A Direct Observation Checklist to Measure Respect and Dignity in the ICU
Carrese, J A et al
Critical Care Medicine: February 2017 - Volume 45 - Issue 2 - p 263–270
Objective: Treating patients and family members with respect and dignity is a core objective of health care, yet it is unclear how best to measure this in the ICU setting. Accordingly, we sought to create a direct observation checklist to assess the “respect and dignity status” of an ICU. Design: A draft checklist based on previous work was iteratively revised to enhance accuracy and feasibility. Setting: Seven ICUs within the Johns Hopkins Health System. Subjects: A total of 351 patient-clinician encounters with 184 different patients. Interventions: Four study team members pilot tested the checklist between January and August 2015.
Measurements and Main Results: Standard psychometric analyses were performed. The direct observation checklist exhibits strong content and face validity as well as high reliability and internal consistency. All items load on one factor that supports the unidimensionality of the total index. Furthermore, concurrent validity of the direct observation checklist is demonstrated by statistically significant differences in mean scores between ICUs, between types of clinicians, and between patients’ clinical status and mood.
Conclusions: We rigorously developed, pilot tested, and analyzed a direct observation checklist designed to assess the extent to which patients and families in the ICU setting are treated with respect and dignity. Future research should validate this checklist in other settings and compare its results with other measures. Data gathered about individual items on the direct observation checklist could be used to target areas for training and education; doing so should help facilitate more respectful treatment of patients and their families.
Wednesday, 22 February 2017
Quality Improvement Initiative for Severe Sepsis and Septic Shock Reduces 90-Day Mortality: A 7.5-Year Observational Study
Quality Improvement Initiative for Severe Sepsis and Septic Shock Reduces 90-Day Mortality: A 7.5-Year Observational Study
Scheer, CS et al
Critical Care Medicine: February 2017 - Volume 45 - Issue 2 - p 241–252
Objective: To investigate the impact of a quality improvement initiative for severe sepsis and septic shock focused on the resuscitation bundle on 90-day mortality. Furthermore, effects on compliance rates for antiinfective therapy within the recommended 1-hour interval are evaluated. Design: Prospective observational before-after cohort study. Setting: Tertiary university hospital in Germany. Patients: All adult medical and surgical ICU patients with severe sepsis and septic shock. Intervention: Implementation of a quality improvement program over 7.5 years. Measurements: The primary endpoint was 90-day mortality. Secondary endpoints included ICU and hospital mortality rates and length of stay, time to broad-spectrum antiinfective therapy, and compliance with resuscitation bundle elements. Main Results: A total of 14,115 patients were screened. The incidence of severe sepsis and septic shock was 9.7%. Ninety-day mortality decreased from 64.2% to 45.0% (p < 0.001). Hospital length of stay decreased from 44 to 36 days (p < 0.05). Compliance with resuscitation bundle elements was significantly improved. Antibiotic therapy within the first hour after sepsis onset increased from 48.5% to 74.3% (p < 0.001). Multivariate analysis revealed blood cultures before antibiotic therapy (hazard ratio, 0.60–0.84; p < 0.001), adequate calculated antibiotic therapy (hazard ratio, 0.53–0.75; p < 0.001), 1–2 L crystalloids within the first 6 hours (hazard ratio 0.67–0.97; p = 0.025), and greater than or equal to 6 L during the first 24 hours (hazard ratio, 0.64–0.95; p = 0.012) as predictors for improved survival. Conclusions: The continuous quality improvement initiative focused on the resuscitation bundle was associated with increased compliance and a persistent reduction in 90-day mortality over a 7.5-year period. Based on the observational study design, a causal relationship cannot be proven, and respective limitations need to be considered.
