Antimicrobial resistance and antibiotic stewardship programs in the ICU: insistence and persistence in the fight against resistance. A position statement from ESICM/ESCMID/WAAAR round table on multi-drug resistance.

Antimicrobial resistance and antibiotic stewardship programs in the ICU: insistence and persistence in the fight against resistance. A position statement from ESICM/ESCMID/WAAAR round table on multi-drug resistance.

Author(s) De Waele, Jan J; Akova, Murat; Antonelli, Massimo; Canton, Rafael; Carlet, Jean et al.

Source Intensive care medicine; Feb 2018; vol. 44 (no. 2); p. 189-196

Publication Date Feb 2018

DOI 10.1007/s00134-017-5036-1

ISSN 1432-1238

Database Medline

Antimicrobial resistance (AMR) is a clear and present danger to patients in any intensive care unit (ICU) around the world. Whereas AMR may affect any patient in the hospital, patients in the ICU are particularly at risk of acquiring AMR infections due to the intensity of the treatment, use of invasive devices, increased risk of transmission and exposure to antibiotics. AMR is present in every ICU, although prevalence is geographically different and AMR pathogens encountered are variable. Intensive care and infectious disease specialists from the European Society of Intensive Care Medicine, European Society of Microbiology and Infectious Diseases and World Alliance Against Antimicrobial Resistance, united in the ANTARCTICA (Antimicrobial Resistance in Critical Care) coalition, call for increased awareness and action among health care professionals to reduce AMR development in critically ill patients, to improve treatment of AMR infections and to coordinate scientific research in this high-risk patient population. Close collaboration with other specialties, and combining these and other interventions in antibiotic stewardship programmes should be a priority in every ICU. Considerate antibiotic use and adopting strict infection control practices to halt AMR remains a responsibility shared by all healthcare workers, from physicians to maintenance personnel, from nurses to physiotherapists, from consultants to medical students. Together, we can reduce AMR in our ICUs and continue to treat our patients effectively.

Predictors of pressure ulcer risk in adult intensive care patients: A retrospective case-control study.

Predictors of pressure ulcer risk in adult intensive care patients: A retrospective case-control study.

Author(s) de Almeida Medeiros, Ana Beatriz; da Conceição Dias Fernandes, Maria Isabel; de Sá Tinôco, Jéssica Dantas; Cossi, Marcelly Santos; de Oliveira Lopes, Marcos Venicios; de Carvalho Lira, Ana Luisa Brandão

Source Intensive & critical care nursing; Apr 2018; vol. 45 ; p. 6-10

Publication Date Apr 2018

Place of Publication Netherlands

DOI 10.1016/j.iccn.2017.09.007

Accession Number 29223413

ISSN 1532-4036

PubMed ID 29223413

Publication Type(s) Journal Article

Database Medline

Abstract

OBJECTIVESTo evaluate the predictive power of risk factors for pressure ulcers in adult intensive care patients.METHODA retrospective case-control study was performed utilising a heterogeneous sample group allocated into a case group with pressure ulcers (n=90) and a control group without pressure ulcers (n=90). The analysis explored the predictive power of risk factors for pressure ulcers using a hierarchical logistic regression model.RESULTSThe risk factors that predicted pressure ulcers were friction (OR=5.97), previous history of pressure ulcers (OR=5.43), prolonged intensive care unit stay (OR=3.92), dehydration (OR=3.18), elevated skin temperature by 1-2°C (OR=3.12) and treatment of other comorbidities (OR=2.79).CONCLUSIONAdult intensive care patients have an increased risk of developing a pressure ulcer. These risk factors are regarded as strong predictors for pressure ulceration. This study advances nursing knowledge in that it investigates additional risk factors for the development of pressure ulcers and it identifies a set of factors that best predict their occurrence, which may contribute to the nurses' diagnostic reasoning in the intensive care unit.

Person-centred care during prolonged weaning from mechanical ventilation, nurses’ views: an interview study

Person-centred care during prolonged weaning from mechanical ventilation, nurses’ views: an interview study

1 Intensive and Critical Care Nursing by Carl-Johan Cederwall, Sepideh Olausson, Louise Rose, Silvana Naredi, Mona Ringdal 

Abstract

Objective

To determine: 1) if the three elements of person-centred care (initiating, working and safeguarding the partnership) were present, and 2) to identify evidence of barriers to person-centred care during prolonged weaning from mechanical ventilation.

Research methodology

Secondary analysis of semi structured interviews with 19 critical care nurses using theoretical thematic analysis.

