sumaya; O'Neill, Carla L
The process of dying in intensive care units is complex as the technological environment shapes clinical decisions. Decisions at the end of life require the involvement of patient, families and healthcare professionals. The degree of involvement can vary depending on the professional and social culture of the unit. Nurses have an important role to play in caring for dying patients and their families; however, their knowledge is not always sought. This study explored nurses' care practices at the end of life, with the objective of describing and identifying end of life care practices that nurses contribute to, with an emphasis on culture, religious experiences and professional identity. Research Design and context: Grounded theory was used. In all, 10 nurses from intensive care unit in two large hospitals in Bahrain were participated. Ethical Considerations: Approval to carry out the research was given by the Research Ethics Committee of the host institution, and the two hospitals. A core category, Death Avoidance Talk, was emerged. This was supported by two major categories: (1) order-oriented care and (2) signalling death and care shifting. Death talk was avoided by the nurses, doctors and family members. When a decision was made by the medical team that a patient was not to be resuscitated, the nurses took this as a sign that death was imminent. This led to a process of signalling death to family and of shifting care to family members. Despite the avoidance of death talk and nurses' lack of professional autonomy, they created awareness that death was imminent to family members and ensured that end of life care was given in a culturally sensitive manner and aligned to Islamic values.
Loovere, L.; Boyle, E.M.; Blatz, S.; Bowslaugh, M.; Kereliuk, M.; Paes, B.
The primary objective of this study was to ensure that X-rays performed consistently adhere to established technological quality standards and are achieved without compromising patient care while minimizing exposure risks. The secondary objective was to evaluate whether educational sessions targeting areas deemed suboptimal would facilitate improvement. A retrospective, 1-week review of all neonatal X-rays and documentation of clinical information on X-ray requisitions (n = 132) was completed in a tertiary care neonatal intensive care unit (NICU), by a single observer. Standards for X-ray evaluation were defined a priori based on radiographic principles and essential documented medical information for correct interpretation. Targeted areas for improvement were identified and addressed through brief educational sessions and printed pamphlets. The review was repeated after recommendations were implemented. 1 month (n = 93) and 1 year (n = 76) later. Improvements were evident in both the completion of X-ray requisitions and image quality. In particular, there was a statistically significant improvement in requisition legibility (P = 0.019), completeness of the medical history (P < 0.001), reduction in X-ray rotation (P < 0.001), collimation to the specific area of interest (P <0.001), gonadal shielding (P < 0.001), and decrease in monitor leads or artifacts obscuring views (P < 0.001). These improvements were sustained both 1 month and 1 year following the educational sessions. A neonatal X-ray audit is a simple, effective way to evaluate radiographic technique and encourage provision of basic clinical information for diagnostic interpretation by radiologists and neonatologists. As well, structured, collaborative educational sessions between radiology and neonatology staff appear to be a successful and sustainable method to effect overall improvement. (author)
Full Text Available The goals and recommendations for ICU (Intensive Care Unit patients’ sedation and analgesia should be to have adequately sedated patients who are calm and arousal, so that they can guarantee a proper evaluation and an adequate control of pain. This way, it is also possible to perform their neurological evaluation, preserving intellectual faculties and helping them in actively participating to their care. Dexmedetomidine is a selective alpha-2 receptor agonist, member of theraputical cathegory: “other hypnotics and sedatives” (ATC: N05CM18. Dexmedetomidine is recommended for the sedation of adult ICU patients who need a sedation level not deeper than arousal in response to verbal stimulation (corresponding to Richmond Agitation-Sedation Scale 0 to -3. After the EMA approval, some European government authorities have elaborated HTA on dexmedetomidine, based on clinical evidence derived from Prodex and Midex trials. Dexmedetomidine resulted to be as effective as propofol and midazolam in maintaining the target depth of sedation in ICU patients. The mean duration of mechanical ventilation with dexmedetomidine was numerically shorter than with propofol and significantly shorter than with midazolam. The resulting favourable economic profile of dexmedetomidine supported the clinical use in ICU. Dexmedetomidine seems to provide clinical benefits due to the reduction of mechanical ventilation and ventilator weaning duration. Within the present review, an economic analysis of costs associated to the use of dexmedetomidine was therefore performed also in the Italian care setting. Thus, four different analyses were carried out based on the quantification of the total number of days in ICU, the time spent on mechanical ventilation, the weighted average number of days with mechanical ventilation or not and TISS points (Therapeutic Intervention Scoring System. Despite the incremental cost for drug therapy associated with dexmedetomidine, a reduction of
Winsett, Rebecca P; Rottet, Kendra; Schmitt, Abby; Wathen, Ellen; Wilson, Debra
The purpose of the study was to explore the nurse work environment by evaluating the self-report of missed nursing care and the reasons for the missed care. A convenience sample of medical surgical nurses from four hospitals was invited to complete the survey for this descriptive study. The sample included 168 nurses. The MISSCARE survey assessed the frequency and reason of 24 routine nursing care elements. The most frequently reported missed care was ambulation as ordered, medications given within a 30 minute window, and mouth care. Moderate or significant reasons reported for the missed care were: unexpected rise in volume/acuity, heavy admissions/discharges, inadequate assistants, inadequate staff, meds not available when needed, and urgent situations. Identifying missed nursing care and reasons for missed care provides an opportunity for exploring strategies to reduce interruptions, develop unit cohesiveness, improve the nurse work environment, and ultimately leading to improved patient outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.
