Validation of the Critical Care Pain Observation Tool in Critically Ill Patients With Delirium: A Prospective Cohort Study

Validation of the Critical Care Pain Observation Tool in Critically Ill Patients With Delirium: A Prospective Cohort Study

Critical Care Medicine: May 2016 - Volume 44 - Issue 5 - p 943–947

Kanji, S

Objectives: The 2013 clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the ICU suggest that pain be routinely assessed using a validated pain assessment tool. Currently available tools have only been evaluated in nondelirious critically ill patients, yet delirium can affect as many as 80% of ICU patients. The validated pain assessment tool adopted by our institution is the Critical Care Pain Observation Tool, and the objective of this study was to investigate the validity of this tool in patients with evidence of delirium. Design: Prospective cohort study. Setting: Two ICUs within a Canadian tertiary healthcare center. Patients: Forty consecutive adult patients deemed delirious on the day of enrollment using the Confusion Assessment Method for ICU. Measurements and Main Results: Serial Critical Care Pain Observation Tool assessments were conducted simultaneously by study personnel and objective nurses at baseline and after nonpainful and painful stimuli. Subjective opinions about pain and objective physical variables (including mean arterial pressure, heart rate, respiratory rate, and oxygen saturation) were collected at the same time points. Discriminant validity was described using paired t tests, whereas internal consistency was described using the Cronbach α statistic. Responsiveness of the Critical Care Pain Observation Tool was measured by effect size, and reliability was described as the agreement between raters. Comparisons between the Critical Care Pain Observation Tool and the subjective assessments and objective measurements were based on positive and negative percent agreement. Critical Care Pain Observation Tool demonstrated excellent discriminant validity as evidenced by a highly statistically and clinically significant change in mean Critical Care Pain Observation Tool scores between baseline and painful procedures (mean difference, 3.13 ± 1.56; p < 0.001; Cohen D, 2.0). Interrater agreement was also excellent (κ > 0.6), and scores between raters were highly correlated (r = 0.957). The Critical Care Pain Observation Tool possessed a high level of internal consistency (overall Cronbach α, 0.778). Percent agreement was found to be greater between the Critical Care Pain Observation Tool and the nurse’s subjective opinion of the presence or absence of pain when compared with that between the Critical Care Pain Observation Tool and physiologic variables (80.5% vs 67.5%, respectively). Conclusions: The Critical Care Pain Observation Tool is a valid pain assessment tool in noncomatose, delirious adult ICU patients who are unable to reliably self-report the presence or absence of pain.

Quality of patient care in the critical care unit in relation to nurse patient ratio: A descriptive study

Quality of patient care in the critical care unit in relation to nurse patient ratio: A descriptive study

Intensive and Critical Care Nursing: Article in Press

Falk AC,  Wallin EM

Intensive care is one of the most resource-intensive forms of medical care due to severely ill patients that are cared for in units with high staffing levels. Nursing's impact on the health of patients has shown that the number of nurses per patient and nurse education effects patient outcome. However, there are a lack of studies investigating highly specialised nurses in intensive care and their relation to patient outcome.

The Efficacy of Earplugs as a Sleep Hygiene Strategy for Reducing Delirium in the ICU: A Systematic Review and Meta-Analysis

The Efficacy of Earplugs as a Sleep Hygiene Strategy for Reducing Delirium in the ICU: A Systematic Review and Meta-Analysis

Critical Care Medicine: May 2016 - Volume 44 - Issue 5 - p 992–999

Litton, E et al

Objective: A systematic review and meta-analysis to assess the efficacy of earplugs as an ICU strategy for reducing delirium. Data Sources: MEDLINE, EMBASE, and the Cochrane Central Register of controlled trials were searched using the terms “intensive care,” “critical care,” “earplugs,” “sleep,” “sleep disorders,” and “delirium.” Study Selection: Intervention studies (randomized or nonrandomized) assessing the efficacy of earplugs as a sleep hygiene strategy in patients admitted to a critical care environment were included. Studies were excluded if they included only healthy volunteers, did not report any outcomes of interest, did not contain an intervention group of interest, were crossover studies, or were only published in abstract form. Data Extraction: Nine studies published between 2009 and 2015, including 1,455 participants, fulfilled the eligibility criteria and were included in the systematic review. Studies included earplugs as an isolated intervention (n = 3), or as part of a bundle with eye shades (n = 2), or earplugs, eye shades, and additional sleep noise abatement strategies (n = 4). The risk of bias was high for all studies. Data Synthesis: Five studies comprising 832 participants reported incident delirium. Earplug placement was associated with a relative risk of delirium of 0.59 (95% CI, 0.44–0.78) and no significant heterogeneity between the studies (I2, 39%; p = 0.16). Hospital mortality was reported in four studies (n = 481) and was associated with a relative risk of 0.77 (95% CI, 0.54–1.11; I2, 0%; p < 0.001). Compliance with the placement of earplugs was reported in six studies (n = 681). The mean per-patient noncompliance was 13.1% (95% CI, 7.8–25.4) of those assigned to receive earplugs. Conclusions: Placement of earplugs in patients admitted to the ICU, either in isolation or as part of a bundle of sleep hygiene improvement, is associated with a significant reduction in risk of delirium. The potential effect of cointerventions and the optimal strategy for improving sleep hygiene and associated effect on patient-centered outcomes remains uncertain.

