Implementing selective digestive tract decontamination in the intensive care unit: A qualitative analysis of nurse-identified considerations

Objective

To describe factors senior critical care nurses identify as being important to address when introducing selective digestive tract decontamination (SDD) in the clinical setting.

Background

Critically ill patients are at risk of developing ventilator-associated pneumonia (VAP). SDD is one strategy shown to prevent VAP and possibly improve survival in the critically ill.

Methods

We performed a secondary analysis of qualitative data obtained from 20 interviews. An inductive thematic analysis approach was applied to data obtained from senior critical care nurses during phase two of a multi-methods study.

Results

There were four primary considerations identified that should be addressed or considered prior to implementation of SDD. These considerations included education of health care professionals, patient comfort, compatibility of SDD with existing practices, and cost.

Conclusions

Despite a lack of experience with, or knowledge of SDD, nurses were able to articulate factors that may influence its implementation and delivery. Organizations or researchers considering implementation of SDD should include nurses as key members of the implementation team.     

Effect of a multi-level intervention on nurse–patient communication in the intensive care unit: Results of the SPEACS trial

Objective

To test the impact of two levels of intervention on communication frequency, quality, success, and ease between nurses and intubated intensive care unit (ICU) patients.

Design

Quasi-experimental, 3-phase sequential cohort study: (1) usual care, (2) basic communication skills training (BCST) for nurses, (3) additional training in augmentative and alternative communication devices and speech language pathologist consultation (AAC + SLP). Trained observers rated four 3-min video-recordings for each nurse–patient dyad for communication frequency, quality and success. Patients self-rated communication ease.

Setting

Two ICUs in a university-affiliated medical center.

Participants

89 intubated patients awake, responsive and unable to speak and 30 ICU nurses.

Main results

Communication frequency (mean number of communication acts within a communication exchange) and positive nurse communication behaviors increased significantly in one ICU only. Percentage of successful communication exchanges about pain were greater for the two intervention groups than the usual care/control group across both ICUs (p = .03) with more successful sessions about pain and other symptoms in the AAC + SLP group (p = .07). Patients in the AAC + SLP intervention group used significantly more AAC methods (p = .002) and rated communication at high difficulty less often (p < .01).

Conclusions

This study provides support for the feasibility, utility and efficacy of a multi-level communication skills training, materials and SLP consultation intervention in the ICU.     

Feasibility and inter-rater reliability of the ICU Mobility Scale

Objectives

The objectives of this study were to develop a scale for measuring the highest level of mobility in adult ICU patients and to assess its feasibility and inter-rater reliability.

Background

Growing evidence supports the feasibility, safety and efficacy of early mobilization in the intensive care unit (ICU). However, there are no adequately validated tools to quickly, easily, and reliably describe the mobility milestones of adult patients in ICU. Identifying or developing such a tool is a priority for evaluating mobility and rehabilitation activities for research and clinical care purposes.

Methods

This study was performed at two ICUs in Australia. Thirty ICU nursing, and physiotherapy staff assessed the feasibility of the ‘ICU Mobility Scale’ (IMS) using a 10-item questionnaire. The inter-rater reliability of the IMS was assessed by 2 junior physical therapists, 2 senior physical therapists, and 16 nursing staff in 100 consecutive medical, surgical or trauma ICU patients.

Results

An 11 point IMS scale was developed based on multidisciplinary input. Participating clinicians reported that the scale was clear, with 95% of respondents reporting that it took <1 min to complete. The junior and senior physical therapists showed the highest inter-rater reliability with a weighted Kappa (95% confidence interval) of 0.83 (0.76–0.90), while the senior physical therapists and nurses and the junior physical therapists and nurses had a weighted Kappa of 0.72 (0.61–0.83) and 0.69 (0.56–0.81) respectively.

Conclusion

The IMS is a feasible tool with strong inter-rater reliability for measuring the maximum level of mobility of adult patients in the ICU.     

