ICUs worldwide: an overview of critical care medicine in South Africa

South Africa has undergone rapid changes in the political and social arenas since 1994. With new policy-makers in the Department of Health, the distribution of health care resources are being rationalised and redirected to benefit the majority of the previously disadvantaged population of the country. The role and rationalisation of intensive care medicine has to be re-evaluated to ascertain that it is at a level appropriate for a developing country. Despite progress made, the subspecialty of intensive care medicine faces challenges from changing disease patterns and from lack of human and financial resources as these are redirected to primary health care and other priorities facing the country.     

Oral care practices of intensive care nurses: A descriptive study

The aim of this study was to investigate intensive care unit (ICU) nurses’ views and practices on oral care and to define the factors related to oral care measures. A study was carried out in eight ICUs of a teaching hospital in 2008. One hundred one nurses constituted the study sample. The data were collected using ‘Oral Care Practices Survey’ which included demographic characteristics (5 items) and current oral care practices (13 items). Oral care was given the highest priority by nearly 60% of the nurses. The most commonly used solution was sodium bicarbonate (79.2%), and the most frequently used equipment was foam swab (82.2%). Oral care was carried out less than every 4 h per day by 44.5% of the nurses. The oral care products and solutions were reported to be different in almost every unit. The relationship between the use of toothpaste and the place of employment was statistically significant (x² = 24.566, d.f. = 6, P = 0.000). There was a statistical significance between the clinics and frequency of oral care (x² = 81.486, d.f. = 42, P = 0.000). This study suggests that there is a wide variety of type and frequency of oral care measures among ICU nurses. Optimal oral care supported by evidence is an effective prevention method for eliminating oral complications.     

The impact of a physician-staffed mobile intensive care unit

In the United States, mobile intensive care units (MICU) staffed by paramedical personnel are the means by which virtually all patients are transported to hospitals. However, in many other countries, MICUs are physician-staffed. The role of physicians in the MICU in delivering emergency pre-hospital care in Israel was examined. In one year's experience on a physician-attended MICU, 1,200 of 3,919 patients (31%) were definitively treated in the pre-hospital phase and not transported to a hospital facility. A careful follow-up of these patients is reported. In 235 cases death was pronounced by the MICU physician, and the patient was not transported. In 965 cases, the problem was diagnosed and the patient treated without a referral for further immediate treatment. Follow-up was obtained for 869 (90%) of these patients, of whom 843 (97%) required no additional emergency attention during the 48-hour follow-up period. The use of a physician-attended MICU reduces the service load on emergency departments.     

Influence of a dedicated paediatric cardiac intensive care unit on patient outcomes

Background: The impact of a designated intensive care unit (ICU) for postoperative cardiac care in children is not clear. In our hospital (in the USA), we started a new Paediatric Cardiac Surgery programme 5 years ago, in September 2004. During the first 2 years of the programme, postoperative care was accomplished within the general paediatric ICU (PICU or c‐ICU). Subsequently, in September 2006, a dedicated cardiac ICU (d‐ICU) was established. We looked at our experience during these two periods to determine whether the designation of a separate ICU affected outcomes for these children. Design and Methods: We obtained Institutional Review Board (IRB) approval to review the medical records for all postoperative cardiac admissions to the ICU during the first 4 years of the programme (September 2004–September 2008). Variables collected included age, gender, diagnosis, type of cardiac surgery, Risk Adjustment for Congenital Cardiac Surgery, version 1 (RACHS‐1) classification, ventilator use, hospital stay, invasive line infections, ventilator‐related infections, wound infections, need for cardiopulmonary support, return to the operating room, re‐exploration of the chest, delayed sternal closure, accidental extubations, re‐intubation and mortality rates. These variables were summed and compared for the combined PICU and the dedicated paediatric cardiac ICU. Results: There were 199 cases performed in the first 2 years compared with 244 in the following 2 years. We saw a statistically insignificant increase in the number and complexity of cases during the second period (p = 0·08). However, morbidity declined as evidenced by the decrease in wound infection (p < 0·001) and need for chest re‐exploration (p < 0·001). In addition, mortality declined from 7 of 199 (3·5%) to 2 of 244 (0·8%). p < 0·04 and less children required resuscitation (p < 0·01). Conclusions: We believe the designation of a specific area for postoperative cardiac care was instrumental in the growth and development of our cardiac programme. This rapid change accomplished several crucial elements that lead to accelerated improvement in patient care and a decline in morbidity and mortality.     