Scheer, CS et al
Critical Care Medicine: February 2017 - Volume 45 - Issue 2 - p 241–252
Objective: To investigate the impact of a quality improvement initiative for severe sepsis and septic shock focused on the resuscitation bundle on 90-day mortality. Furthermore, effects on compliance rates for antiinfective therapy within the recommended 1-hour interval are evaluated. Design: Prospective observational before-after cohort study. Setting: Tertiary university hospital in Germany. Patients: All adult medical and surgical ICU patients with severe sepsis and septic shock. Intervention: Implementation of a quality improvement program over 7.5 years. Measurements: The primary endpoint was 90-day mortality. Secondary endpoints included ICU and hospital mortality rates and length of stay, time to broad-spectrum antiinfective therapy, and compliance with resuscitation bundle elements. Main Results: A total of 14,115 patients were screened. The incidence of severe sepsis and septic shock was 9.7%. Ninety-day mortality decreased from 64.2% to 45.0% (p < 0.001). Hospital length of stay decreased from 44 to 36 days (p < 0.05). Compliance with resuscitation bundle elements was significantly improved. Antibiotic therapy within the first hour after sepsis onset increased from 48.5% to 74.3% (p < 0.001). Multivariate analysis revealed blood cultures before antibiotic therapy (hazard ratio, 0.60–0.84; p < 0.001), adequate calculated antibiotic therapy (hazard ratio, 0.53–0.75; p < 0.001), 1–2 L crystalloids within the first 6 hours (hazard ratio 0.67–0.97; p = 0.025), and greater than or equal to 6 L during the first 24 hours (hazard ratio, 0.64–0.95; p = 0.012) as predictors for improved survival. Conclusions: The continuous quality improvement initiative focused on the resuscitation bundle was associated with increased compliance and a persistent reduction in 90-day mortality over a 7.5-year period. Based on the observational study design, a causal relationship cannot be proven, and respective limitations need to be considered.
Overcoming nursing barriers to intensive care unit early mobilisation: A quality improvement project
Overcoming nursing barriers to intensive care unit early mobilisation: A quality improvement project
Hunter, Oluwatobi O. et al.
Intensive and Critical Care Nursing, Article in Press
Technological advancements in critical care have increased intensive care unit (ICU) survivorship. Survivors may experience functional impairment 5–15 years after critical illness, resulting in decreased quality of life and increased use and cost of healthcare services (Herridge et al., 2011; Yosef-Brauner et al., 2015). These long-term post-ICU physical impairments are due in part to intensive care unit acquired weakness (ICUAW). ICUAW is a syndrome of multifactorial etiology that results in impaired ventilator weaning and prolonged intensive care unit length of stay (LOS) (Desai et al., 2011; Lipshutz and Gropper, 2013).
Hunter, Oluwatobi O. et al.
Intensive and Critical Care Nursing, Article in Press
Technological advancements in critical care have increased intensive care unit (ICU) survivorship. Survivors may experience functional impairment 5–15 years after critical illness, resulting in decreased quality of life and increased use and cost of healthcare services (Herridge et al., 2011; Yosef-Brauner et al., 2015). These long-term post-ICU physical impairments are due in part to intensive care unit acquired weakness (ICUAW). ICUAW is a syndrome of multifactorial etiology that results in impaired ventilator weaning and prolonged intensive care unit length of stay (LOS) (Desai et al., 2011; Lipshutz and Gropper, 2013).
An interventional skin care protocol (InSPiRE) to reduce incontinence-associated dermatitis in critically ill patients in the intensive care unit: A before and after study
An interventional skin care protocol (InSPiRE) to reduce incontinence-associated dermatitis in critically ill patients in the intensive care unit: A before and after study
Coyer, Fiona et al.
Intensive and Critical Care Nursing Article in Press.
Critically ill patients in the intensive care unit (ICU) are a unique, vulnerable population at high risk of skin damage. The nature of the critical illness necessitating admission to the ICU often dictates that patients are mechanically ventilated, managed with sedative and opiate infusions, receive multiple antimicrobial therapy and are enterally fed. These factors all contribute to faecal incontinence and diarrhoea (Jack et al., 2010). Incontinence, specifically faecal incontinence in critically ill patients, is a significant and direct causal factor for the development of a hospital-acquired skin injury; incontinence-associated dermatitis (IAD) (Beeckman et al., 2015).