The Diagnostic Yield,Safety, and Impact of Flexible Bronchoscopy in Non-HIV Immunocompromised Critically Ill Patients in the Intensive Care Unit

Background

Flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) have major roles in the evaluation of parenchymal lung diseases in immunocompromised patients. Given the limited evidence, lack of standardized practice, and variable perception of procedural safety, uncertainty still exists on what constitutes the best approach in critically ill patients with immunocompromised state who present with pulmonary infiltrates in the era of prophylactic antimicrobials and the presence of new diagnostic tests.

Objective

To evaluate the diagnostic yield, safety and impact of FB and BAL on management decisions in immunocompromised critically ill patients admitted to the intensive care unit (ICU).

Methods

A prospective, observational study of 106 non-HIV immunocompromised patients admitted to the intensive care unit with pulmonary infiltrates who underwent FB with BAL.

Results

FB and BAL established the diagnosis in 38 (33%) of cases, and had a positive impact on management in 44 (38.3%) of cases. Escalation of ventilator support was not required in 94 (81.7%) of cases, while 18 (15.7%) required invasive and 3 (2.6%) required non-invasive positive pressure ventilation after the procedure. Three patients (2.6%) died within 24 h of bronchoscopy, and 46 patients (40%) died in ICU. Significant hypoxemia developed in 5% of cases.

Conclusion

FB can be safely performed in immunocompromised critically ill patients in the ICU. The yield can be improved when FB is done prior to initiation of empiric antimicrobials, within 24 h of admission to the ICU, and in patients with focal disease.

     

Retrospective Outcomes of Glucose Control in Critically Ill Children

Background

Hyperglycemia is a significant problem for critically ill children. Treatment for hyperglycemia remains controversial. This study explores the effect of controlling blood glucose (BG) in hyperglycemic critically ill children.

Methods

A retrospective cohort of nondiabetic critically ill children (defined as requiring mechanical ventilation and/or vasopressors) with BG persistently ≥150 mg/dl and treated with insulin (treatment group) were compared with a historical cohort of similar children who did not receive interventions to control hyperglycemia (baseline group).

Results

There were 130 children in the treatment group and 137 children in the baseline group. Mean BG in the treatment group was 140 ± 24 mg/dl compared with 179 ± 47 mg/dl in the baseline group (p < .001). After adjusting for patient characteristics, cointerventions, and glucose metrics, patients in the treatment group had 2.5 fewer intensive care unit (ICU)-free days (i.e., number of days alive and discharged from ICU within 28 days after inclusion) than the baseline group (p = .023). Glucose control was not independently associated with duration of ICU stay, ventilator-free days, vasopressor-free days, or mortality.

Conclusions

Blood glucose control appears associated with worse outcomes in critically ill children. Our data combined with conflicting results in adults leads us to strongly advocate for the conduct of randomized trials on glucose control in critically ill children.     

Uso precoz de la ventilación mecánica no invasiva en pacientes con insuficiencia respiratoria hipercápnica aguda ingresados en una sala de neumología: estudio prospectivo

Background

In recent years, the optimal location for noninvasive mechanical ventilation (NIMV) has been a matter of debate. Our aim was to detect the effectiveness of NIMV in acute hypercapnic respiratory failure (AHRF) in respiratory ward and factors associated with failure.

Methods

69 patients treated with NIMV in respiratory ward were prospectively evaluated. The success of NIMV was defined as absence of need for intensive care unit (ICU) transfer with patient's dishcarge from hospital (group 1), failure of NIMV was defined as need for ICU transfer (group 2).

Results

The mean age was significantly higher in group 2. The cause of respiratory failure was COPD in 51 patients, obesity-hypoventilation syndrome in 14 and kyphoscoliosis in 4 patients. NIMV was successful in 55 patients and unsuccessful in 14. There was no significant difference between the two groups for pretreatment pH, PaCO₂ and PaO₂/FiO₂. After 1 h and 3 h of NIMV there was significant improvement in group 1. After 3 h of NIMV, in group 1 respiratory rate was significantly decreased. The pretreatment APACHE II score, respiratory rate, frequency of pneumoniae, associated complication and comorbid disease was significantly higher in group 2. The success rate was higher in patients with good compliance to NIMV.