Lung ultrasound as a tool to guide respiratory physiotherapy

Lung ultrasound (LUS) is becoming an invaluable tool in the management of critically ill patients. We report two cases showing the importance of LUS as a guide to optimize respiratory physiotherapy in the intensive care unit, allowing a successful lung donation process and to redirect the physiotherapist's approach. The use of LUS requires an adequate training but it is becoming an important tool in management algorithms for critically ill patients.     

Posttraumatic Stress Symptoms in the Pediatric Intensive Care Unit

PURPOSE: Children who experience acute injury or illness severe enough to result in a pediatric intensive care unit (PICU) stay are at risk for posttraumatic stress symptoms, as are their parents. A distinction is made between injury-related traumatic events, illness-related traumatic events, and treatment-related traumatic events, all of which contribute to this risk. CONCLUSIONS: This paper reviews what the PICU experience is like for children and their parents, the emerging literature on posttraumatic stress symptoms in PICU patients and their parents, and current knowledge regarding risk and resiliency factors for these children. PRACTICE IMPLICATIONS: Children hospitalized in the PICU should be monitored for posttraumatic stress disorder during and after their stay. Risk and resiliency factors are a focus for practice and for future research.     

Clinical review: impact of emergency department care on intensive care unit costs

Critical care is both expensive and increasing. Emergency department (ED) management of critically ill patients before intensive care unit (ICU) admission is an under-explored area of potential cost saving in the ICU. Although limited, current data suggest that ED care has a significant impact on ICU costs both positive and negative. ICU practices can also affect the ED, with a lack of ICU beds being the primary reason for ED overcrowding and ambulance diversion in the USA. Earlier application in the ED of intensive therapies such as goal-directed therapy and noninvasive ventilation may reduce ICU costs by decreasing length of stay and need for admission. Future critical care policies and health services research should include both the ED and ICU in their analyses.     

Using the prone position for ventilated patients with respiratory failure: a review

Aims: This review explored the evidence relating to prone positioning in ventilated patients diagnosed with respiratory failure, including acute lung injury (ALI) or adult respiratory distress syndrome (ARDS). Background: Mortality rates for ventilated patients with ALI or ARDS are high, and there is a growing body of evidence suggesting that the position these patients are nursed in may influence clinical outcomes. However, there are no guidelines to inform nursing practice in positioning these patients. Method: Medline, Scopus, Cinahl and the Cochrane Library databases were searched for original research reports or systematic reviews of evidence between 2000 and 2009. Reference lists of retrieved papers were hand searched and included studies were analysed using the Critical Appraisal and Skills Programme framework. A narrative data synthesis considered the strengths and limitations of studies, and findings were collated and interpreted. Results: Application of the search strategy identified a systematic review, currently underway, which has not yet reported and 14 relevant studies eligible for inclusion in this review. Analysis showed considerable variation in study design, but suggests that PaO₂/FiO₂ ratio, incidence of VAP and mortality may be positively affected by prone positioning. Conclusions: Evidence of the clinical benefits associated with prone positioning is inconclusive and provides little guidance for nursing practice. There is a need for further research into the clinical outcomes of prone positioning, and greater understanding of the practicalities of prone positioning critically ill patients is required. Relevance to clinical practice: Nurses have a central role to play in the continual assessment and management of this patient group, including the position they are nursed in, not only to ensure the best clinical outcomes but also to provide care and comfort to the patient and their family. It is therefore important that their nursing practice and interventions are informed by the best available evidence.     

Reconsidering the transfer of patients from the intensive care unit to the ward: a case study approach

Evidence indicates that the poorly managed transfer of a patient from the intensive care unit (ICU) to the ward can lead to physical and psychological complications for the patient, and often require ICU readmission and rehospitalization. Reviewing this patient transfer process to improve the quality of care would be a positive step towards enhancing patients' recovery and providing skills to staff. The aim of this paper is to review case studies of transferring ICU patients to general wards in order to identify the shortcomings of this process. A literature review was conducted to evaluate current practices in the ICU transfer process. The results of this paper have clinical implications, suggest approaches to improve support for patients and their carers, and provide strategies to improve the transfer procedure.