Intensive care acquired infection is an independent risk factor for hospital mortality: a prospective cohort study

Introduction  

The aim of this study was to elucidate the impact of intensive care unit (ICU)-acquired infection on hospital mortality.     

One-year mortality among Danish intensive care patients with acute kidney injury: a cohort study

ABSTRACT: INTRODUCTION: There are few studies on long-term mortality among intensive care unit (ICU) patients with acute kidney injury (AKI). We assessed the prevalence of AKI at ICU admission, its impact on mortality during one year of follow-up, and whether the influence of AKI varied in subgroups of ICU patients. METHODS: We identified all adults admitted to any ICU in Northern Denmark (approximately 1.15 million inhabitants) from 2005 through 2010 using population-based medical registries. AKI was defined at ICU admission based on the risk, injury, failure, loss of kidney function, and end-stage kidney disease (RIFLE) classification, using plasma creatinine changes. We included four severity levels: AKI-risk, AKI-injury, AKI-failure, and without AKI. We estimated cumulative mortality by the Kaplan-Meier method and hazard ratios (HRs) using a Cox model adjusted for potential confounders. We computed estimates for all ICU patients and for subgroups with different comorbidity levels, chronic kidney disease status, surgical status, primary hospital diagnosis, and treatment with mechanical ventilation or with inotropes/vasopressors. RESULTS: We identified 30,762 ICU patients, of which 4,793 (15.6%) had AKI at ICU admission. Thirty-day mortality was 35.5% for the AKI-risk group, 44.2% for the AKI-injury group, and 41.0% for the AKI-failure group, compared with 12.8% for patients without AKI. The corresponding adjusted HRs were 1.96 (95% confidence interval (CI) 1.80-2.13), 2.60 (95% CI 2.38 to 2.85) and 2.41 (95% CI 2.21 to 2.64), compared to patients without AKI. Among patients surviving 30 days (n = 25,539), 31- to 365 day mortality was 20.5% for the AKI-risk group, 23.8% for the AKI-injury group, and 23.2% for the AKI-failure group, compared with 10.7% for patients without AKI, corresponding to adjusted HRs of 1.33 (95% CI 1.17 to 1.51), 1.60 (95% CI 1.37 to1.87), and 1.64 (95% CI 1.42 to 1.90), respectively. The association between AKI and 30-day mortality was evident in subgroups of the ICU population, with associations persisting in most subgroups during the 31- to 365-day follow-up period, although to a lesser extent than for the 30-day period. CONCLUSIONS: AKI at ICU admission is an important prognostic factor for mortality throughout the subsequent year.     

Evaluation of a nurse-led education program to improve cross-cultural care for older people in aged care

BackgroundCultural diversity is significant in aged care facilities. Registered nurses play a leading role in the care setting. Nurse-led education interventions to improve the cultural competence of aged care workers are in high demand.AimThe aims of the study were to evaluate the effect of a nurse-led cross-cultural care program on cultural competence of Australian and overseas-born care workers.DesignA pre- and post-evaluation design and a sub-group analysis.Settings and participantsThis study was undertaken in four large-sized aged care facilities in Australia. Direct care workers were invited to participate in the study.MethodsThe intervention lasted 12 months. Data were collected at baseline, 6 months and 12 months using the Clinical Cultural Competency Questionnaire and site champion reports. One-way ANOVA was applied to determine the changes of outcomes over time for the whole group. A mixed effect linear regression model was applied in the sub-group analyses to compare the differences of outcomes between the Australian-born and overseas-born groups.ResultsOne hundred and thirteen staff participated in the study including Australian-born (n = 62) and overseas-born (n = 51). Registered nurses were trained as site champions to lead the program. The results showed a statistically significant increase in participants' scores in Knowledge (p = .000), Skills (p = .000), Comfort Level (p = .000), Importance of awareness (p = .01) and Self-Awareness (p = .000) in a 12-month follow-up. The increased scores in the Skills (p = .02) and Comfort Level (p = .001) were higher in the Australian-born group compared to the overseas-born group. The results also showed a statistically significant increase in participants' overall satisfaction scores with the program at 12 months (p = .009). The overseas-born group demonstrated a higher score in Desire to Learn More (p = .016) and Impact of the Program on Practice (p = .014) compared to the Australian-born group.ConclusionA nurse-led cross-cultural care program can improve aged care workers' cultural competence.     