Awad, Aya; Bader-El-Den, Mohamed; McNicholas, James; Briggs, Jim
Mortality prediction of hospitalized patients is an important problem. Over the past few decades, several severity scoring systems and machine learning mortality prediction models have been developed for predicting hospital mortality. By contrast, early mortality prediction for intensive care unit patients remains an open challenge. Most research has focused on severity of illness scoring systems or data mining (DM) models designed for risk estimation at least 24 or 48h after ICU admission. This study highlights the main data challenges in early mortality prediction in ICU patients and introduces a new machine learning based framework for Early Mortality Prediction for Intensive Care Unit patients (EMPICU). The proposed method is evaluated on the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) database. Mortality prediction models are developed for patients at the age of 16 or above in Medical ICU (MICU), Surgical ICU (SICU) or Cardiac Surgery Recovery Unit (CSRU). We employ the ensemble learning Random Forest (RF), the predictive Decision Trees (DT), the probabilistic Naive Bayes (NB) and the rule-based Projective Adaptive Resonance Theory (PART) models. The primary outcome was hospital mortality. The explanatory variables included demographic, physiological, vital signs and laboratory test variables. Performance measures were calculated using cross-validated area under the receiver operating characteristic curve (AUROC) to minimize bias. 11,722 patients with single ICU stays are considered. Only patients at the age of 16 years old and above in Medical ICU (MICU), Surgical ICU (SICU) or Cardiac Surgery Recovery Unit (CSRU) are considered in this study. The proposed EMPICU framework outperformed standard scoring systems (SOFA, SAPS-I, APACHE-II, NEWS and qSOFA) in terms of AUROC and time (i.e. at 6h compared to 48h or more after admission). The results show that although there are many values missing in the first few hour of ICU admission
Grudzen, Corita; Richardson, Lynne D; Baumlin, Kevin M; Winkel, Gary; Davila, Carine; Ng, Kristen; Hwang, Ula
Charged with transforming geriatric emergency care by applying palliative care principles, a process improvement team at New York City's Mount Sinai Medical Center developed the GEDI WISE (Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements) model. The model introduced workforce enhancements for emergency department (ED) and adjunct staff, including role redefinition, retraining, and education in palliative care principles. Existing ED triage nurses screened patients ages sixty-five and older to identify those at high risk of ED revisit and hospital readmission. Once fully trained, these nurses screened all but 6 percent of ED visitors meeting the screening criteria. Newly hired ED nurse practitioners identified high-risk patients suitable for and desiring palliative and hospice care, then expedited referrals. Between January 2011 and May 2013 the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3 percent to 0.9 percent, generating an estimated savings of more than $3 million to Medicare. The decline in these admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. GEDI WISE programs are now running at Mount Sinai and two partner sites, and their potential to affect the quality and value of geriatric emergency care continues to be examined. Project HOPE—The People-to-People Health Foundation, Inc.