Analgesia in Neurocritical Care: An International Survey and Practice Audit

Analgesia in Neurocritical Care: An International Survey and PracticeAudit

Critical Care Medicine: May 2016 - Volume 44 - Issue 5 - p 973–980

Zeiler, FA et al

Objective: To characterize analgesic administration in neurocritical care. Design: ICU pharmacy database analgesic delivery audits from five countries. A 31-question analgesic agent survey was constructed, validated, and e-distributed in four countries. Setting: International multicenter neuro-ICU database audit and electronic survey. Patients: Six ICUs provided individual, anonymized analgesic delivery data in primary neurological diagnosis patients. Prescriber surveys were disseminated by neurocritical care societies. Interventions: None. Measurements and Main Results: Analgesic delivery data from 173 patients in French, Canadian, American, and Australian and New Zealand ICUs suggest that acetaminophen/paracetamol is the most common first-line analgesic (49.1% of patients); opiates are the “second line” in 31.5% of patients; however, 33% patients received no second agent. In the 2.3% with demyelinating disease, gabapentin was the most likely second analgesic (50.0%). Third-line analgesics were scarce across sites and neuropathologies. Few national or regional differences were found. The analgesic preference rankings noted by the 95 international physicians who completed the survey matched the audits. However, self-reported analgesic prescription rates were much higher than pharmacy records indicate, with self-reported prescribing of both acetaminophen/paracetamol and opiates in 97% of patients and gabapentin in 45% of patients. Third-line analgesic variability appeared to be driven by neuropathology; ibuprofen was preferred for traumatic brain injury, postcraniotomy, and thromboembolic stroke patients, whereas gabapentin/pregabalin were favored in subarachnoid hemorrhage, intracranial hemorrhage, spine, demyelinating disease, and epileptic patients. Conclusions: Opiates and acetaminophen are preferred analgesic agents, and gabapentin is a contextual third choice, in neurocritically ill patients. Other agents are rarely prescribed. The discordance in physician self-reports and objective audits suggest that pain management optimization studies are warranted.

Conflict Management Strategies in the ICU Differ Between Palliative Care Specialists and Intensivists

Conflict Management Strategies in the ICU Differ Between Palliative Care Specialists and Intensivists

Critical Care Medicine: May 2016 - Volume 44 - Issue 5 - p 934–942
Chiarchiaro, J et al

