High‐flow nasal cannulae for respiratory support in adult intensive care patients

This systematic review produced by Corley and colleagues was published online in Cochrane Library in May 2017.

Backcochrane-57-1ground:  A common reason for intensive care unit (ICU) admission is the need for breathing (or respiratory) support. HFNC are small plastic tubes that sit inside the nostrils and deliver a heated mix of air and oxygen at high flow rates to patients requiring breathing support. They are used frequently in the ICU, yet no clear evidence shows whether they provide patients with long-term benefits such as reduced ICU stay or improved chances of survival.

Study characteristics:  The evidence is current to March 2016. We included in the review 11 studies with 1972 participants. Most participants had respiratory failure, or had just been taken off an artificial breathing machine. Included studies compared HFNC with low-flow oxygen given through face masks, through low-flow cannulae, or through devices that use mild pressure to aid oxygen delivery. We reran the search in December 2016 and will deal with any studies of interest when we update the review.

Key results:  We found no evidence that HFNC reduced the rate of treatment failure or risk of death compared with low-flow oxygen devices. We found no evidence of any advantages for HFNC in terms of adverse event rates, ICU length of stay, or duration of respiratory support. We observed no differences in participants’ blood oxygen levels or carbon dioxide blood levels, and we noted that any differences in breathing rates were small and were not considered clinically important. Studies reported no differences in patient-rated measures of comfort. Only one study found evidence of less dry mouth when HFNC was used.

Quality of evidence:  Most studies had reported methods inadequately, and we did not know whether risk of bias may have affected study results. We identified few eligible studies and noted some differences among participants within our included studies, particularly in reasons for requiring respiratory support. We used the GRADE system to rate the evidence for each of our outcomes, and we judged all evidence to be of low or very low quality.

Conclusion:  We were not able to collect sufficient evidence from good quality studies to determine whether HFNC offer a safe and effective way of delivering respiratory support for adults in the ICU.

The full text of the review can be accessed via this link to the Cochrane Library.

Identifying barriers to early mobilisation among mechanically ventilated patients

Mechanically ventilated patients can be at risk for functional decline. Early mobilisation of mechanically ventilated patients can improve outcomes after critical illness to prevent this decline | Intensive & Critical Care Nursing

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Aim: The aim of this study is to examine whether nurses’ attitudes and beliefs are barriers for early mobilisation and evaluate whether an education intervention can improve early mobilisation.

Results: Dependent Sample T-test revealed a statistically significant increase in post-test responses for the subscales knowledge, attitudes, and behaviours with early mobilisation. This over-all increase in post-test results support that understanding barriers can improve patient outcomes.

Conclusion: Use of structured surveys to identify barriers for early mobilisation among nursing can assist in providing targeted education that address nurse’s perception. The education intervention appeared to have a positive impact on attitudes but it is unknown if the difference was sustained over time or affected participants practice or patient outcomes.

Full reference: Johnson, K. et al. (2017) Identifying barriers to early mobilisation among mechanically ventilated patients in a trauma intensive care unit. Intensive & Critical Care Nursing. Published online: 22 July 2017

Effectiveness of supporting intensive care units on implementing the guideline ‘End-of-life care in the intensive care unit, nursing care’: a cluster randomized controlled trial

This article was published in the Journal of Advanced Nursing June 2017 volume 73 number 6 by Noome et al.

Aim:  To examine the effectiveness of supporting intensive care units on implementing the guidelines.

Background:  Quality of care can be achieved through evidence-based practice. Guidelines can facilitate evidence-based practice, such as the guidelines ‘End-of-life care in the intensive care unit, nursing care’. Before intensive care nurses are able to use these guidelines, they needs to be implemented in clinical practice. Implementation is a complex process and may need support.

Methods:  Intensive care nurses of eight intensive care units in the intervention group followed a supportive programme that educated them on implementation, strategies, goals, project management and leadership. The intervention group focused on a stepwise approach to implement the guidelines. The control group (n = 5) implemented the guidelines independently or used the standard implementation plan supplementary to the guideline. The effectiveness of the programme was measured using questionnaires for nurses, interviews with nurses and a questionnaire for family of deceased patients, in the period from December 2014-December 2015.

Results:  Overall, an increase in adherence to the guidelines was found in both groups. Overall, use of the guidelines in the intervention group was higher, but on some aspects the control group showed a higher score. Care for the patient and the overall nursing care scored significantly higher according to family in the intervention group.

Conclusion:  The increase in adherence to the guidelines and the significantly higher satisfaction of family in the intervention group indicate that the supportive programme had a more positive effect.

The physical copy of available Journal of Advanced Nursing is available in the Healthcare Library on Level D of Rotherham Hospital.

Nurse-perceived quality of care in intensive care units and associations with work environment characteristics: a multicentre survey study

This article by Staplers et al in published in the Journal of Advanced Nursing June 2017 volume 73 number 6

Aims:  To examine nurse-perceived quality of care, controlling for overall job satisfaction among critical care nurses and to explore associations with work environment characteristics.

Background:  Nurse-perceived quality of care and job satisfaction have been positively linked to quality outcomes for nurses and patients. Much evidence exists on factors contributing to job satisfaction. Understanding specific factors that affect nurse-perceived quality potentially enables for improvements of nursing care quality.

Design:  A multicentre survey was conducted in three Dutch intensive care units.

