Rating the quality of intensive care units: is it a function of the intensive care unit scoring system?

OBJECTIVE: Intensive care units (ICUs) use severity-adjusted mortality measures such as the standardized mortality ratio to benchmark their performance. Prognostic scoring systems such as Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score II, and Mortality Probability Model II0 permit performance-based comparisons of ICUs by adjusting for severity of disease and case mix. Whether different risk-adjustment methods agree on the identity of ICU quality outliers within a single database has not been previously investigated. The objective of this study was to determine whether the identity of ICU quality outliers depends on the ICU scoring system used to calculate the standardized mortality ratio. DESIGN, SETTING, PATIENTS: Retrospective cohort study of 16,604 patients from 32 hospitals based on the outcomes database (Project IMPACT) created by the Society of Critical Care Medicine. The ICUs were a mixture of medical, surgical, and mixed medical-surgical ICUs in urban and nonurban settings. Standardized mortality ratios for each ICU were calculated using APACHE II, Simplified Acute Physiology Score II, and Mortality Probability Model II. ICU quality outliers were defined as ICUs whose standardized mortality ratio was statistically different from 1. Kappa analysis was used to determine the extent of agreement between the scoring systems on the identity of hospital quality outliers. The intraclass correlation coefficient was calculated to estimate the reliability of standardized mortality ratios obtained using the three risk-adjustment methods. MEASUREMENTS AND MAIN RESULTS: Kappa analysis showed fair to moderate agreement among the three scoring systems in identifying ICU quality outliers; the intraclass correlation coefficient suggested moderate to substantial agreement between the scoring systems. The majority of ICUs were classified as high-performance ICUs by all three scoring systems. All three scoring systems exhibited good discrimination and poor calibration in this data set. CONCLUSION: APACHE II, Simplified Acute Physiology Score II, and Mortality Probability Model II0 exhibit fair to moderate agreement in identifying quality outliers. However, the finding that most ICUs in this database were judged to be high-performing units limits the usefulness of these models in their present form for benchmarking.     

Stakeholders’ perceptions of family-centred care in the intensive care unit: An associative group analysis

AimTo explore different stakeholders’ including nurses, health care professionals and family member’s perceptions of ideal family-centred care in an intensive care unit.Research design and methodsWe used a mixed method approach to identify perceptions of family-centred care with 60 stakeholders of equal numbers who voluntarily participated in the study. Data were collected over one month using an associative group analysis method. The responses were ranked, scored, thematically themed and weighted.SettingA 23 bed adult intensive care unit in an urban private hospital in South Africa.FindingsAccording to the stakeholders’ responses, ideal family-centred care should be built around communication based on expectations and engagement. In addition, the physical environment should allow for overall comfort and spiritual care must be incorporated.ConclusionStakeholders had similar perceptions on the main themes however; nuances of different perspectives were identified showing some of the complexities related to family-centred care. Spiritual care was highlighted by the family members, revealing the need to broaden the care perspectives of healthcare providers.     

The effects of chlorhexidine gluconate bathing on health care–associated infection in intensive care units: A meta-analysis

PurposeThe purpose was to assess the effects of chlorhexidine gluconate (CHG) bathing on health care–associated infections among critically ill patients.MethodsThis meta-analysis evaluated English-language studies from the PubMed, Embase, and Cochrane databases. The Cochrane Collaboration methodology was used to evaluate all publications regarding daily CHG bathing and the risks of acquiring central line–associated bloodstream infection (CLABSI), methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE). Risk ratios (RRs) and the ratio of the log RRs (RRR) were estimated with 95% confidence intervals (CIs).ResultsEighteen studies were included. Compared with conventional care, the RRs (95% CIs) for CLABSI, MRSA, and VRE with CHG bathing were 0.45 (0.37-0.55), 0.67 (0.59-0.77), and 0.60 (0.42-0.85), respectively (all, P < .05). For MRSA acquisition, CHG bathing with concomitant nasal antibiotics provided a lower incidence compared with only CHG bathing (RRR: 0.81, 95% CI: 0.66-0.98, P = .035). Greater risk reduction was also observed in studies with prolonged interventions (RRR per 1-month extension: − 0.02, P = .027).ConclusionsDaily CHG bathing was associated with reduced risks of acquiring CLABSI, MRSA, and VRE. A prolonged intervention period and concomitant nasal antibiotic use were associated with lower risks of MRSA acquisition.     

