How to optimize critical care resources in surgical patients: intensive care without physical borders

The article by Pelosi, Ball and Schultz was published in the October 2018 issue of Current Opinion in Critical Care.
Purpose of Review:  Timely identification of surgery patients at risk of postoperative complications is important to improve the care process, including critical care. This review discusses epidemiology and impact of postoperative complications; prediction scores used to identify surgical patients at risk of complications, and the role of critical care in the postoperative management. It also discusses how critical care may change, with respect to admission to the ICU.
Recent Finding:  Optimization of postoperative outcome, next to preoperative and intraoperative optimization, consists of using risk scores to early identify patients at risk of developing complications. Critical care consultancy should be performed in the ward after surgery, if necessary. ICUs could work at different levels of intensity, but remain preferably multidisciplinary, combining care for surgical and medical patients. ICU admission should still be considered for those patients at very high risk of postoperative complications, and for those receiving complex or emergency interventions.
Summary:  To optimize critical care resources for surgery patients at high risk of postoperative complications, the care process should not only include critical care and monitoring in ICUs, but also strict monitoring in the ward. Prediction scores could help to timely identify patients at risk. More intense care (monitoring) outside the ICU could improve outcome. This concept of critical care without borders could be implemented in the near future to optimize the local resources and improve patient safety. Predict more, do less in ICUs, and more in the ward.
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Noise in the intensive care unit and its influence on sleep quality: a multicenter observational study in Dutch intensive care units

This article by Simons and colleagues was published in the Critical Care October 2018 issue.
Background:  High noise levels in the intensive care unit (ICU) are a well-known problem. Little is known about the effect of noise on sleep quality in ICU patients. The study aim is to determine the effect of noise on subjective sleep quality.
Methods:  This was a multi-centre observational study in six Dutch ICUs. Noise recording equipment was installed in 2-4 rooms per ICU. Adult patients were eligible for the study 48 h after ICU admission and were followed up to maximum of five nights in the ICU. Exclusion criteria were presence of delirium and/or inability to be assessed for sleep quality. Sleep was evaluated using the Richards Campbell Sleep Questionnaire (range 0-100 mm). Noise recordings were used for analysis of various auditory parameters, including the number and duration of restorative periods. Hierarchical mixed model regression analysis was used to determine associations between noise and sleep.
Results:  In total, 64 patients (68% male), mean age 63.9 (± 11.7) years and mean Acute Physiology and Chronic Health Evaluation (APACHE) II score 21.1 (± 7.1) were included. Average sleep quality score was 56 ± 24 mm. The mean of the 24-h average sound pressure levels (LAeq, 24h) was 54.0 dBA (± 2.4). Mixed-effects regression analyses showed that background noise (β = - 0.51, p < 0.05) had a negative impact on sleep quality, whereas number of restorative periods (β = 0.53, p < 0.01) and female sex (β = 1.25, p < 0.01) were weakly but significantly correlated with sleep.
Conclusions:  Noise levels are negatively associated and restorative periods and female gender are positively associated with subjective sleep quality in ICU patients.
The full text of the article is available via this link.

Intensive care nurses fail to translate knowledge and skills into practice – A mixed-methods study on perceptions of oral care

This research by Andersson et al was published in “Intensive and Critical Care Nursing” October 2018 issue.
Objectives:  To identify intensive care nurses’ perceptions of oral care according to Coker et al.’s (2013) conceptual framework and to contribute to the knowledge base of oral care in intensive care.
Design/Methods:  This was a concurrent embedded mixed-methods design, with more weight given to the quantitative part. Participants responded to the Nursing Care related to Oral Health questionnaire, including perceptions of oral care antecedents (18 items), defining attributes (17 items), and consequences (6 items) and two open-ended questions. The data were analysed with descriptive and correlation statistics and qualitative content analysis.
Setting:  Intensive care nurses (n = 88) in six general intensive care units.
Results:  Intensive care nurses perceived that an important part of nursing care was oral care, especially to intubated patients. They perceived that the nursing staff was competent in oral care skills and had access to different kinds of equipment and supplies to provide oral care. The oral cavity was inspected on a daily basis, mostly without the use of any assessment instruments. Oral care seemed to be task-oriented, and documentation of the patients’ experiences of the oral care process was rare.
Conclusions:  The antecedents, knowledge and skills are available to provide quality oral care, but intensive care nurses seem to have difficulties translating these components into practice. Thus they might have to shift their task-oriented approach towards oral care to a more person-centred approach in order to be able to meet patients’ needs.
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Critical Care Reviews Newsletter 356 8th October 2018

The 356th Critical Care Reviews Newsletter brings you the best critical care research and open access articles from across the medical literature over the past seven days.  The highlights of the latest edition include “a randomised controlled trial on airway pressure rcritcal care reviewselease ventilation; systematic reviews and meta analyses on thromboembolism prophylaxis in neurosurgical patients & hydrocortisone in septic shock; and observational studies on a Candida auris outbreak, an assay discriminating sepsis from SIRS in the ICU & minimal-flow ECCO2R in patients needing CRRT. There are also guidelines on clinical nutrition in the ICU & polytrauma; narrative reviews on myocardial injury after non-cardiac surgery & direct oral anticoagulants; editorials on science without publication paywalls & airway management; and commentaries on bile acids in nutritional support & driving pressure.” The full text of the newsletter is available via this link.

