Early intervention of patients at risk for acute respiratory failure and prolonged mechanical ventilation with a checklist aimed at the prevention of organ failure

Gong, M.N. et al. BMJ Open. 2016. 6:e011347

Introduction: Acute respiratory failure (ARF) often presents and progresses outside of the intensive care unit. However, recognition and treatment of acute critical illness is often delayed with inconsistent adherence to evidence-based care known to decrease the duration of mechanical ventilation (MV) and complications of critical illness. The goal of this trial is to determine whether the implementation of an electronic medical record-based early alert for progressive respiratory failure coupled with a checklist to promote early compliance to best practice in respiratory failure can improve the outcomes of patients at risk for prolonged respiratory failure and death.

Methods and analysis: A pragmatic stepped-wedged cluster clinical trial involving 6 hospitals is planned. The study will include adult hospitalised patients identified as high risk for MV >48 hours or death because they were mechanically ventilated outside of the operating room or they were identified as high risk for ARF on the Accurate Prediction of PROlonged VEntilation (APPROVE) score. Patients with advanced directives limiting intubation will be excluded. The intervention will consist of (1) automated identification and notification of clinician of high-risk patients by APPROVE or by invasive MV and (2) checklist of evidence-based practices in ARF (Prevention of Organ Failure Checklist—PROOFCheck). APPROVE and PROOFCheck will be developed in the pretrial period. Primary outcome is hospital mortality. Secondary outcomes include length of stay, ventilator and organ failure-free days and 6-month and 12-month mortality. Predefined subgroup analysis of patients with limitation of aggressive care after study entry is planned. Generalised estimating equations will be used to compare patients in the intervention phase with the control phase, adjusting for clustering within hospitals and time.

Ethics and dissemination: The study was approved by the institutional review boards. Results will be published in peer-reviewed journals and presented at international meetings.

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Latest issue of Journal of Critical Care Volume 34 August 2016

The content page of this issue can be accessed via this link

Articles featured in this issue include“End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine”, “Early procalcitonin kinetics and appropriateness of empirical antimicrobial therapy in critically ill patients: A prospective observational study” and “Is inhaled prophylactic heparin useful for prevention and Management of Pneumonia in ventilated ICU patients?: The IPHIVAP investigators of the Australian and New Zealand Intensive Care Society Clinical Trials Group”.

A personal subscription to the journal is required to access the full text of these articles direct from this website.  However, articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  This can be done either in person or via this link if you are a registered member of the library.

New issue of “Intensive and Critical Care Nursing” Volume 35 Issue August 2016

The contents page of this current issue can be accessed via this link.

Amongst the articles that are included in this issue are “The effectiveness of a standardised positioning tool and bedside education on the
developmental positioning proficiency of NICU nurses”, “Obstetric admissions
to ICUs in Finland: A multicentre study” and “Prevalence of obesity in an intensive care unit patient population”.

To access the full text of these articles direct from the journal’s homepage requires a personal subscription.  Individual articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make requests online via this link.

The full text of articles from Intensive and Critical Care Nursing from issue older than one year ago is available via this link.  A Rotherham NHS Athens password is required.  Eligible staff can register for one via this link.

A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care

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Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors–appropriate catheter use, aseptic insertion, and proper maintenance–and socioadaptive factors, such as cultural and behavioural changes in hospital units, are important in preventing catheter-associated UTI. The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates. Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs. Tests for heterogeneity (ICU vs. non-ICU) were significant for catheter use (P=0.004) and catheter-associated UTI rates (P=0.001). A national prevention program appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. (

This article by fourteen authors was published in the New England Journal of Medicine issued dated 2nd June 2016.  The issue is available in the Healthcare Library on Level D of Rotherham Hospital.

Current Issue of Intensive Care Medicine July 2016 Volume 42 Number 7

The contents page of this current issue can be accessed via this link.

This issue includes articles on “Ultrasonography evaluation during the weaning process: the heart, the diaphragm, the pleura and the lung”, “Delayed Awakening after Cardiac Arrest” and “Nurses versus physician-led interhospital critical care transport: a randomized non-inferiority trial.”

To access the full text of these articles direct from the journal’s homepage requires a personal subscription.  Individual articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make requests online via this link.

The full text of articles from Intensive Care Medicine from issue older than one year ago is available via this link.  A Rotherham NHS Athens password is required.  Eligible staff can register for one via this link.

Bedside dressing changes for open abdomen in the intensive care unit is safe and time and staff efficient

Seternes, A et al. Critical Care 2016 20:164. Published online: 28 May 2016

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Image source: Seternes, A. et al. In BMC CC

Background: Patients with an open abdomen (OA) treated with temporary abdominal closure (TAC) need multiple surgical procedures throughout the hospital stay with repeated changes of the vacuum-assisted closure device (VAC changes). The aim of this study was to examine if using the intensive care unit (ICU) for dressing changes in OA patients was safe regarding bloodstream infections (BSI) and survival. Secondary aims were to evaluate saved time, personnel, and costs.

Methods: All patients treated with OA in the ICU from October 2006 to June 2014 were included. Data were retrospectively obtained from registered procedure codes, clinical and administrative patients’ records and the OR, ICU, anesthesia and microbiology databases. Outcomes were 30-, 60- and 90-day survival, BSI, time used and saved personnel costs.