Ballangrud, Randi; Hall-Lord, Marie Louise; Persenius, Mona; Hedelin, Birgitta
To describe intensive care nurses' perceptions of simulation-based team training for building patient safety in intensive care. Failures in team processes are found to be contributory factors to incidents in an intensive care environment. Simulation-based training is recommended as a method to make health-care personnel aware of the importance of team working and to improve their competencies. The study uses a qualitative descriptive design. Individual qualitative interviews were conducted with 18 intensive care nurses from May to December 2009, all of which had attended a simulation-based team training programme. The interviews were analysed by qualitative content analysis. One main category emerged to illuminate the intensive care nurse perception: "training increases awareness of clinical practice and acknowledges the importance of structured work in teams". Three generic categories were found: "realistic training contributes to safe care", "reflection and openness motivates learning" and "finding a common understanding of team performance". Simulation-based team training makes intensive care nurses more prepared to care for severely ill patients. Team training creates a common understanding of how to work in teams with regard to patient safety. Copyright © 2014 Elsevier Ltd. All rights reserved.
Martin, Jan; Blobner, Manfred; Busch, Raymonde; Moser, Norman; Kochs, Eberhard; Luppa, Peter B
The aim of the study was to retrospectively investigate whether parameters of routine point-of-care testing (POCT) predict hospital mortality in critically ill surgical patients on admission to the intensive care unit (ICU). Arterial blood analyses of 1551 patients on admission to the adult surgical ICU of the Technical University Munich were reviewed. POCT was performed on a blood gas analyser. The association between acid-base status and mortality was evaluated. Metabolic acidosis was defined by base excess (BE) lactate >50% of BE, anion gap (AG)-acidosis by AG >16 mmol/L, hyperchloraemic acidosis by chloride >115 mmol/L. Metabolic alkalosis was defined by BE ≥3 mmol/L. Logistic regression analysis identified variables independently associated with mortality. Overall mortality was 8.8%. Mortality was greater in male patients (p=0.012). Mean age was greater in non-survivors (p55 mm Hg (mortality 23.1%). Three hundred and seventy-seven patients presented with acidosis (mortality 11.4%), thereof 163 patients with lactic acidosis (mortality 19%). Mortality for alkalosis (174 patients) was 12.1%. Mean blood glucose level for non-survivors was higher compared to survivors (plactate, glucose, age, male gender as independent predictors of mortality. Lactate and glucose on ICU admission independently predict mortality. BE and AG failed as prognostic markers. Lactic acidosis showed a high mortality rate implying that lactate levels should be obtained on ICU admission. Prevalence of hyperchloraemic acidosis was low. Metabolic alkalosis was associated with an increased mortality. Further studies on this disturbance and its attendant high mortality are warranted.
Marra, Alexandre R; Cal, Ruy Guilherme Rodrigues; Silva, Cláudia Vallone; Caserta, Raquel Afonso; Paes, Angela Tavares; Moura, Denis Faria; dos Santos, Oscar Fernando Pavão; Edmond, Michael B; Durão, Marcelino Souza
Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections (HAIs) in critical care settings. Our objective was to examine the effect of a series of interventions, implemented in 3 different periods to reduce the incidence of VAP in an intensive care unit (ICU). A quasiexperimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed during different phases. From March 2001 to December 2002 (phase 1: P1), some Centers for Disease Control and Prevention (CDC) evidence-based practices were implemented. From January 2003 to December 2006 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and, from January 2007 to September 2008 (P3), we continued P2 interventions and implemented the Institute for Healthcare Improvement's ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions. The incidence density of VAP in the ICU per 1000 patient-days was 16.4 in phase 1, 15.0 in phase 2, and 10.4 in phase 3, P=.05. Getting to zero VAP was possible only in P3 when compliance with all interventions exceeded 95%. These results suggest that reducing VAP rates to zero is a complex process that involves multiple performance measures and interventions.
Ledwidge, S F C; Bryden, E; Halestrap, P; Galland, R B
Continuity of patient care is an important component of surgical education. This study assesses continuity of care in the current working climate. Data were collected prospectively on consecutive emergency general surgical admissions during one month. Our SpR rota is a partial shift 24 hour on call with the SpR's own consultant. The SpR is free of commitments the next day following post-take work. The on call general surgery SpR was designated the 'assessor'. Data were analysed according to involvement of the 'assessor' at subsequent stages of the admission--consent, operation, review during admission and review on discharge. Data were also collected defining whether the 'assessor' and operator followed-up the patient. There were 200 admissions; 108 female and 92 male. Overall 23% admissions had the same 'assessor' for all stages of patient care. The 'assessor' dealt with an aspect of patient care in 11% of admissions who underwent an operation and 29% of admissions who were conservatively managed. SpR follow-up of admissions on whom they operated was 70% but only 41% of admissions who were conservatively managed were followed-up by the assessing SpR. Complete in-hospital continuity of care was poor, although SpR follow-up of patients on whom they had operated was better. Introduction of shift patterns has reduced continuity of patient care. This will have a negative impact on both surgical training and patient care.