Objectives: Conflict is common between physicians and surrogate decision makers around end-of-life care in ICU. Involving experts in conflict management improve outcomes, but little is known about what differences in conflict management styles may explain the benefit. We used simulation to examine potential differences in how palliative care specialists manage conflict with surrogates about end-of-life treatment decisions in ICUs compared with intensivists. Design: Subjects participated in a high-fidelity simulation of conflict with a surrogate in an ICU. In this simulation, a medical actor portrayed a surrogate decision maker during an ICU family meeting who refuses to follow an advance directive that clearly declines advanced life-sustaining therapies. We audiorecorded the simulation encounters and applied a coding framework to quantify conflict management behaviors, which was organized into two categories: task-focused communication and relationship building. We used negative binomial modeling to determine whether there were differences between palliative care specialists’ and intensivists’ use of task-focused communication and relationship building. Setting: Single academic medical center ICU. Subjects: Palliative care specialists and intensivists. Interventions: None. Measurements and Main Results: We enrolled 11 palliative care specialists and 25 intensivists. The palliative care specialists were all attending physicians. The intensivist group consisted of 11 attending physicians, 9 pulmonary and critical care fellows, and 5 internal medicine residents rotating in the ICU. We excluded five residents from the primary analysis in order to reduce confounding due to training level. Physicians’ mean age was 37 years with a mean of 8 years in practice. Palliative care specialists used 55% fewer task-focused communication statements (incidence rate ratio, 0.55; 95% CI, 0.36–0.83; p = 0.005) and 48% more relationship-building statements (incidence rate ratio, 1.48; 95% CI, 0.89–2.46; p = 0.13) compared with intensivists. Conclusions: We found that palliative care specialists engage in less task-focused communication when managing conflict with surrogates compared with intensivists. These differences may help explain the benefit of palliative care involvement in conflict and could be the focus of interventions to improve clinicians’ conflict resolution skills. Objectives: Conflict is common between physicians and surrogate decision makers around end-of-life care in ICU. Involving experts in conflict management improve outcomes, but little is known about what differences in conflict management styles may explain the benefit. We used simulation to examine potential differences in how palliative care specialists manage conflict with surrogates about end-of-life treatment decisions in ICUs compared with intensivists. Design: Subjects participated in a high-fidelity simulation of conflict with a surrogate in an ICU. In this simulation, a medical actor portrayed a surrogate decision maker during an ICU family meeting who refuses to follow an advance directive that clearly declines advanced life-sustaining therapies. We audiorecorded the simulation encounters and applied a coding framework to quantify conflict management behaviors, which was organized into two categories: task-focused communication and relationship building. We used negative binomial modeling to determine whether there were differences between palliative care specialists’ and intensivists’ use of task-focused communication and relationship building. Setting: Single academic medical center ICU. Subjects: Palliative care specialists and intensivists. Interventions: None. Measurements and Main Results: We enrolled 11 palliative care specialists and 25 intensivists. The palliative care specialists were all attending physicians. The intensivist group consisted of 11 attending physicians, 9 pulmonary and critical care fellows, and 5 internal medicine residents rotating in the ICU. We excluded five residents from the primary analysis in order to reduce confounding due to training level. Physicians’ mean age was 37 years with a mean of 8 years in practice. Palliative care specialists used 55% fewer task-focused communication statements (incidence rate ratio, 0.55; 95% CI, 0.36–0.83; p = 0.005) and 48% more relationship-building statements (incidence rate ratio, 1.48; 95% CI, 0.89–2.46; p = 0.13) compared with intensivists. Conclusions: We found that palliative care specialists engage in less task-focused communication when managing conflict with surrogates compared with intensivists. These differences may help explain the benefit of palliative care involvement in conflict and could be the focus of interventions to improve clinicians’ conflict resolution skills.

Predicting Fluid Responsiveness by Passive Leg Raising: A Systematic Review and Meta-Analysis of 23 Clinical Trials

Predicting Fluid Responsivenessby Passive Leg Raising: A Systematic Review and Meta-Analysis of 23 ClinicalTrials

Critical Care Medicine: May 2016 - Volume 44 - Issue 5 - p 981–991
Cherpanath, TGV et al


Objective: Passive leg raising creates a reversible increase in venous return allowing for the prediction of fluid responsiveness. However, the amount of venous return may vary in various clinical settings potentially affecting the diagnostic performance of passive leg raising. Therefore we performed a systematic meta-analysis determining the diagnostic performance of passive leg raising in different clinical settings with exploration of patient characteristics, measurement techniques, and outcome variables. Data Sources: PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and citation tracking of relevant articles. Study Selection: Clinical trials were selected when passive leg raising was performed in combination with a fluid challenge as gold standard to define fluid responders and non-responders. Data Extraction: Trials were included if data were reported allowing the extraction of sensitivity, specificity, and area under the receiver operating characteristic curve. Data Synthesis: Twenty-three studies with a total of 1,013 patients and 1,034 fluid challenges were included. The analysis demonstrated a pooled sensitivity of 86% (95% CI, 79–92), pooled specificity of 92% (95% CI, 88–96), and a summary area under the receiver operating characteristic curve of 0.95 (95% CI, 0.92–0.98). Mode of ventilation, type of fluid used, passive leg raising starting position, and measurement technique did not affect the diagnostic performance of passive leg raising. The use of changes in pulse pressure on passive leg raising showed a lower diagnostic performance when compared with passive leg raising–induced changes in flow variables, such as cardiac output or its direct derivatives (sensitivity of 58% [95% CI, 44–70] and specificity of 83% [95% CI, 68–92] vs sensitivity of 85% [95% CI, 78–90] and specificity of 92% [95% CI, 87–94], respectively; p < 0.001). Conclusions: Passive leg raising retains a high diagnostic performance in various clinical settings and patient groups. The predictive value of a change in pulse pressure on passive leg raising is inferior to a passive leg raising–induced change in a flow variable.