A complete and multifaceted overview of antibiotic use and infection diagnosis in the intensive care unit: results from a prospective four-year registration

This article in Critical Care September 2018 issue was produced by De Bus and colleagues.
Background:  Preparing an antibiotic stewardship program requires detailed information on overall antibiotic use, prescription indication and ecology. However, longitudinal data of this kind are scarce. Computerization of the patient chart has offered the potential to collect complete data of high resolution. To gain insight in our global antibiotic use, we aimed to explore antibiotic prescription in our intensive care unit (ICU) from various angles over a prolonged time period.
Methods:  We studied all adult patients admitted to Ghent University Hospital ICU from 1 January 2013 until 31 December 2016. Antibiotic prescription data were prospectively merged with diagnostic (suspected focus, severity and probability of infection at the time of prescription, or prophylaxis) and microbiology data by ICU physicians during daily workflow through dedicated software. Definite focus of infection and probability of infection (classified as high/moderate/low) were reassessed by dedicated ICU physicians at patient discharge.
Results:  During the study period, 8763 patients were admitted and overall antibiotic consumption amounted to 1232 days of therapy (DOT)/1000 patient days. Antibacterial DOT (84% of total DOT) were linked with infection in 80%; the predominant foci were the respiratory tract (49%) and the abdomen (19%). A microbial cause was identified in 56% (3169/5686). Moderate/low probability infections accounted for 42% of antibacterial DOT prescribed for respiratory tract infections; for abdominal infections, this figure was 15%. The median treatment duration of moderate/low probability respiratory infections was 4 days (IQR 3-7). Antifungal DOT (16% of total DOT) were linked with infection in 47% of total antifungal DOT. Antifungal prophylaxis was primarily administered in the surgical ICU (76%), with a median duration of 4 DOT (IQR 2-9).
Conclusions:  By prospectively combining antibiotic, microbiology and clinical data we were able to construct a longitudinal, multifaceted data set on antibiotic use and infection diagnosis. A complete overview of this kind may allow the identification of antibiotic prescription patterns that require future antibiotic stewardship attention.
The full text of the article is available via this link.

Accidental dual humidification in intensive care units: Repeated alerts and system changes are not enough

This article by Patel and colleagues was published in the Journal of Critical Care in October 2018.
Purpose:  The inadvertent, simultaneous use of heat and moisture exchangers (HMEs) and heated humidifiers (HHs) can result in waterlogging of the filter and sudden ventilation tube occlusion, with potentially fatal consequences. Following an NHS England Safety Alert, a near miss and educational reminders in our institution, we introduced new guidelines to solely use HHs in the intensive care unit and HMEs only for patient transfers. No further incidents have occurred, however this solution is potentially fallible. Two years later, we sought to assess staff knowledge and likelihood of recognising this error should it occur.
Materials and methods:  In a simulation study, a tracheally intubated and ventilated mannequin had a breathing circuit containing both a HME and a HH. Participants were asked to assess the circuit, identify errors and undertake corrective measures.
Results:  Only 30% (6/20) recognised and undertook corrective measures.
Conclusions:  Despite educational efforts and system changes, recognition of this error remained poor. System changes may reduce the likelihood of the error occurring, but when it does, recognition may not occur. Substantial reductions or elimination of this error may be achieved through a safety-engineered fail-safe within the equipment, which alerts staff to improve recognition and prevent the mistake.

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Peripherally Inserted Central Catheters in the ICU: A Retrospective Study of Adult Medical Patients in 52 Hospitals

This article was published in the September 2018 issue of Critical Care Medicine by Govindan and colleagues.
Objectives:  To quantify variation in use and complications from peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the general ward.
Design:  Retrospective cohort study.
Setting:  Fifty-two hospital Michigan quality collaborative.
Patients:  Twenty-seven-thousand two-hundred eighty-nine patients with peripherally inserted central catheters placed during hospitalization.
Measurements and main results:  Descriptive statistics were used to summarize patient, provider, and device characteristics. Bivariate tests were used to assess differences between peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the ward. Multilevel mixed-effects generalized linear models adjusting for patient and device factors with a logit link clustered by hospital were used to examine the association between peripherally inserted central catheter complications and location of peripherally inserted central catheter placement. Variation in ICU peripherally inserted central catheter use, rates of complications, and appropriateness of use across hospitals was also examined. Eight-thousand two-hundred eighty patients (30.3%) received peripherally inserted central catheters in the ICU versus 19,009 (69.7%) on the general ward. The commonest indication for peripherally inserted central catheter use in the ICU was difficult IV access (35.1%) versus antibiotic therapy (53.3%) on wards. Compared with peripherally inserted central catheters placed in wards, peripherally inserted central catheters placed in the ICU were more often multilumen (59.5% vs 39.3; p < 0.001) and more often associated with a complication (odds ratio, 1.30; 95% CI, 1.18-1.43; p < 0.001). Substantial variation in ICU peripherally inserted central catheter use and outcomes across hospitals was observed, with median peripherally inserted central catheter dwell time ranging from 3 to 38.5 days (p < 0.001) and complications from 0% to 40.2% (p < 0.001). Importantly, 87% (n = 45) of ICUs reported median peripherally inserted central catheter dwell times less than or equal to 14 days, a duration where traditional central venous catheters, not peripherally inserted central catheters, are considered appropriate by published criteria.
Conclusions:  Peripherally inserted central catheter use in the ICU is highly variable, associated with complications and often not appropriate. Further study of vascular access decision-making in the ICU appears necessary.
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