Coyer, Fiona et al.
Intensive and Critical Care Nursing Article in Press.
Critically ill patients in the intensive care unit (ICU) are a unique, vulnerable population at high risk of skin damage. The nature of the critical illness necessitating admission to the ICU often dictates that patients are mechanically ventilated, managed with sedative and opiate infusions, receive multiple antimicrobial therapy and are enterally fed. These factors all contribute to faecal incontinence and diarrhoea (Jack et al., 2010). Incontinence, specifically faecal incontinence in critically ill patients, is a significant and direct causal factor for the development of a hospital-acquired skin injury; incontinence-associated dermatitis (IAD) (Beeckman et al., 2015).
Which Models Can I Use to Predict Adult ICU Length of Stay? A Systematic Review
Which Models Can I Use to Predict Adult ICU Length of Stay? A Systematic Review
Verburg, I et al
Critical Care Medicine: February 2017 - Volume 45 - Issue 2 - p e222–e231
Objective: We systematically reviewed models to predict adult ICU length of stay. Data Sources: We searched the Ovid EMBASE and MEDLINE databases for studies on the development or validation of ICU length of stay prediction models. Study Selection: We identified 11 studies describing the development of 31 prediction models and three describing external validation of one of these models. Data Extraction: Clinicians use ICU length of stay predictions for planning ICU capacity, identifying unexpectedly long ICU length of stay, and benchmarking ICUs. We required the model variables to have been published and for the models to be free of organizational characteristics and to produce accurate predictions, as assessed by R2 across patients for planning and identifying unexpectedly long ICU length of stay and across ICUs for benchmarking, with low calibration bias. We assessed the reporting quality using the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies. Data Synthesis: The number of admissions ranged from 253 to 178,503. Median ICU length of stay was between 2 and 6.9 days. Two studies had not published model variables and three included organizational characteristics. None of the models produced predictions with low bias. The R2 was 0.05–0.28 across patients and 0.01–0.64 across ICUs. The reporting scores ranged from 49 of 78 to 60 of 78 and the methodologic scores from 12 of 22 to 16 of 22. Conclusion: No models completely satisfy our requirements for planning, identifying unexpectedly long ICU length of stay, or for benchmarking purposes. Physicians using these models to predict ICU length of stay should interpret them with reservation.
Verburg, I et al
Critical Care Medicine: February 2017 - Volume 45 - Issue 2 - p e222–e231
Objective: We systematically reviewed models to predict adult ICU length of stay. Data Sources: We searched the Ovid EMBASE and MEDLINE databases for studies on the development or validation of ICU length of stay prediction models. Study Selection: We identified 11 studies describing the development of 31 prediction models and three describing external validation of one of these models. Data Extraction: Clinicians use ICU length of stay predictions for planning ICU capacity, identifying unexpectedly long ICU length of stay, and benchmarking ICUs. We required the model variables to have been published and for the models to be free of organizational characteristics and to produce accurate predictions, as assessed by R2 across patients for planning and identifying unexpectedly long ICU length of stay and across ICUs for benchmarking, with low calibration bias. We assessed the reporting quality using the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies. Data Synthesis: The number of admissions ranged from 253 to 178,503. Median ICU length of stay was between 2 and 6.9 days. Two studies had not published model variables and three included organizational characteristics. None of the models produced predictions with low bias. The R2 was 0.05–0.28 across patients and 0.01–0.64 across ICUs. The reporting scores ranged from 49 of 78 to 60 of 78 and the methodologic scores from 12 of 22 to 16 of 22. Conclusion: No models completely satisfy our requirements for planning, identifying unexpectedly long ICU length of stay, or for benchmarking purposes. Physicians using these models to predict ICU length of stay should interpret them with reservation.