Methods:  The Dutch version of the Essentials of Magnetism II questionnaire was used; including the single-item indicators: (i) nurse-perceived quality of care; (ii) overall job satisfaction; and (iii) 58 statements on work environments. Data were collected between October 2013 – June 2014.

Results:  The majority of 123 responding nurses (response rate 45%) were more than satisfied with quality of care (55%) and with their job (66%). No associations were found with nurse characteristics, besides differences in job satisfaction between the units. After controlling for job satisfaction, nurse-perceived quality was positively associated with the work environment characteristics: adequacy of staffing, patient-centeredness, competent peers and support for education. Patient-centeredness and autonomy were the most important predictors for overall job satisfaction.

Conclusion:  Factors that contribute to nurse-perceived quality of care in intensive care units, independent from the effects of overall job satisfaction, were identified. Hereby, offering opportunities to maximize high quality of care to critically ill patients. Research in a larger sample is needed to confirm our findings.

The physical copy of available Journal of Advanced Nursing is available in the Healthcare Library on Level D of Rotherham Hospital.

Current issue of Critical Care Reviews Newsletter 293 23rd July 2017

Critical Care Reviews Newsletter issue 293 includes the critical care research from the last week.  Contained in it are a randomised controlled trial examining simvastatin in the prevention and treatment of delirium in critically ill patients, an observational study on veno-venous extracorporeal CO2 removal for acute hypercapnic respiratory failure and a review on hyperventilation therapy for control of posttraumatic intracranial hypertension.  In conference news, FemInEM.org is excited to bring you their first ever, in person conference, FIX2017! The FemInEM Idea Exchange is all about education, inspiration and motivation.

The full text of the newsletter can be accessed via this link.

A comparison of pre ICU admission SIRS, EWS and q SOFA scores for predicting mortality and length of stay in ICU.

This research was published in the Journal of Critical Care May 2017 Volume 41 by Siddiqui et al

Introduction:  The 2015 sepsis definitions suggest using the quick SOFA score for risk stratification of sepsis patients among other changes in sepsis definition. Our aim was to validate the q sofa score for diagnosing sepsis and comparing it to traditional scores of pre ICU admission sepsis outcome prediction such as EWS and SIRS in our setting in order to predict mortality and length of stay.

Methods:  This was a retrospective cohort study. We retrospectively calculated the q sofa, SIRS and EWS scores of all ICU patients admitted with the diagnosis of sepsis at our center in 2015. This was analysed using STATA 12. Logistic regression and ROC curves were used for analysis in addition to descriptive analysis.

Results:  58 patients were included in the study. Based on our one year results we have shown that although q SOFA is more sensitive in predicting LOS in ICU of sepsis patients, the EWS score is more sensitive and specific in predicting mortality in the ICU of such patients when compared to q SOFA and SIRS scores.

Conclusion:  We find that in our setting, EWS is better than SIRS and q SOFA for predicting mortality and perhaps length of stay as well. The q Sofa score remains validated for diagnosis of sepsis.

The full text of the Journal of Critical Care is available via NHS Evidence Journals listing with an NHS Athens Password approximately sixty days after publication.  You can register for an NHS Athens Password via this link.  Please ask staff in the Library and Knowledge Service for assistance.

Management of hypoxaemic respiratory failure in a Respiratory High-dependency Unit.

This paper was published by Hukins and colleagues in Internal Medicine Journal in July 2017 volume 47 number 7 addressing the limited data on outcomes of hypoxaemic respiratory failure (HRF), especially in non-intensive care unit (ICU) settings.

 

Aim:  To assess outcomes in HRF (without multi-system disease and not requiring early intubation) of patients directly admitted to a Respiratory High-dependency Unit (R-HDU).

Methods:  This is a retrospective cohort study of HRF compared to hypercapnic respiratory failure (HCRF) in a R-HDU (2007-2011). Patient characteristics (age, gender, pre-morbid status, diagnoses) and outcomes (non-invasive ventilation (NIV) use, survival, ICU admission) were assessed. 

Results:  There were 1207 R-HDU admissions in 2007-2011, 205 (17%) with HRF and 495 (41%) with HCRF. The proportion with HRF increased from 12.2% in 2007 to 20.1% in 2011 (P < 0.05). HRF patients were younger, more often male and had better pre-morbid performance. Compared to HCRF, HRF was more frequently associated with lung consolidation (61% vs 15%, P < 0.001), interstitial lung disease (12% vs 1%, P < 0.001) and pulmonary hypertension (7% vs 0%, P < 0.001) and less frequently with chronic obstructive pulmonary disease (24% vs 65%, P < 0.001) and obstructive sleep apnoea (8% vs 26%, P < 0.001). Fewer patients with HRF were treated with NIV (28% vs 87%, P < 0.001), but NIV was discontinued early more often (28% vs 7%, P < 0.001). A total of 18% with HRF was transferred to ICU compared to 6% with HCRF (P = 0.06). More patients with HRF died (19.5% vs 12.3%, P = 0.02). Interstitial lung disease, consolidation, shock, malignancy and poorer pre-morbid function were associated with increased mortality.

Conclusions:  Initial R-HDU management is an effective option in selected HRF to reduce ICU demand, although mortality and clinical deterioration despite NIV are more common than in HCRF.

The full paper can be accessed by subscribers to “Internal Medicine Journal” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.