Sequelae after infection with Trichinella spiralis: a prospective cohort study

It is still a matter of debate whether or not infection with Trichinella spiralis is followed by long lasting sequelae. A common source epidemic of trichinosis which occurred in Bitburg, FRG, in October 1982 gave us the opportunity of performing a controlled cohort study (171 patients and 51 controls). 145 patients and 44 controls completed the 3 year follow-up. Complaints persisted in 36% of patients aged less than 30 years and in 100% of patients aged greater than 50 years. Complaints in order of frequency were: muscular complaints 84%, ocular complaints 63%, cardiac complaints 48%, cephalgia 43%, neurological complaints 35%, gastrointestinal complaints 18%, m fatigue and weakness 18%, oedema 12% and fever less than 1%. IgG antibodies to T. spiralis were still present in all but 5 patients 3 years after infection. IgM antibodies were either low or absent. In our patients the frequency and pattern of complaints and the correlation to the specific antibody response provide evidence that trichinosis causes long-lasting disease. Yet, from our data we were unable to draw conclusions as to the causative pathophysiological mechanisms.     

Prehospital management of the difficult airway: a prospective cohort study

The role of prehospital endotracheal intubation (ETI) remains controversial, with significant national variability in practice. The purpose of this project was to evaluate ETI management in a system of advanced life support (ALS) providers experienced in ETI and other advanced airway techniques, and describe management and outcomes of patients with a "difficult airway." Data were collected prospectively for all ETIs performed by the fire department over a 4-year period (2001-2005), and included demographics, number of laryngoscopy attempts, airway procedures, complications, and outcomes. Of 80,501 ALS patient contacts, 4091 (5.1%) underwent attempted oral ETI, with a 96.8% success rate in four or fewer attempts. The difficult airway cohort included 130 patients (3.2%), whose airway management consisted of oral ETI after more than four attempts (46%), bag-valve-mask ventilation (33%), cricothyroidotomy (8%), retrograde ETI (5%), and digital ETI (1%). Procedural success rates ranged from 14% (digital ETI) to 91% (cricothyroidotomy). Nine patients (7%) had failed airway management, of whom 5 were found in cardiac arrest. The two most common reasons subjectively reported by ALS providers for airway difficulty were anterior trachea (39%) and small mouth (30%). Overall mortality for the difficult airway cohort was 44%. Prehospital ETI can be performed with a high success rate by experienced ALS providers, but may still require advanced airway techniques in a small subset of patients. Patient anatomy is a primary factor in failed ETI. Among the advanced procedures, cricothyroidotomy had the highest success rate and should not be delayed by other interventions.     

Migraine and coronary heart disease mortality: a prospective cohort study

A recent population-based prospective study reported that in women, migraine with aura (MA), but not migraine without aura (MoA), was associated with increased risk of coronary heart disease events (CHD). We sought to confirm this association in an Australian population-based cohort of older men and women (n = 2331, aged 49-97 years). We defined MA and MoA from face-to-face interview using International Headache Society criteria. Over a mean 6-year follow-up, 30 women (2.8%) and 30 men (4.4%) without any prior CHD history died from CHD-related causes. In women, a history of MA was associated with a non-significant twofold higher risk of CHD death (age-adjusted relative risk 2.2, 95% confidence interval 0.8, 5.8, P = 0.11), which remained similar after adjustment for cardiovascular risk factors. There were no CHD deaths in men with a history of migraine. Our findings support reports that in women, MA, but not MoA, may be associated with increased risk of CHD.     

Impact of compliance with infection management guidelines on outcome in patients with severe sepsis: a prospective observational multi-center study

Introduction

Current sepsis guidelines recommend antimicrobial treatment (AT) within one hour after onset of sepsis-related organ dysfunction (OD) and surgical source control within 12 hours. The objective of this study was to explore the association between initial infection management according to sepsis treatment recommendations and patient outcome.

Methods

In a prospective observational multi-center cohort study in 44 German ICUs, we studied 1,011 patients with severe sepsis or septic shock regarding times to AT, source control, and adequacy of AT. Primary outcome was 28-day mortality.

Results

Median time to AT was 2.1 (IQR 0.8 – 6.0) hours and 3 hours (-0.1 – 13.7) to surgical source control. Only 370 (36.6%) patients received AT within one hour after OD in compliance with recommendation. Among 422 patients receiving surgical or interventional source control, those who received source control later than 6 hours after onset of OD had a significantly higher 28-day mortality than patients with earlier source control (42.9% versus 26.7%, P <0.001). Time to AT was significantly longer in ICU and hospital non-survivors; no linear relationship was found between time to AT and 28-day mortality. Regardless of timing, 28-day mortality rate was lower in patients with adequate than non-adequate AT (30.3% versus 40.9%, P < 0.001).