Chloride Content of Fluids Used for Large-Volume Resuscitation Is Associated With Reduced Survival
Chloride Content of Fluids Used for Large-Volume Resuscitation Is Associated With Reduced Survival
Sen, A et al.
Critical Care Medicine: February 2017 - Volume 45 - Issue 2 - p e146–e153
Objective: We sought to investigate if the chloride content of fluids used in resuscitation was associated with short- and long-term outcomes. Design: We identified patients who received large-volume fluid resuscitation, defined as greater than 60 mL/kg over a 24-hour period. Chloride load was determined for each patient based on the chloride ion concentration of the fluids they received during large-volume fluid resuscitation multiplied by the volume of fluids. We compared the development of hyperchloremic acidosis, acute kidney injury, and survival among those with higher and lower chloride loads. Setting: University Medical Center. Patients: Patients admitted to ICUs from 2000 to 2008. Interventions: None. Measurements and Main Results: Among 4,710 patients receiving large-volume fluid resuscitation, hyperchloremic acidosis was documented in 523 (11%). Crude rates of hyperchloremic acidosis, acute kidney injury, and hospital mortality all increased significantly as chloride load increased (p < 0.001). However, chloride load was no longer associated with hyperchloremic acidosis or acute kidney injury after controlling for total fluids, age, and baseline severity. Conversely, each 100 mEq increase in chloride load was associated with a 5.5% increase in the hazard of death even after controlling for total fluid volume, age, and severity (p = 0.0015) over 1 year. Conclusions: Chloride load is associated with significant adverse effects on survival out to 1 year even after controlling for total fluid load, age, and baseline severity of illness. However, the relationship between chloride load and development of hyperchloremic acidosis or acute kidney injury is less clear, and further research is needed to elucidate the mechanisms underlying the adverse effects of chloride load on survival.
Sen, A et al.
Critical Care Medicine: February 2017 - Volume 45 - Issue 2 - p e146–e153
Objective: We sought to investigate if the chloride content of fluids used in resuscitation was associated with short- and long-term outcomes. Design: We identified patients who received large-volume fluid resuscitation, defined as greater than 60 mL/kg over a 24-hour period. Chloride load was determined for each patient based on the chloride ion concentration of the fluids they received during large-volume fluid resuscitation multiplied by the volume of fluids. We compared the development of hyperchloremic acidosis, acute kidney injury, and survival among those with higher and lower chloride loads. Setting: University Medical Center. Patients: Patients admitted to ICUs from 2000 to 2008. Interventions: None. Measurements and Main Results: Among 4,710 patients receiving large-volume fluid resuscitation, hyperchloremic acidosis was documented in 523 (11%). Crude rates of hyperchloremic acidosis, acute kidney injury, and hospital mortality all increased significantly as chloride load increased (p < 0.001). However, chloride load was no longer associated with hyperchloremic acidosis or acute kidney injury after controlling for total fluids, age, and baseline severity. Conversely, each 100 mEq increase in chloride load was associated with a 5.5% increase in the hazard of death even after controlling for total fluid volume, age, and severity (p = 0.0015) over 1 year. Conclusions: Chloride load is associated with significant adverse effects on survival out to 1 year even after controlling for total fluid load, age, and baseline severity of illness. However, the relationship between chloride load and development of hyperchloremic acidosis or acute kidney injury is less clear, and further research is needed to elucidate the mechanisms underlying the adverse effects of chloride load on survival.