Sukhminder Jit Singh Bajwa
Full Text Available The advancements in neuro-endocrine surgical interventions have been well supported by similar advancements in anesthesiology and intensive care. Surgery of the pituitary tumor poses unique challenges to the anesthesiologists and the intensivists as it involves the principles and practices of both endocrine and neurosurgical management. A multidisciplinary approach involving the endocrine surgeon, neurosurgeon, anesthesiologist, endocrinologist and intensivist is mandatory for a successful surgical outcome. The focus of pre-anesthetic checkup is mainly directed at the endocrinological manifestations of pituitary hypo or hyper-secretion as it secretes a variety of essential hormones, and also any pathological state that can cause imbalance of pituitary secretions. The pathophysiological aspects associated with pituitary tumors mandate a thorough airway, cardiovascular, neurologic and endocrinological assessment. A meticulous preoperative preparation and definite plans for the intra-operative period are the important clinical components of the anesthetic strategy. Various anesthetic modalities and drugs can be useful to provide a smooth intra-operative period by countering any complication and thus providing an uneventful recovery period.
Full Text Available Introduction: Reasons for acute renal failure in hospitalized infants were sepsis, hypovolemia, asphyxia, respiratory distress syndrome, surgical interventions and congenital heart defects. The aim of this study was to determine the frequency and and main etiologies, and early outcome of neonatal acute renal failure. Materials and Methods: At Intensive Care Unit, Clinical Center Tuzla, from 15. 01. 2013 to 15. 01. 2015 in 21 newborn was diagnosed renal failure, based on the amount of excreted urine and serum creatinine. Results: The prevalence of renal failure was 6.84%, with a higher incidence of female. 33.3% of infants were term neonates. Oliguria was diagnosed in 71.4% of newborns. Sepsis was the most common predisposing factor for the development of renal failure, associated with high mortality. Other causes of renal failure were perinatal hypoxia, RDS, surgical interventions and congenital heart defects. There was a positive correlation between the gestational age of the newborn and serum creatinine. Discussion: Early prevention of risk factors with rapid diagnosis and effective treatment, can affect further outcome of acute renal failure in infants.
Coughlin, Mary; Gibbins, Sharyn; Hoath, Steven
This paper is a discussion of evidence-based core measures for developmental care in neonatal intensive care units. Inconsistent definition, application and evaluation of developmental care have resulted in criticism of its scientific merit. The key concept guiding data organization in this paper is the United States of America's Joint Commission's concept of 'core measures' for evaluating and accrediting healthcare organizations. This concept is applied to five disease- and procedure-independent measures based on the Universe of Developmental Care model. Electronically accessible, peer reviewed studies on developmental care published in English were culled for data supporting the selected objective core measures between 1978 and 2008. The quality of evidence was based on a structured predetermined format that included three independent reviewers. Systematic reviews and randomized control trials were considered the strongest level of evidence. When unavailable, cohort, case control, consensus statements and qualitative methods were considered the strongest level of evidence for a particular clinical issue. Five core measure sets for evidence-based developmental care were evaluated: (1) protected sleep, (2) pain and stress assessment and management, (3) developmental activities of daily living, (4) family-centred care, and (5) the healing environment. These five categories reflect recurring themes that emerged from the literature review regarding developmentally supportive care and quality caring practices in neonatal populations. This practice model provides clear metrics for nursing actions having an impact on the hospital experience of infant-family dyads. Standardized disease-independent core measures for developmental care establish minimum evidence-based practice expectations and offer an objective basis for cross-institutional comparison of developmental care programmes.
Hamze, Fernanda Luiza; de Souza, Cristiane Chaves; Chianca, Tânia Couto Machado
to identify care interventions, performed by the health team, and their influence on the continuity of sleep of patients hospitalized in the Intensive Care Unit. descriptive study with a sample of 12 patients. A filming technique was used for the data collection. The awakenings from sleep were measured using the actigraphy method. The analysis of the data was descriptive, processed using the Statistical Package for the Social Sciences software. 529 care interventions were identified, grouped into 28 different types, of which 12 (42.8%) caused awakening from sleep for the patients. A mean of 44.1 interventions/patient/day was observed, with 1.8 interventions/patient/hour. The administration of oral medicine and food were the interventions that caused higher frequencies of awakenings in the patients. it was identified that the health care interventions can harm the sleep of ICU patients. It is recommended that health professionals rethink the planning of interventions according to the individual demand of the patients, with the diversification of schedules and introduction of new practices to improve the quality of sleep of Intensive Care Unit patients.