Patients’ characterization, hospital course and clinical outcomes in five Italian respiratory intensive care units

Background

Respiratory intensive care units (RICU) dedicated to weaning could be suitable facilities for clinical management of “post-ICU” patients.

Methods

We retrospectively analyzed the time course of patients’ characteristics, clinical outcomes and medical staff utilization in five Italian RICUs by comparing three periods of 5 consecutive years (from 1991 to 2005).

Results

A total of 3,106 patients (age 76 ± 4 years; 72% males) were analyzed. The number of co-morbidities per patient (from 1.8 to 3.0, p = 0.05) and the previous intensive care unit (ICU) stay (from 25 to 32 days, p = 0.002) increased over time. The doctor-to-patient ratio significantly decreased over time (from 1:3 to 1:5, p < 0.01), whereas the physiotherapist-to-patient ratio mildly increased (from 1:6 to 1:4.5, p < 0.05). The overall weaning success rate decreased (from 87 to 66%, p < 0.001), and the discharge destination changed (p < 0.001) over time; fewer patients were discharged to home (from 22 to 10%), and more patients to nursing home (from 3 to 6%), acute hospitals (from 6 to 10%) and rehabilitative units (from 70 to 75%). The mortality rate increased over time (from 9 to 15%). Significant correlations between the doctor-to-patient ratio and the rates of weaning success (r = 0.679, p = 0.005), home discharge (r = 0.722, p = 0.002) and the RICU length of stay (LOS) (r = ?0.683, p = 0.005) were observed.

Conclusions

The clinical outcomes of our units worsened over 15 years, likely as consequence of admitting more severely ill patients. The potential further negative influence of reduced medical staff availability on weaning success, home discharge and LOS warrants future prospective investigations.     

“Noise Factory”: A qualitative study exploring healthcare providers’ perceptions of noise in the intensive care unit

ObjectivesThis study aimed to explore healthcare providers’ perceptions of noise in the intensive care unit.DesignA qualitative exploratory study was conducted using group interviews.SettingThe setting comprised a total of 15 participants (five physicians and ten registered nurses) working in an 18-bed medical surgical intensive care unit at a teaching hospital in Istanbul, Turkey. Semi-structured questions were formulated and used in focus group interviews, after which the recorded interviews were transcribed by the researchers. Thematic analysis was used to identify significant statements and initial codes.FindingsFour themes were identified: the meaning of noise, sources of noise, effects of noise and prevention and management of noise. It was found that noise was an inevitable feature of the intensive care unit. The most common sources of noise were human-induced. It was also determined that device-induced noise, such as alarms, did not produce a lot of noise; however, when staff were late in responding, the sound transformed into noise. Furthermore, it was observed that efforts to decrease noise levels taken by staff had only a momentary effect, changing nothing in the long term because the entire team failed to implement any initiatives consistently. The majority of nurses stated that they were now becoming insensitive to the noise due to the constant exposure to device-induced noise.ConclusionThe data obtained from this study showed that especially human-induced noise threatened healthcare providers’ cognitive task functions, concentration and job performance, impaired communication and negatively affected patient safety. In addition, it was determined that any precautions taken to reduce noise were not fully effective. A team approach should be used in managing noise in intensive care units with better awareness.     

Quality assessment in intensive care units: proposal for a scoring system in terms of structure and process

Objective We present a score for assessing the quality of ICU care in terms of structure and process, based on bibliographic review, expert consultations, field test, analysis, and final consensus, and analyze its initial application in the field. Design and setting This feasibility and observational study was conducted within the framework of a French regional clinical research project (NosoQual); 40 ICUs were visited and assessed between November 2002 and March 2003 according to standardized procedures. Measurements and results The grid consisted of 95 variables. The overall score derived from seven independent quality dimensions: human resources, architecture, safety and environment, management of documentation, patient care management, risk management of infections and evaluation, and surveillance. The average level of achievement of the scores varied from 48% to 63% of theoretical maxima. Variability in the individual dimensional subscores was greater than that of the overall score (CV = 0.15). Conclusions Evaluation this scoring system encounters the limitation of the absence of a “gold standard.” However, this is counterbalanced by the rigorous design methodology, the characteristic strengths of the quality dimensions. The survey also highlights also feasibility and the potential interest for specific tools for the assessment of ICUs. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Professional nurses’ facilitation of self-care in intensive care units: A concept analysis