Conclusion

NIMV can be succesfully applied in patients with AHRF in respiratory ward. The associated factors with NIMV failure are absence of early improvement in blood gases and respiratory rate, bad compliance to NIMV, older age, presence of associated complication, comorbid disease, pneumonia and high baseline respiratory rate.     

Feasibility study of unattended polysomnography in medical intensive care unit patients

Objectives

To evaluate the feasibility of using unattended, portable polysomnography (PSG) to measure sleep among patients in the medical intensive care unit (MICU).

Background

Accurate measurement of sleep is critical to studies of MICU sleep deprivation. Although PSG is the gold standard, there is limited data regarding the feasibility of utilizing unattended, portable PSG modalities in the MICU.

Methods

MICU based observational pilot study. We conducted unattended, 24-h PSG studies in 29 patients. Indicators of feasibility included attainment of electroencephalography data sufficient to determine sleep stage, sleep efficiency, and arousal indices.

Results

Electroencephalography data were not affected by electrical interference and were of interpretable quality in 27/29 (93%) of patients. Overnight sleep efficiency was 48% reflecting a mean overnight sleep duration of 3.7 h.

Conclusions

Unattended, portable PSG produces high quality sleep data in the MICU and can facilitate investigation of sleep deprivation among critically ill patients. Patient sleep was short and highly fragmented.     

Home discharge following critical illness: A qualitative analysis of family caregiver experience

Background

Few studies have longitudinally explored the experience and needs of family caregivers of ICU survivors after patients' home discharge.

Elevated Cardiac Troponin T Levels in Critically Ill Patients with Sepsis

Background

It is known that troponin elevations have prognostic importance in critically ill patients. We examined whether cardiac troponin T elevations are independently associated with in-hospital, short-term (30 days), and long-term (3 years) mortality in intensive care unit (ICU) patients admitted with sepsis, severe sepsis, and septic shock after adjusting for the severity of disease with the Acute Physiology, Age and Chronic Health Evaluation III system.

Methods

We studied the Mayo Clinic's Acute Physiology, Age and Chronic Health Evaluation III database and cardiac troponin T levels from patients admitted consecutively to the medical ICU. Between January 2001 and December 2006, 926 patients with sepsis had cardiac troponin T measured at ICU admission. In-hospital, short-term, and long-term all-cause mortality were determined.

Results

Among study patients, 645 (69.7%) had elevated cardiac troponin T levels and 281 (30.3%) had undetectable cardiac troponin T. During hospitalization, 15% of the patients with troponin T <0.01 ng/mL died compared with 31.9% of those with troponin T ≥0.01 ng/mL (P < .0001). At 30 days, mortality was 31% and 17% in patients with and without elevations, respectively (P < .0001). The Kaplan-Meier probability of survival at 1-, 2-, and 3-year follow-ups was 68.1%, 56.3%, and 46.8% with troponin T ≥0.01 ng/mL, respectively, and 76.4%, 69.1%, and 62.0% with troponin T <0.01 μg/L, respectively (P < .0001). After adjustment for severity of disease and baseline characteristics, cardiac troponin T levels remained associated with in-hospital and short-term mortality but not with long-term mortality.

Conclusions

In patients with sepsis who are admitted to an ICU, cardiac troponin T elevations are independently associated with in-hospital and short-term mortality but not long-term mortality.     

Endoscopic surveillance for hereditary non-polyposis colorectal cancer (HNPCC) family members in a Southern Italian region

Background

Surveillance in hereditary non-polyposis colorectal cancer (HNPCC) family members recommends baseline colonoscopy starting at age 20 and then surveillance colonoscopy every 1–2 years.

Aims

To verify adherence to the guidelines for HNPCC family members enrolled in endoscopic surveillance.

Methods

Data regarding 11 HNPCC families was retrieved from our database. Excluding 11 probands, 106 family members were evaluated and 40 underwent surveillance.