Functional Status in ICU Survivors and Out of Hospital Outcomes: A Cohort Study

Functional Status in ICUSurvivors and Out of Hospital Outcomes: A Cohort Study

Critical Care Medicine: May 2016 - Volume 44 - Issue 5 - p 869–879
Rydingsward, JE et al


Objectives: Functional status at hospital discharge may be a risk factor for adverse events among survivors of critical illness. We sought to examine the association between functional status at hospital discharge in survivors of critical care and risk of 90-day all-cause mortality after hospital discharge. Design: Single-center retrospective cohort study. Setting: Academic Medical Center. Patients: Ten thousand three hundred forty-three adults who received critical care from 1997 to 2011 and survived hospitalization. Interventions: None. Measurements and Main Results: The exposure of interest was functional status determined at hospital discharge by a licensed physical therapist and rated based on qualitative categories adapted from the Functional Independence Measure. The main outcome was 90-day post hospital discharge all-cause mortality. A categorical risk-prediction score was derived and validated based on a logistic regression model of the function grades for each assessment. In an adjusted logistic regression model, the lowest quartile of functional status at hospital discharge was associated with an increased odds of 90-day postdischarge mortality compared with patients with independent functional status (odds ratio, 7.63 [95% CI, 3.83–15.22; p < 0.001]). In patients who had at least 7 days of physical therapy treatment prior to hospital discharge (n = 2,293), the adjusted odds of 90-day postdischarge mortality in patients with marked improvement in functional status at discharge was 64% less than patients with no change in functional status (odds ratio, 0.36 [95% CI, 0.24–0.53]; p < 0.001). Conclusions: Lower functional status at hospital discharge in survivors of critical illness is associated with increased postdischarge mortality. Furthermore, patients whose functional status improves before discharge have decreased odds of postdischarge mortality.

Significance of Prior Digestive Colonization With Extended-Spectrum β-Lactamase–Producing Enterobacteriaceae in Patients With Ventilator-Associated Pneumonia

Significance of Prior Digestive Colonization With Extended-Spectrum β-Lactamase–Producing Enterobacteriaceae in Patients With Ventilator-Associated Pneumonia

Critical Care Medicine: April 2016 - Volume 44 - Issue 4 - p 699–70

Bruyère, R et al

Objectives: Ventilator-associated pneumonia is frequent in ICUs. Extended-spectrum β-lactamase–producing Enterobacteriaceae are difficult-to-treat pathogens likely to cause ventilator-associated pneumonia. We sought to assess the interest of screening for extended-spectrum β-lactamase–producing Enterobacteriaceae rectal carriage as a way to predict their involvement in ventilator-associated pneumonia. Design: A retrospective cohort study of patients with suspected ventilator-associated pneumonia in a medical ICU was conducted. Patients: Every patient admitted between January 2006 and August 2013 was eligible if subjected to mechanical ventilation for more than 48 hours. Each patient with suspected ventilator-associated pneumonia was included in the cohort. Active surveillance culture for extended-spectrum β-lactamase–producing Enterobacteriaceae detection was routinely performed in all patients at admission and then weekly throughout the study period. Extended-spectrum β-lactamase colonization was defined by the isolation of at least one extended-spectrum β-lactamase–producing Enterobacteriaceae from rectal swab culture. Interventions: None. Measurements and Main Results: Among 587 patients with suspected ventilator-associated pneumonia, 40 (6.8%) were colonized with extended-spectrum β-lactamase–producing Enterobacteriaceae prior to the development of pneumonia. Over the study period, 20 patients (3.4%) had ventilator-associated pneumonia caused by extended-spectrum β-lactamase–producing Enterobacteriaceae; of whom, 17 were previously detected as being colonized with extended-spectrum β-lactamase–producing Enterobacteriaceae. Sensitivity and specificity of prior extended-spectrum β-lactamase–producing Enterobacteriaceae colonization as a predictor of extended-spectrum β-lactamase–producing Enterobacteriaceae involvement in ventilator-associated pneumonia were 85.0% and 95.7%, respectively. The positive and negative predictive values were 41.5% and 99.4%, respectively. The positive likelihood ratio was 19.8. Conclusions: Screening for extended-spectrum β-lactamase–producing Enterobacteriaceae digestive colonization by weekly active surveillance cultures could reliably exclude the risk of the involvement of such pathogens in patients with ventilator-associated pneumonia in low-prevalence area.

Cardio-thoracic surgical patients’ experience on bedside nursing handovers: Findings from a qualitative study

Cardio-thoracic surgical patients’ experience on bedside nursing handovers: Findings from a qualitative study

Intensive and Critical Care Nursing, Article in Press
Lupieri G, Creatti C, Palese A

The purpose of this study was to describe the experiences of postoperative cardio-thoracic surgical patients experiencing nursing bedside handover. A descriptive qualitative approach was undertaken. A purposeful sampling technique was adopted, including 14 patients who went through cardio-thoracic surgery and witnessed at least two bedside handovers. The study was performed in a Cardio-thoracic ICU localised in a Joint Commission International accredited Academic Hospital in north-eastern Italy from August to November 2014.