ObjectiveThis article aims to provide an in-depth analysis of the concept of self-care in the intensive care unit and outline its defining attributes, antecedents, consequences and empirical referents.MethodsThe literature was searched electronically using databases such as CINAHL, Medline, Psych INFO, ERIC, ScienceDirect, Amed, EBSCO (Health Source: Nursing and Academic Edition), Sage, Ujoogle and Google Scholar. Articles from 2013 to 2020 were searched to target recent and up-to-date information about the definitions, attributes, antecedents and consequences of the concept of self-care. Walker and Avant’s framework was utilised to analyse the concept of self-care.ResultsThe results of the concept analysis identified seven attributes, namely process, activity, capability, autonomous choice, education, self-control and interaction. The seven identified antecedents are self-motivation, participation, commitment, resources, religious and cultural beliefs, social, spiritual and professional support, and the availability of time. The consequences are the maintenance of health and wellbeing, autonomy, increased self-esteem, disease prevention, empowerment, increased social support and the ability to cope with stress.ConclusionsThe result of the concept analysis was used to describe a model to facilitate professional nurses’ self-care in the intensive care unit.     

Effectiveness of cognitive-behavioral counseling on the mental health of premature infants’ mothers in neonatal intensive care unit

Introductionand Purpose: Mental health of mothers at the time of birth of premature infants is one of the important factors in the mental health of children and stability of their families. Maternal mental disorders impose heavy burdens on the second generation and the community. Due to psychological and emotional sensitivities, women are more susceptible than men to psychological injuries such as depression, anxiety, and other disorders during their children's sever problems. In such a situation, mothers can no longer establish a normal relationship with their children and the fear of taking care of premature hospitalized neonates leads to these disorders. Counseling with mothers at the time of hospitalization may help to improve their mental health. Therefore, the present study was done to investigate the effect of cognitive-behavioral counseling on the mental health of mothers with premature infants in Neonatal Intensive Care Unit.MethodThis study was a clinical trial conducted on 50 mothers with premature infants in neonatal intensive care unit of Zeinabiyyeh Hospital of Shiraz in 2016-2017. Through purposive sampling, mothers who agreed to attend the sessions and fulfilled the inclusion criteria, were randomly assigned to the control and intervention group. Goldberg-Hiller Questionnaire was used to measure their general mental health. The data were analyzed using SPSS Software Version 19.ResultsThe results showed that there was no significant difference between the control and intervention group before the counseling with regard to mean mental health scores and its subscales. After the intervention, a significant difference was observed between physical symptoms and anxiety/insomnia subscales and total mental health scores but no difference was observed with regard to social function and depression dimensions between two groups.ConclusionCognitive-behavioral counseling improved mental health and subscales of physical symptoms, anxiety/insomnia of mothers under study. This method can be used to improve the acute negative effects on the mental health of mothers with premature infants in neonatal intensive care units (NICU)s.     

The use of family nurse practitioners and pediatric nurse practitioners as providers of neonatal intensive care: Safe practice or risky business?

Neonatal nurse practitioners (NNPs) have shown their worth as caregivers in the neonatal intensive care unit. Changes in the health care system, including increasingly complex technology, census growth, decreasing support for residency programs, and reductions in the amount of intensive care training for pediatric residents, have placed a burden on neonatal intensive care units. These changes have resulted in a greater demand for NNPs. There are currently 35 graduate programs for NNPs in the United States, which leaves many geographical areas educationally underserved. Thus, there are too few NNPs to address critical staffing problems. To fill this need, it has become common for family nurse practitioners (FNPs) and pediatric nurse practitioners (PNPs) to function in the NNP role. There are no references in the current literature to support or oppose this practice. Although FNPs and PNPs are advanced practice nurses, the belief that they are adequate substitutes for NNPs in the acute care neonatal setting is fraught with misconception. This article discusses the ethical and legal implications posed by issues surrounding role definition, educational preparation, specialty certification and credentialing, and scope of practice of FNPs and PNPs in the neonatal intensive care unit. Copyright © 2001 by W.B. Saunders Company     