Setting

This study was conducted in three Swedish intensive care units, one in a regional hospital and two in a university hospital.

Findings

Three themes and nine subthemes related to person-centred care were identified. The three themes included: 1) ‘finding a person behind the patient’ related to the ‘initiating the partnership’ phase, 2) ‘striving to restore patient́s sense of control’ related to ‘working the partnership’ phase and 3) ‘impact of patient involvement’ related to ‘safeguarding the partnership’ phase of person-centred care’. Additionally a further theme ‘barriers to person-centred care’ was identified.

Conclusion

We found evidence of all three person-centred care routines. Barriers to person-centred care comprised of lack team collaboration and resources. Facilitating patients to actively participate in decision-making during the weaning process may optimise weaning outcomes and warrants further research.

Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock*

Pruinelli, Lisiane PhD, RN1; Westra, Bonnie L. PhD, RN, FAAN, FACMI1,2; Yadav, Pranjul PhD3; Hoff, Alexander3; Steinbach, Michael PhD3; Kumar, Vipin PhD3; Delaney, Connie W. PhD, RN, FAAN, FACMI1,2; Simon, Gyorgy PhD2,4

Critical Care Medicine: April 2018 - Volume 46 - Issue 4 - p 500–505

doi: 10.1097/CCM.0000000000002949

Objectives: To specify when delays of specific 3-hour bundle Surviving Sepsis Campaign guidelinerecommendations applied to severe sepsis or septic shock become harmful and impact mortality.

Design: Retrospective cohort study.

Setting: One health system composed of six hospitals and 45 clinics in a Midwest state from January 01, 2011, to July 31, 2015.

Patients: All adult patients hospitalized with billing diagnosis of severe sepsis or septic shock.

Interventions: Four 3-hour Surviving Sepsis Campaign guideline recommendations: 1) obtain blood culture before antibiotics, 2) obtain lactate level, 3) administer broad-spectrum antibiotics, and 4) administer 30 mL/kg of crystalloid fluid for hypotension (defined as “mean arterial pressure” < 65) or lactate (> 4).

Measurements and Main Results: To determine the effect of t minutes of delay in carrying out each intervention, propensity score matching of “baseline” characteristics compensated for differences in health status. The average treatment effect in the treated computed as the average difference in outcomes between those treated after shorter versus longer delay. To estimate the uncertainty associated with the average treatment effect in the treated metric and to construct 95% CIs, bootstrap estimation with 1,000 replications was performed. From 5,072 patients with severe sepsis or septic shock, 1,412 (27.8%) had in-hospital mortality. The majority of patients had the four 3-hour bundle recommendations initiated within 3 hours. The statistically significant time in minutes after which a delay increased the risk of death for each recommendation was as follows: lactate, 20.0 minutes; blood culture, 50.0 minutes; crystalloids, 100.0 minutes; and antibiotic therapy, 125.0 minutes.

Conclusions: The guideline recommendations showed that shorter delays indicates better outcomes. There was no evidence that 3 hours is safe; even very short delays adversely impact outcomes. Findings demonstrated a new approach to incorporate time t when analyzing the impact on outcomes and provide new evidence for clinical practice and research.

Practice Patterns and Outcomes Associated With Early SedationDepth in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis*

Stephens, Robert J. BS1; Dettmer, Matthew R. MD2; Roberts, Brian W. MD3; Ablordeppey, Enyo MD, MPH4,5; Fowler, Susan A. MLIS6; Kollef, Marin H. MD7; Fuller, Brian M. MD, MSCI4,5

Critical Care Medicine: March 2018 - Volume 46 - Issue 3 - p 471–479

doi: 10.1097/CCM.0000000000002885

Objectives: Emerging data suggest that early deep sedation may negatively impact clinical outcomes. This systematic review and meta-analysis defines and quantifies the impact of deep sedation within 48 hours of initiation of mechanical ventilation, as described in the world’s literature. The primary outcome was mortality. Secondary outcomes included hospital and ICU lengths of stay, mechanical ventilation duration, and delirium and tracheostomy frequency.

Data Sources: The following data sources were searched: MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews and Effects, Cochrane Database of Systematic Reviews databases, ClinicalTrials.gov, conference proceedings, and reference lists.

Study Selection: Randomized controlled trials and nonrandomized studies were included.

Data Extraction: Two reviewers independently screened abstracts of identified studies for eligibility.