Sepsis Pathophysiology, Chronic Critical Illness, and Persistent Inflammation-Immunosuppression and Catabolism Syndrome
Sepsis Pathophysiology, Chronic Critical Illness, and Persistent Inflammation-Immunosuppression and Catabolism Syndrome
Mira, JC et al
Critical Care Medicine February 2017 - Volume 45 - Issue 2 - p 253–262
Objectives: To provide an appraisal of the evolving paradigms in the pathophysiology of sepsis and propose the evolution of a new phenotype of critically ill patients, its potential underlying mechanism, and its implications for the future of sepsis management and research. Design: Literature search using PubMed, MEDLINE, EMBASE, and Google Scholar. Measurements and Main Results: Sepsis remains one of the most debilitating and expensive illnesses, and its prevalence is not declining. What is changing is our definition(s), its clinical course, and how we manage the septic patient. Once thought to be predominantly a syndrome of over exuberant inflammation, sepsis is now recognized as a syndrome of aberrant host protective immunity. Earlier recognition and compliance with treatment bundles has fortunately led to a decline in multiple organ failure and in-hospital mortality. Unfortunately, more and more sepsis patients, especially the aged, are suffering chronic critical illness, rarely fully recover, and often experience an indolent death. Patients with chronic critical illness often exhibit “a persistent inflammation-immunosuppression and catabolism syndrome,” and it is proposed here that this state of persisting inflammation, immunosuppression and catabolism contributes to many of these adverse clinical outcomes. The underlying cause of inflammation-immunosuppression and catabolism syndrome is currently unknown, but there is increasing evidence that altered myelopoiesis, reduced effector T-cell function, and expansion of immature myeloid-derived suppressor cells are all contributory. Conclusions: Although newer therapeutic interventions are targeting the inflammatory, the immunosuppressive, and the protein catabolic responses individually, successful treatment of the septic patient with chronic critical illness and persistent inflammation-immunosuppression and catabolism syndrome may require a more complementary approach.
Mira, JC et al
Critical Care Medicine February 2017 - Volume 45 - Issue 2 - p 253–262
Objectives: To provide an appraisal of the evolving paradigms in the pathophysiology of sepsis and propose the evolution of a new phenotype of critically ill patients, its potential underlying mechanism, and its implications for the future of sepsis management and research. Design: Literature search using PubMed, MEDLINE, EMBASE, and Google Scholar. Measurements and Main Results: Sepsis remains one of the most debilitating and expensive illnesses, and its prevalence is not declining. What is changing is our definition(s), its clinical course, and how we manage the septic patient. Once thought to be predominantly a syndrome of over exuberant inflammation, sepsis is now recognized as a syndrome of aberrant host protective immunity. Earlier recognition and compliance with treatment bundles has fortunately led to a decline in multiple organ failure and in-hospital mortality. Unfortunately, more and more sepsis patients, especially the aged, are suffering chronic critical illness, rarely fully recover, and often experience an indolent death. Patients with chronic critical illness often exhibit “a persistent inflammation-immunosuppression and catabolism syndrome,” and it is proposed here that this state of persisting inflammation, immunosuppression and catabolism contributes to many of these adverse clinical outcomes. The underlying cause of inflammation-immunosuppression and catabolism syndrome is currently unknown, but there is increasing evidence that altered myelopoiesis, reduced effector T-cell function, and expansion of immature myeloid-derived suppressor cells are all contributory. Conclusions: Although newer therapeutic interventions are targeting the inflammatory, the immunosuppressive, and the protein catabolic responses individually, successful treatment of the septic patient with chronic critical illness and persistent inflammation-immunosuppression and catabolism syndrome may require a more complementary approach.
A return to the basics; nurses’ practices and knowledge about interventional patient hygiene in critical care units
A return to the basics; nurses’ practices and knowledge about interventional patient hygiene in critical care units
El-Soussi, Azza H. et al.
Intensive and Critical Care Nursing Article in Press.
The Nursing profession is struggling to return to basic nursing care to maintain patients’ safety. “Interventional patient hygiene” (IPH) is a measurement model for reducing the bioburden of both the patient and health care worker, and its components are hand hygiene, oral care, skin care/antisepsis, and catheter site care.
Objectives: To identify the level of nurses’ practice and knowledge about interventional patient hygiene and identify barriers for implementing interventional patient hygiene in critical care units.
El-Soussi, Azza H. et al.