Results: A total of 113 patients underwent 960 surgical procedures including 443 VAC changes as a single procedure, of which 165 (37 %) were performed in the ICU. Nine patients died before the first scheduled dressing change and six patients were closed at the first scheduled surgery after established OA, leaving 98 patients for further analysis. The mean duration for the surgical team performing a VAC change in the ICU was 63.4 (60.4–66.4) minutes and in the OR 98.2 (94.6–101.8) minutes (p < 0.001). The mean duration for the anesthesia team in the OR was 115.5 minutes, while this team was not used in the ICU. Personnel costs were reduced by €682 per procedure when using the ICU. Forty-two patients had all the VAC changes done in the OR (VAC-OR), 22 in the ICU (VAC-ICU) and 34 in both OR and ICU (VAC-OR/ICU). BSI was diagnosed in eight (19 %) of the VAC-OR patients, seven (32 %) of the VAC-ICU and eight (24 %) of the VAC-OR/ICU (p = 0.509). Thirty-five patients (83 %) survived 30 days in the VAC-OR group, 17 in the VAC-ICU group (77 %) and 28 (82 %) in the VAC-OR/ICU group (p = 0.844).

Conclusions: VAC change for OA in the ICU saved time for the OR team and the anesthesia team compared to using the OR, and it reduced personnel costs. Importantly, the use of ICU for OA dressing change seemed to be as safe as using the OR.

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Current Issue of Journal of Intensive Care Medicine June 2016 Volume 31 Number 6

The contents page of this latest issue can be accessed via this link.

Articles that are published in this issue include “Chronic Statin Use and Long-Term Rates of Sepsis: A Population-Based Cohort Study”, “Incidence, Risk Factors, and Prognosis of Intra-Abdominal Hypertension in Critically Ill Children: A Prospective Epidemiological Study” and “The Safety and Feasibility of Admitting Patients With Intracerebral Hemorrhage to the Step-Down Unit”.

In order to access the full text of these articles direct from the journal’s homepage requires a personal subscription to the journal.  Particular articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make requests online via this link.

Latest Issue of Journal of Intensive Care Medicine June 2016 Volume 31 Number 5

The contents page of this latest issue can be accessed via this link.

Articles included in this publication include “Critical Care for the Patient With Multiple Trauma”, “Acute Kidney Injury in the Critically Ill Patient: A Current Review of the Literature” and “Ultrasonography for Screening and Follow-Up of Diaphragmatic Dysfunction in the ICU: A Pilot Study”.

In order to access the full text of these articles direct from the journal’s homepage requires a personal subscription to the journal.  Particular articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make requests online via this link.

Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients.

Misperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical information.  This study aimed to determine the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs).

It was published by White et al in the JAMA 17th May 2016.  The issue is available in the Health Care Library on D Level of Rotherham Hospital or for those with a personal subscription to JAMA can be accessed via this link

This mixed-methods study comprising quantitative surveys and qualitative interviews was conducted in 4 ICUs at a major US medical center involving surrogate decision makers and physicians caring for patients at high risk of death from January 4, 2005, to July 10, 2009.

Discordance about prognosis, defined as a difference between a physician’s and a surrogate’s prognostic estimates of at least 20%; misunderstandings by surrogates (defined as any difference between a physician’s prognostic estimate and a surrogate’s best guess of that estimate); differences in belief (any difference between a surrogate’s actual estimate and their best guess of the physician’s estimate). Two hundred twenty-nine surrogate decision makers (median age, 47 [interquartile range {IQR}, 35-56] years; 68% women) and 99 physicians were involved in the care of 174 critically ill patients (median age, 60 [IQR, 47-74] years; 44% women). Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related to both misunderstandings by surrogates and differences in belief about the patient’s prognosis; 38 (17%) were related to misunderstandings by surrogates only; 7 (3%) were related to differences in belief only; and data were missing for 12. Seventy-five patients (43%) died. Surrogates’ prognostic estimates were much more accurate than chance alone, but physicians’ prognostic estimates were statistically significantly more accurate than surrogates’ (C statistic, 0.83 vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163; P = .008). Among 71 surrogates interviewed who had beliefs about the prognosis that were more optimistic than that of the physician, the most common reasons for optimism were a need to maintain hope to benefit the patient (n = 34), a belief that the patient had unique strengths unknown to the physician (n = 24), and religious belief (n = 19).

Among critically ill patients, discordant expectations about prognosis were common between patients’ physicians and surrogate decision makers and were related to misunderstandings by surrogates about physicians’ assessments of patients’ prognoses and differences in beliefs about patients’ prognoses.

Pharmacological Therapy for the Prevention and Treatment of Weakness After Critical Illness: A Systematic Review

Shepherd, S.J. et al.  Critical Care Medicine. June 2016. Volume 44(6). pp. 1198–1205

Objectives: ICU-acquired weakness is a common complication of critical illness and can have significant effects upon functional status and quality of life. As part of preliminary work to inform the design of a randomized trial of a complex intervention to improve recovery from critical illness, we sought to identify pharmacological interventions that may play a role in this area.

Data Sources: We systematically reviewed the published literature relating to pharmacological intervention for the treatment and prevention of ICU-acquired weakness.

Study Selection: We searched MEDLINE, EMBASE, CINAHL+, Web of Science, and both U.S. and European trial registries up to July 2014 alongside reviews and reference lists from populations with no age or language restrictions. We included studies that reported a measure of muscle structure or physical function as an outcome measure.

Data Extraction: We estimated pooled odds ratios and 95% CI using data extracted from published articles or where available, original data provided by the authors. Assessment of bias was performed using the Cochrane Collaboration’s risk of bias tool.

Data Synthesis: Ten studies met the inclusion criteria. The current body of evidence does not support the use of any pharmacological agent in this setting, although maintaining euglycemia may reduce the prevalence of critical illness polyneuropathy.

Conclusions: At present, no pharmacological intervention can be recommended to prevent or treat ICU-acquired weakness. Further research is required into this field to include more novel agents such as myostatin inhibitors. Challenges in the conduct of research in this area are highlighted.

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