Data Synthesis: Nine studies (n = 4,521 patients) published between 2012 and 2017 were included. A random effects meta-analytic model revealed that early light sedation was associated with lower mortality (9.2%) versus deep sedation (27.6%) (odds ratio, 0.34 [0.21–0.54]). Light sedation was associated with fewer mechanical ventilation (mean difference, –2.1; 95% CI, –3.6 to –0.5) and ICU days (mean difference, –3.0 (95% CI, –5.4 to –0.6). Delirium frequency was 28.7% in the light sedation group and 48.5% in the deep sedation group, odds ratio, 0.50 (0.22–1.16).

Conclusions: Deep sedation in mechanically ventilated patients, as evaluated in a small number of qualifying heterogeneous randomized controlled trials and observational studies, was associated with increased mortality and lengths of stay. Interventions targeting early sedation depth assessment, starting in the emergency department and subsequent ICU admission, deserve further investigation and could improve outcome.

The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying

Vranas, Kelly C. MD1,2; Jopling, Jeffrey K. MD, MSHS1,3; Scott, Jennifer Y. MS1; Badawi, Omar PharmD, MPH4,5,6; Harhay, Michael O. PhD7,8; Slatore, Christopher G. MD, MS2,9; Ramsey, Meghan C. MD1,10; Breslow, Michael J. MD4; Milstein, Arnold S. MD, MPH1; Kerlin, Meeta Prasad MD, MSCE11

Objective: Many ICU patients do not require critical care interventions. Whether aggressive care environments increase risks to low-acuity patients is unknown. We evaluated whether ICU acuity was associated with outcomes of low mortality-risk patients. We hypothesized that admission to high-acuity ICUs would be associated with worse outcomes. This hypothesis was based on two possibilities: 1) high-acuity ICUs may have a culture of aggressive therapy that could lead to potentially avoidable complications and 2) high-acuity ICUs may focus attention toward the many sicker patients and away from the fewer low-risk patients.

Design: Retrospective cohort study.

Setting: Three hundred twenty-two ICUs in 199 hospitals in the Philips eICU database between 2010 and 2015.

Patients: Adult ICU patients at low risk of dying, defined as an Acute Physiology and Chronic Health Evaluation-IVa–predicted mortality of 3% or less.

Exposure: ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles.

Measurements and Main Results: We used generalized estimating equations to test whether ICU acuity is independently associated with a primary outcome of ICU length of stay and secondary outcomes of hospital length of stay, hospital mortality, and discharge destination. The study included 381,997 low-risk patients. Mean ICU and hospital length of stay were 1.8 ± 2.1 and 5.2 ± 5.0 days, respectively. Mean Acute Physiology and Chronic Health Evaluation IVa–predicted hospital mortality was 1.6% ± 0.8%; actual hospital mortality was 0.7%. In adjusted analyses, admission to low-acuity ICUs was associated with worse outcomes compared with higher-acuity ICUs. Specifically, compared with the highest-acuity quartile, ICU length of stay in low-acuity ICUs was increased by 0.24 days; in medium-acuity ICUs by 0.16 days; and in high-acuity ICUs by 0.09 days (all p < 0.001). Similar patterns existed for hospital length of stay. Patients in lower-acuity ICUs had significantly higher hospital mortality (odds ratio, 1.28 [95% CI, 1.10–1.49] for low-; 1.24 [95% CI, 1.07–1.42] for medium-, and 1.14 [95% CI, 0.99–1.31] for high-acuity ICUs) and lower likelihood of discharge home (odds ratio, 0.86 [95% CI, 0.82–0.90] for low-, 0.88 [95% CI, 0.85–0.92] for medium-, and 0.95 [95% CI, 0.92–0.99] for high-acuity ICUs).

Conclusions: Admission to high-acuity ICUs is associated with better outcomes among low mortality-risk patients. Future research should aim to understand factors that confer benefit to patients with different risk profiles.

Evaluation of ICU Risk Models Adapted for Use as Continuous Markers of Severity of Illness Throughout the ICU Stay*

Badawi, Omar PharmD, MPH, FCCM1,2,3; Liu, Xinggang MD, PhD1; Hassan, Erkan PharmD, FCCM1; Amelung, Pamela J. MD, FCCP1; Swami, Sunil PhD, MPH, MBBS1

Critical Care Medicine: March 2018 - Volume 46 - Issue 3 - p 361–367

doi: 10.1097/CCM.0000000000002904

Objectives: Evaluate the accuracy of different ICU risk models repurposed as continuous markers of severity of illness.