Fernanda Luiza Hamze
Full Text Available Objective: to identify care interventions, performed by the health team, and their influence on the continuity of sleep of patients hospitalized in the Intensive Care Unit.Method: descriptive study with a sample of 12 patients. A filming technique was used for the data collection. The awakenings from sleep were measured using the actigraphy method. The analysis of the data was descriptive, processed using the Statistical Package for the Social Sciences software.Results: 529 care interventions were identified, grouped into 28 different types, of which 12 (42.8% caused awakening from sleep for the patients. A mean of 44.1 interventions/patient/day was observed, with 1.8 interventions/patient/hour. The administration of oral medicine and food were the interventions that caused higher frequencies of awakenings in the patients.Conclusion: it was identified that the health care interventions can harm the sleep of ICU patients. It is recommended that health professionals rethink the planning of interventions according to the individual demand of the patients, with the diversification of schedules and introduction of new practices to improve the quality of sleep of Intensive Care Unit patients.
Dodek, Peter M; Wong, Hubert; Jaswal, Danny; Heyland, Daren K; Cook, Deborah J; Rocker, Graeme M; Kutsogiannis, Demetrios J; Dale, Craig; Fowler, Robert; Ayas, Najib T
The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture. In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture. Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P organizational and safety culture. Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs. Copyright © 2012 Elsevier Inc. All rights reserved.
Finlayson, Kenneth William; Dixon, Annie; Smith, Chris; Dykes, Fiona Clare; Flacking, Renee
Objective\\ud \\ud To explore mothers’ perceptions of family centred care (FCC) in neonatal intensive care units (NICUs) in England.\\ud Design\\ud \\ud The qualitative experiences of 12 mothers from three NICUs in the UK were elicited using individual interviews. A thematic network analysis was conducted on the transcribed interviews\\ud Main outcome measures\\ud \\ud A central global theme supported by a number of organizing themes were developed reflecting the views of the mothers and their experi...
Koenig, Helen C; Finkel, Barbara B; Khalsa, Satjeet S; Lanken, Paul N; Prasad, Meeta; Urbani, Richard; Fuchs, Barry D
Lung protective ventilation reduces mortality in patients with acute lung injury, but underrecognition of acute lung injury has limited its use. We recently validated an automated electronic acute lung injury surveillance system in patients with major trauma in a single intensive care unit. In this study, we assessed the system's performance as a prospective acute lung injury screening tool in a diverse population of intensive care unit patients. Patients were screened prospectively for acute lung injury over 21 wks by the automated system and by an experienced research coordinator who manually screened subjects for enrollment in Acute Respiratory Distress Syndrome Clinical Trials Network (ARDSNet) trials. Performance of the automated system was assessed by comparing its results with the manual screening process. Discordant results were adjudicated blindly by two physician reviewers. In addition, a sensitivity analysis using a range of assumptions was conducted to better estimate the system's performance. The Hospital of the University of Pennsylvania, an academic medical center and ARDSNet center (1994-2006). Intubated patients in medical and surgical intensive care units. None. Of 1270 patients screened, 84 were identified with acute lung injury (incidence of 6.6%). The automated screening system had a sensitivity of 97.6% (95% confidence interval, 96.8-98.4%) and a specificity of 97.6% (95% confidence interval, 96.8-98.4%). The manual screening algorithm had a sensitivity of 57.1% (95% confidence interval, 54.5-59.8%) and a specificity of 99.7% (95% confidence interval, 99.4-100%). Sensitivity analysis demonstrated a range for sensitivity of 75.0-97.6% of the automated system under varying assumptions. Under all assumptions, the automated system demonstrated higher sensitivity than and comparable specificity to the manual screening method. An automated electronic system identified patients with acute lung injury with high sensitivity and specificity in diverse
Full Text Available Although Saccharomyces boulardii is usually a non-pathogenic fungus, in rare occasions it can cause invasive infection in children. We present the case of an 8-year-old patient in pediatric surgical intensive care unit who developed S. cerevisiae fungemia following probiotic treatment containing S. boulardii. Caspofungin was not effective in this case and he was treated with amphotericin B. We want to emphasize that physicians should be careful about probiotic usage in critically ill patients.