Conclusions

A delay in source control beyond 6 hours may have a major impact on patient mortality. Adequate AT is associated with improved patient outcome but compliance with guideline recommendation requires improvement. There was only indirect evidence about the impact of timing of AT on sepsis mortality.     

Clinical outcomes of a nurse-led post-discharge education program for heart-transplant recipients: A retrospective cohort study

BackgroundAdvances in immunosuppressive therapeutics and medical technology have improved survival rates after heart transplantation. Although there is a rigorous schedule of outpatient visits and testing to detect early signs of rejection and other complications in the first year after transplantation, repeated unplanned readmissions of heart transplant recipients remains a challenge.ObjectiveThis study aimed to compare the effects of specialized nurse-led discharge education, including continuous post-transplant education and counselling, on heart transplant recipients' clinical outcomes, with the effects of existing discharge education.MethodsParticipants were 136 heart transplantation recipients at a university-affiliated hospital in South Korea from November 1, 1994, to November 30, 2018. Participants' electronic medical records were retrospectively analyzed. Participants were grouped according to usual care (n = 25), nurse-led program (n = 66), and nurse-led program with post-discharge education (n = 45). We assessed the number of outpatient visits with clinical problems and days to first unplanned rehospitalization within one year after transplantation.ResultsThe nurse-led program with post-discharge education was associated with significantly reduced outpatient visits with clinical problems, compared to usual care and the existing nurse-led program. We also found a significantly longer time until first unplanned rehospitalization in the nurse-led program with post-discharge education group, compared to the usual care group.ConclusionThis study identified the heart transplantation-specialized nurse-led discharge and subsequent post-discharge education as an effective strategy for positive clinical outcomes within one year after heart transplantation.     

Preadmission beta-blocker use and 30-day mortality among patients in intensive care: a cohort study

Introduction  

Beta-blockers have cardioprotective, metabolic and immunomodulating effects that may be beneficial to patients in intensive care. We examined the association between preadmission beta-blocker use and 30-day mortality following intensive care.     

The effectiveness of nurse-led care in people with rheumatoid arthritis: a systematic review

Objectives

The objective of this systematic review was to determine the effectiveness of nurse-led care in rheumatoid arthritis.

Design

Systematic review of effectiveness.

Data sources

Electronic databases (AMED, CENTRAL, CINAHL, EMBASE, HMIC, HTA, MEDLINE, NHEED, Ovid Nursing and PsycINFO) were searched from 1988 to January 2010 with no language restrictions. Inclusion criteria were: randomised controlled trials, nurse-led care being part of the intervention and including patients with RA.

Review methods

Data were extracted by one reviewer and checked by a second reviewer. Quality assessment was conducted independently by two reviewers using the Cochrane Collaboration's Risk of Bias Tool. For each outcome measure, the effect size was assessed using risk ratio or ratio of means (RoM) with corresponding 95% confidence intervals (CI) as appropriate. Where possible, data from similar outcomes were pooled in a meta-analysis.

Results

Seven records representing 4 RCTs with an overall low risk of bias (good quality) were included in the review. They included 431 patients and the interventions (nurse-led care vs usual care) lasted for 1-2 years. Most effect sizes of disease activity measures were inconclusive (DAS28 RoM = 0.96, 95%CI [0.90-1.02], P = 0.16; plasma viscosity RoM = 1 95%CI [0.8-1.26], p = 0.99) except the Ritchie Articular Index (RoM = 0.89, 95%CI [0.84-0.95], P < 0.001) which favoured nurse-led care. Results from some secondary outcomes (functional status, stiffness and coping with arthritis) were also inconclusive. Other outcomes (satisfaction and pain) displayed mixed results when assessed using different tools making them also inconclusive. Significant effects of nurse-led care were seen in quality of life (RAQoL RoM = 0.83, 95%CI [0.75-0.92], P < 0.001), patient knowledge (PKQ RoM = 4.39, 95%CI [3.35-5.72], P < 0.001) and fatigue (median difference = −330, P = 0.02).