Intensive and Critical Care Nursing Article in Press.
The Nursing profession is struggling to return to basic nursing care to maintain patients’ safety. “Interventional patient hygiene” (IPH) is a measurement model for reducing the bioburden of both the patient and health care worker, and its components are hand hygiene, oral care, skin care/antisepsis, and catheter site care.
Objectives: To identify the level of nurses’ practice and knowledge about interventional patient hygiene and identify barriers for implementing interventional patient hygiene in critical care units.
Relative Bradycardia in Patients With Septic Shock Requiring Vasopressor Therapy
Relative Bradycardia in Patients With Septic Shock Requiring Vasopressor Therapy
Beesley, S et al
Critical Care Medicine:February 2017 - Volume 45 - Issue 2 - p 225–233
Objectives: Tachycardia is common in septic shock, but many patients with septic shock are relatively bradycardic. The prevalence, determinants, and implications of relative bradycardia (heart rate, < 80 beats/min) in septic shock are unknown. To determine mortality associated with patients who are relatively bradycardic while in septic shock.
Design: Retrospective study of patients admitted for septic shock to study ICUs during 2005–2013. Setting: One large academic referral hospital and two community hospitals. Patients: Adult patients with septic shock requiring vasopressors. Intervention: None.
Measurements: Primary outcome was 28-day mortality. We used multivariate logistic regression to evaluate the association between relative bradycardia and mortality, controlling for confounding with inverse probability treatment weighting using a propensity score.
Results: We identified 1,554 patients with septic shock, of whom 686 (44%) met criteria for relative bradycardia at some time. Twenty-eight-day mortality in this group was 21% compared to 34% in the never-bradycardic group (p < 0.001). Relatively bradycardic patients were older (65 vs 60 yr; p < 0.001) and had slightly lower illness severity (Sequential Organ Failure Assessment, 10 vs 11; p = 0.004; and Acute Physiology and Chronic Health Evaluation II, 27 vs 28; p = 0.008). After inverse probability treatment weighting, covariates were balanced, and the association between relative bradycardia and survival persisted (p < 0.001).
Conclusions: Relative bradycardia in patients with septic shock is associated with lower mortality, even after adjustment for confounding. Our data support expanded investigation into whether inducing relative bradycardia will benefit patients with septic shock.
Beesley, S et al
Critical Care Medicine:February 2017 - Volume 45 - Issue 2 - p 225–233
Objectives: Tachycardia is common in septic shock, but many patients with septic shock are relatively bradycardic. The prevalence, determinants, and implications of relative bradycardia (heart rate, < 80 beats/min) in septic shock are unknown. To determine mortality associated with patients who are relatively bradycardic while in septic shock.
Design: Retrospective study of patients admitted for septic shock to study ICUs during 2005–2013. Setting: One large academic referral hospital and two community hospitals. Patients: Adult patients with septic shock requiring vasopressors. Intervention: None.
Measurements: Primary outcome was 28-day mortality. We used multivariate logistic regression to evaluate the association between relative bradycardia and mortality, controlling for confounding with inverse probability treatment weighting using a propensity score.
Results: We identified 1,554 patients with septic shock, of whom 686 (44%) met criteria for relative bradycardia at some time. Twenty-eight-day mortality in this group was 21% compared to 34% in the never-bradycardic group (p < 0.001). Relatively bradycardic patients were older (65 vs 60 yr; p < 0.001) and had slightly lower illness severity (Sequential Organ Failure Assessment, 10 vs 11; p = 0.004; and Acute Physiology and Chronic Health Evaluation II, 27 vs 28; p = 0.008). After inverse probability treatment weighting, covariates were balanced, and the association between relative bradycardia and survival persisted (p < 0.001).
Conclusions: Relative bradycardia in patients with septic shock is associated with lower mortality, even after adjustment for confounding. Our data support expanded investigation into whether inducing relative bradycardia will benefit patients with septic shock.
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