Design: Nonintervention cohort study.

Setting: eICU Research Institute ICUs using tele-ICU software calculating continuous ICU Discharge Readiness Scores between January 2013 and March 2016.

Patients: Five hundred sixty-one thousand four hundred seventy-eight adult ICU patients with an ICU length of stay between 4 hours and 30 days.

Interventions: Not available.

Measurements and Main Results: Hourly Acute Physiology and Chronic Health Evaluation IV, Sequential Organ Failure Assessment, and Discharge Readiness Scores were calculated beginning hour 4 of the ICU stay. Primary outcome was the area under the receiver operating characteristic curve for the mean score with ICU mortality. Secondary outcomes included area under the receiver operating characteristic curves for ICU mortality with admission, median, maximum and last scores, and for death within 24 hours. The trajectories of each score were visualized by plotting the hourly averages against time in the ICU, stratified by mortality and length of stay. The area under the receiver operating characteristic curves for mean Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores were 0.90 (0.89–0.90), 0.86 (0.86–0.86), and 0.94 (0.94–0.94), respectively. The area under the receiver operating characteristic curves for hourly Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores predicting 24-hour mortality were 0.81 (0.81–0.81), 0.76 (0.76–0.76), and 0.86 (0.86–0.86). Discharge Readiness Scores had a higher area under the receiver operating characteristic curve than both Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment for each metric. Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores increased throughout the first 24 hours in both survivors and nonsurvivors; Discharge Readiness Scores continuously decreased in survivors and temporarily decreased before increasing by hour 36 in nonsurvivors with longer length of stays.

Conclusions: Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores all have relatively high discrimination for ICU mortality when used continuously; Discharge Readiness Scores tended to have slightly higher area under the receiver operating characteristic curves for each endpoint. These findings validate the use of these models on a population level for continuous risk adjustment in the ICU, although Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment appear slower to respond to improvements in patient status than Discharge Readiness Scores, and Discharge Readiness Scores may reflect physiologic improvement from interventions, potentially underestimating risk.

Temporal Trends in Incidence, Sepsis-Related Mortality, and Hospital-Based Acute Care After Sepsis

Meyer, Nathaniel MD1; Harhay, Michael O. PhD2; Small, Dylan S. PhD3,4; Prescott, Hallie C. MD, MSc5; Bowles, Kathryn H. PhD, RN6,7; Gaieski, David F. MD8; Mikkelsen, Mark E. MD, MSCE2,4,9

Critical Care Medicine: March 2018 - Volume 46 - Issue 3 - p 354–360doi: 10.1097/CCM.0000000000002872 Late Breaker Articles

Objectives: A growing number of patients survive sepsis hospitalizations each year and are at high risk for readmission. However, little is known about temporal trends in hospital-based acute care (emergency department treat-and-release visits and hospital readmission) after sepsis. Our primary objective was to measure temporal trends in sepsis survivorship and hospital-based acute care use in sepsis survivors. In addition, because readmissions after pneumonia are subject to penalty under the national readmission reduction program, we examined whether readmission rates declined after sepsis hospitalizations related to pneumonia.

Design and Setting: Retrospective, observational cohort study conducted within an academic healthcare system from 2010 to 2015.

Patients: We used three validated, claims-based approaches to identify 17,256 sepsis or severe sepsis hospitalizations to examine trends in hospital-based acute care after sepsis.

Interventions: None.

Measurements and Main Results: From 2010 to 2015, sepsis as a proportion of medical and surgical admissions increased from 3.9% to 9.4%, whereas in-hospital mortality rate for sepsis hospitalizations declined from 24.1% to 14.8%. As a result, the proportion of medical and surgical discharges at-risk for hospital readmission after sepsis increased from 2.7% to 7.8%. Over 6 years, 30-day hospital readmission rates declined modestly, from 26.4% in 2010 to 23.1% in 2015, driven largely by a decline in readmission rates among survivors of nonsevere sepsis, and nonpneumonia sepsis specifically, as the readmission rate of severe sepsis survivors was stable. The modest decline in 30-day readmission rates was offset by an increase in emergency department treat-and-release visits, from 2.8% in 2010 to a peak of 5.4% in 2014.

Conclusions: Owing to increasing incidence and declining mortality, the number of sepsis survivors at risk for hospital readmission rose significantly between 2010 and 2015. The 30-day hospital readmission rates for sepsis declined modestly but were offset by a rise in emergency department treat-and-release visits.