Atıcı, Serkan; Soysal, Ahmet; Karadeniz Cerit, Kıvılcım; Yılmaz, Şerife; Aksu, Burak; Kıyan, Gürsu; Bakır, Mustafa
Although Saccharomyces boulardii is usually a non-pathogenic fungus, in rare occasions it can cause invasive infection in children. We present the case of an 8-year-old patient in pediatric surgical intensive care unit who developed S. cerevisiae fungemia following probiotic treatment containing S. boulardii . Caspofungin was not effective in this case and he was treated with amphotericin B. We want to emphasize that physicians should be careful about probiotic usage in critically ill patients.
E De Plecker
Full Text Available In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC, we assessed the a characteristics of women at risk of, or with an obstetric complication and their types b the number and type of obstetric surgical procedures and anaesthesia performed c human resource cadres who performed surgery and anaesthesia and d hospital exit outcomes.A retrospective analysis of EmOC data (2011 and 2012.A total of 6084 women were referred for EmOC of whom 2534(42% underwent a major surgical procedure while 1345(22% required a minor procedure (36% women did not require any surgical procedure. All cases with uterine rupture(73 and extra-uterine pregnancy(10 and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61% and normal delivery (34%. A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65% required spinal and 578(23% required general anaesthesia; 2341(92% procedures were performed by 'general practitioners with surgical skills' and in 2451(96% cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97% were discharged, 21(0.8% were referred to tertiary care and 2(0.1% died.Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.
The purposes of this study is first, to investigate intensive care patients' perceptions of stressors; second, to investigate the health care provider's perception of what constitutes a stressor from the patient's perspective; and third, to describe how health care providers manage their patients' stressors. This was a mixed-methods study; the quantitative section replicated Cornock's 1998 study of stress in the intensive care unit (ICU), with difference in sampling to include all health care providers in the ICU, in addition to nurses. The qualitative section added information to the current literature by describing how health care providers manage their patient's stressors. This article reports the quantitative findings of this study, as the qualitative section is presented in a separate article. It is important to describe ICU patients' stressful experiences to assess patient's stressors, provide holistic care to eliminate stressors, and provide feedback to health care providers. There is a need to describe the clinical practice related to stress perception and management of stressors in the critical care environment. A mixed-methods comparative descriptive design was used for the quantitative section, and a phenomenological approach guided the qualitative section. Lazarus and Folkman's theory formed the bases for integrating all variables investigated in this study. The sample included 70 ICU patients and 70 ICU health care providers. After consenting to participate in this study, subjects were given a demographic form and a paper-based tool, the Environmental Stressors graphic data form Questionnaire. Questionnaires were filled out by subjects anonymously in the ICU and returned to the researcher in the same setting. Descriptive statistics were analyzed using SPSS data analysis software. The top 3 most stressful items ranked by the patients included "being in pain," followed by "not being able to sleep" and "financial worries"; on the other hand, health care
de Heer, Geraldine; Saugel, Bernd; Sensen, Barbara; Rübsteck, Charlotte; Pinnschmidt, Hans O; Kluge, Stefan
Advance directives and powers of attorney are increasingly common, yet data on their use in clinical situations remain sparse. In this single center cross-sectional study, we collected data by questionnaire from 1004 intensive care patients in a university hospital. The frequencies of advance directives and powers of attorney were determined, and the factors affecting them were studied with multivariate logistic regression analysis. Usable data were obtained from 998 patients. 51.3% stated that they had prepared a document of at least one of these two kinds. Among them, 39.6% stated that they had given the relevant document(s) to the hospital, yet such documents were present in the patient's hospital record for only 23%. 508 patients stated their reasons for preparing an advance directive or a power of attorney: the most common reason (48%) was the fear of being at other people's mercy, of the lack of self-determination, or of medical overtreatment. The most important factors associated with a patient's statement that he/she had prepared such a document were advanced age (advance directive: 1.022 [1.009; 1.036], p = 0.001; power of attorney: 1.027 [1.014; 1.040], padvance directive: 1.622 [1.138; 2.311], padvance directives and 44.1% of the powers of attorney that were present in the hospital records were poorly interpretable because of the incomplete filling-out of preprinted forms. Half of the patients who did not have such a document had already thought of preparing one, but had not yet done so. For patients hospitalized in intensive care units, there should be early discussion about the presence or absence of documents of these kinds and early evaluation of the patient's concrete wishes in critical situations. Future studies are needed to determine how best to assure that these d