Results

At baseline colonoscopy, 7 colorectal cancers (CRC), 14 polyps (PO) [1 inflammatory, 2 hyperplastic, 10 adenomas with low grade dysplasia (LGD-AD) and 1 adenoma with high-grade dysplasia (HGD-AD)] were diagnosed in sixteen individuals. Twenty-eight HNPCC family members underwent endoscopic surveillance, with a total of 94 surveillance colonoscopies. Of these, 45 were positive (4 CRC, 3 inflammatory PO, 34 hyperplastic PO, 21 LGD-AD and 5 HGD-AD).Mean time between two consecutive surveillance colonoscopies was 24.6 months (range 4–168). Median time to first positive surveillance colonoscopy was 84 months for HNPCC family members with negative baseline colonoscopy, and 60 months for those with positive baseline colonoscopy (p = 0.21).

Conclusions

Our data suggests that surveillance colonoscopy every 2 years is adequate to diagnose advanced lesions in HNPCC family members, and improves their compliance with surveillance.     

Barriers to health information seeking in Iranian patients with cardiovascular disease: A qualitative study

Objective

Providing patients with health care information is a critical component of the process of cardiovascular disease (CVD) management. The purpose of this study was to explore obstacles to seeking health care information among cardiovascular patients from the perspectives of patients, their family caregivers, and health care providers.

Methods

This study was conducted with a qualitative approach using conventional qualitative content analysis. The study included 31 Iranian participants including 16 cardiovascular patients, 5 family members, and 10 health care providers (multidisciplinary). Data were collected with semi-structured interviews and continued to the point of data saturation. Analysis of the data was performed continually and concurrently with data collection of using a comparative method.

Results

Five themes emerged including ‘poor quality of information provision,’ ‘mutual ambiguity,’ ‘beliefs, faith, and expectations,’ ‘from routine life to obtaining information,’ and ‘conditions governing information seekers.’ Seven sub-themes indicated participants' experiences and understandings of obstacles in health care information seeking.

Conclusion

Health care information seeking in cardiovascular patients and their family members occurs as a result of the influence of beliefs, interaction with numerous information sources, and in the context and structure that the care and information are provided. Understanding the nature of obstacles to health information seeking will help health care policy makers to provide evidence-based, reliable, and patient-centered information to encourage cardiovascular patients' involvement in treatment decisions.     

Patient ventilator asynchrony in critically ill adults: Frequency and types

Background

Patient ventilator asynchrony (PVA) occurs frequently, but little is known about the types and frequency of PVA. Asynchrony is associated with significant patient discomfort, distress and poor clinical outcomes (duration of mechanical ventilation, intensive care unit and hospital stay).

Methods

Pressure–time and flow–time waveform data were collected on 27 ICU patients using the Noninvasive Cardiac Output monitor for up to 90 min per subject and blinded waveform analysis was performed.

Results

PVA occurred during all phases of ventilated breaths and all modes of ventilation. The most common type of PVA was Ineffective Trigger. Ineffective trigger occurs when the patient's own breath effort will not trigger a ventilator breath. The overall frequency of asynchronous breaths in the sample was 23%, however 93% of the sample experienced at least one incident of PVA during their observation period. Seventy-seven percent of subjects experienced multiple types of PVA.

Conclusions

PVA occurs frequently in a variety of types although the majority of PVA is ineffective trigger. The study uncovered previously unidentified waveforms that may indicate that there is a greater range of PVAs than previously reported. Newly described PVA, in particular, PVA combined in one breath, may signify substantial patient distress or poor physiological circumstance that clinicians should investigate.     

Parenteral nutrition-associated hyperglycemia in noncritically ill inpatients is associated with higher mortality

BACKGROUND:

Hyperglycemia is a marker of poor clinical outcomes in studies evaluating hospitalized critically ill patients.

OBJECTIVES:

To identify whether glycemic control is associated with health outcomes including acute coronary events, renal failure, infection, hospital length of stay, intensive care unit (ICU) admission, sepsis and mortality in noncritically ill patients administered parenteral nutrition (PN), and to compare the current standard of care for glucose monitoring at the Foothills Medical Centre (Calgary, Alberta) with the 2009 American Society of Parenteral and Enteral Nutrition guidelines.

METHODS:

A retrospective chart review of 100 adult (18 years of age or older) non-ICU inpatients who received PN for seven days or longer at the Foothills Medical Centre was conducted.