Evaluation of nurses’ workload in intensive care unit of a tertiary care university hospital in relation to the patients’ severity of illness: A prospective study

BackgroundsCosts of intensive care reach up to 30% of the hospital budget with workforce expenses being substantial. Determining proper nurse—patient ratio is necessary for optimizing patients’ health related outcomes and hospitals’ cost effective functioning.ObjectivesTo evaluate nurses’ workload using Nine Equivalents of Nursing Manpower Use Score and Nursing Activities Score scoring systems while assessing correlation between both scores and the severity of illness measured by Simplified Acute Physiology Score II.DesignA Prospective studySettingsCardiac Surgery Intensive Care Unit of the Clinical Hospital Centre Rijeka, Croatia, from October 2014 to February 2015. This Intensive Care Unit has 3 beds that can be expanded upon need.ParticipantsThe study included 99 patients treated at this Unit during the study’s period. The scores were obtained by 6 nurses, working in 12 h shifts.MethodsMeasurements were obtained for each patient 24 h after admission and subsequently twice a day, at the end of the day shift (7 pm) and at the end of the night shift (7 am). The necessary data were obtained from the patient’s medical records.ResultsNursing Activities Score showed significantly higher number of nurses are required for one 12 h shift (Z = 3.76, p < 0.001). Higher scores were obtained on day shifts vs. night shifts. (Nursing Manpower Use Score, z = 3.25, p < 0.001; Nursing Activities Score, z = 4.16, p < 0.001). When comparing Nursing Activities Score and Nursing Manpower Use Score during the week, we calculated higher required number of nurses on weekdays than on weekends and holidays, (Nursing Manpower Use Score, p < 0.001; Nursing Activities Score, p < 0.001). Correlation analysis of Nursing Activities Score and Nursing Manpower Use Score with Simplified Acute Physiology Score II has shown that Nursing Manpower Use Score positively associated with severity of disease, while Nursing Activities Score shows no association.ConclusionBoth scores can be used to estimate required number of nurses in 12-h shifts, although Nursing Activities Score seems more suitable for units with prolonged length of stay, while Nursing Manpower Use Score appears better for units with shorter duration of stay (up to four days). Higher workload measured by Nursing Manpower Use Score scale can be predicted with higher Simplified Acute Physiology Score II. However, with low Simplified Acute Physiology Score II scores it cannot be assumed that the nursing workload will also be low. Further research is needed to determine the best tool to asses nursing workload in intensive care units.     

The impact of family centred care interventions in a neonatal or paediatric intensive care unit on parents’ satisfaction and length of stay: A systematic review

ObjectiveTo explore the impact of family centred care interventions on parents’ satisfaction and length of stay for patients admitted to a paediatric intensive care unit or a neonatal intensive care unit.MethodsA systematic review was conducted. Searches have been done in Cinahl, Cochrane, Embase and PubMed from February 2016 till October 2017. All included studies were quality appraised. Due to the heterogeneity of interventions findings were narratively reviewed.ResultsSeventeen studies were included in this review of which 12/17 studies investigated parents’ satisfaction and 7/17 length of stay. For this review two types of interventions were found. Interventions improving parents-professional collaboration which increased parents’ satisfaction, and interventions improving parents’ involvement which decreased length of stay. Overall quality of the included studies was weak to good.ConclusionsStrong evidence was found for a significant decrease in length of stay when parents where participating in caring for their infant in a neonatal intensive care unit. Moderate evidence was found in parents’ satisfaction, which increased when collaboration between parents and professionals at a neonatal intensive care unit improved. Studies performed in a paediatric intensive care setting were of weak to moderate quality and too few to show evidence regarding parents satisfaction and length of stay.     

Too much too soon? The risk of ‘overuse’ injuries in young football players

The risk of overuse injuries in elite young players due to ‘overplay’ has been a topic for discussion by many medical professionals across a wide range of sports. The results of medical examinations of young elite players seeking entry to The Football Association National School for two intakes, 1992 and 1993, are reported and the precautions and subsequent actions taken by The Football Association as a consequence of the findings.