RESULTS:

Seventeen patients (17%) had a mean blood glucose level of 10.0 mmol/L or greater. PN patients with a mean blood glucose level of 10 mmol/L or greater had a higher rate of mortality than patients with a mean blood glucose level of less than 10 mmol/L (OR 7.22; 95% CI 1.08 to 48.29; P=0.042). Hyperglycemia was independently and significantly associated with mortality when adjusted for age and sex. Acute coronary events, renal failure, infection, hospital length of stay, ventilator use and ICU admissions were not associated with hyperglycemia. Only one-half of those with hyperglycemia, and none of the patients in the euglycemic group, received adequate glucose monitoring during the first two days of PN.

CONCLUSION:

Hyperglycemia in noncritically ill inpatients receiving PN was found to be a risk factor for increased mortality.     

Corticosteroid therapy in critical illness due to seasonal and pandemic influenza

BACKGROUND:

Survey data suggest that Canadian intensivists administer corticosteroids to critically ill patients primarily in response to airway obstruction, perceived risk for adrenal insufficiency and hemodynamic instability.

OBJECTIVE:

To describe variables independently associated with systemic corticosteroid therapy during an influenza outbreak.

METHODS:

The present analysis was retrospective cohort study involving critically ill patients with influenza in two Canadian cities. Hospital records were reviewed for critically ill patients treated in the intensive care units (ICUs) of eight hospitals in Canada during the 2008 to 2009 and 2009 to 2010 influenza outbreaks. Abstracted data included demographic information, symptoms at disease onset, chronic comorbidities and baseline illness severity scores. Corticosteroid use data were extracted for every ICU day and expressed as hydrocortisone dose equivalent in mg. Multivariable regression models were constructed to identify variables independently associated with corticosteroid therapy in the ICU.

RESULTS:

The study cohort included 90 patients with a mean (± SD) age of 55.0±17.3 years and Acute Physiology and Chronic Health Evaluation II score of 19.8±8.3. Patients in 2009 to 2010 were younger with more severe lung injury but similar exposure to corticosteroids. Overall, 54% of patients received corticosteroids at a mean daily dose of 343±330 mg of hydrocortisone for 8.5±4.8 days. Variables independently associated with corticosteroid therapy in the ICU were history of airway obstruction (OR 4.8 [95% CI 1.6 to 14.9]) and hemodynamic instability (OR 4.6 [95% CI 1.2 to 17.8]).

CONCLUSION:

Observational data revealed that hemodynamic instability and airway obstruction were associated with corticosteroid therapy in the critical care setting, similar to a recent survey of stated practice. Efforts to determine the effects of corticosteroids in the ICU for these specific clinical situations are warranted.     

Delayed hospital presentation in acute decompensated heart failure: Clinical and patient reported factors

Background

Patients with acute decompensated heart failure (ADHF) often wait a considerable amount of time before going to the hospital. Prior studies have examined the reasons why such delays may occur, but additional studies are needed to identify modifiable factors contributing to these delays.

Purpose

To describe care-seeking delay times, factors associated with prolonged delay, and patient's thoughts and actions in adult men and women hospitalized with ADHF.

Methods

We surveyed 1271 patients hospitalized with ADHF at 8 urban medical centers between 2007 and 2010.

Results

The average age of our study population was 73 years, 47% were female, and 72% had prior heart failure. The median duration of pre-hospital delay prior to hospital presentation was 5.3 h. Patients who delayed longer than the median were older, more likely to have diabetes, peripheral edema, to have symptoms that began in the afternoon, and to have contacted their medical provider(s) about their symptoms. Prolonged care seekers were less likely to have attributed their symptoms to ADHF, less likely to want to have bothered their doctor or family, and were more likely to be concerned about missing work due to their illness (all p values < 0.05).

Conclusions

Care-seeking delays are common among patients with ADHF. A variety of factors contribute to these delays, which in some cases may represent efforts to manage ADHF symptoms at home. More research is needed to better understand the detrimental effects of these delays and how best to encourage timely care-seeking behavior in the setting of ADHF.