Conclusions

The estimates of the primary outcome and most secondary outcomes showed no significant difference between nurse-led care and the usual care. While few outcomes favoured nurse-led care, there is insufficient evidence to conclude whether this is the case. More good quality RCTs of nurse-led care effectiveness in rheumatoid arthritis are required.     

Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study

Introduction  

When the number of patients who require intensive care is greater than the number of beds available, intensive care unit (ICU) entry flow is obstructed. This phenomenon has been associated with higher mortality rates in patients that are not admitted despite their need, and in patients that are admitted but are waiting for a bed. The purpose of this study is to evaluate if a delay in ICU admission affects mortality for critically ill patients.     

Self-rated coping styles and registered sickness absence among nurses working in hospital care: a prospective 1-year cohort study

Background

Sickness absence is an important problem in healthcare that affects the quality of care. Sickness absence has been related to coping strategies. Problem-focused coping was shown to be associated with low sickness absence and emotion-focused coping with high sickness absence among postal workers.

Objectives

This study investigated the relationship between coping styles and sickness absence in healthcare.

Design

Prospective study linking self-rated coping styles at baseline with the number of episodes of sickness absence during one year of follow-up.

Setting

Somatic hospital employing 1153 persons.

Participants

Convenience sample of 566 female nurses working in the hospital's clinical wards and outpatient clinic. Of these, 386 (68%) nurses had complete data for analysis.

Methods

The nurses completed a questionnaire at baseline with items on health, work, and coping styles. Three styles of coping were defined: problem-solving coping (i.e., looking for opportunities to solve a problem), social coping (i.e., seeking social support in solving a problem), and palliative avoidant coping (i.e., seeking distraction and avoiding problems). Sickness absence data were retrieved from the hospital's register in the following year. The association between the coping styles and the number of both short (1-7 days) and long (>7 days) episodes of sickness absence was assessed by Poisson regression analyses with age, work hours per week, general health, mental health, and effort-reward [ER] ratio as covariates.

Results

Problem-solving coping was negatively associated with the number of long episodes of sickness absence (rate ratio [RR] = 0.78, 95% confidence interval [CI] = 0.64-0.95). Social coping was negatively associated with the number of both short episodes (RR = 0.88, 95% CI = 0.79-0.97) and long episodes (RR = 0.79, 95% CI = 0.64-0.97) of sickness absence. After adjustment for the ER-ratio, the associations of coping with short episodes of sickness absence strengthened and associations with long episodes weakened, however, significance was lost for both types of sickness absence. Palliative avoidant coping was not associated with sickness absence among female hospital nurses.

Conclusion

Problem-solving coping and social coping styles were associated with less sickness absence among female nurses working in hospital care. Nurse managers may use this knowledge and reduce sickness absence and understaffing by stimulating problem-solving strategies and social support within nursing teams.     

个案管理护理实践对改善乳腺癌患者生活质量的效果研究

目的 探讨个案管理护理实践对改善乳腺癌患者生活质量的效果.方法 按所在病区将90例乳腺癌术后患者分为试验组和对照组各45例,试验组接受为期6个月的个案管理护理实践,对照组接受常规护理和随访.分别在术后第1个月、3个月和6个月进行生活质量各指标的测量,并采用重复测量方差分析和多因素方差分析,对各测量指标在半年中的变化及趋势进行统计学分析.结果 试验组患者生活质量总体优于对照组,除婚姻关系维度效果不显著外,两组在各维度3个时间点测量值间的差异均有统计学意义(P＜0.05).结论 个案管理护理实践能够改善乳腺癌患者的生活质量,针对乳腺癌患者应有条件地开展个案管理.     

Continuity of care is good for elderly people with diabetes: retrospective cohort study of mortality and hospitalization

Objective

To examine the relationship between continuity of family physician care and all-cause mortality and acute hospitalizations in older people with diabetes.

Design

Retrospective cohort study of administrative health databases. Continuity of family physician care for elderly patients newly diagnosed with diabetes was estimated by 3 continuity indexes using physician claims data. The relationship of continuity of family physician care to mortality and acute hospitalizations was investigated.

Setting

The province of Newfoundland and Labrador.

Participants

A total of 305 family practice patients 65 years of age or older with diabetes.

Main outcome measures

Death rate and hospitalization rate during a 3-year period.

Results

Overall, continuity of family physician care was high. In the 3 years examined, the higher-continuity group had lower rates of hospitalization (53.5% vs 68.2%) and death (8.6% vs 18.5%) than the lower-continuity group.

Conclusion

The findings suggest an association between higher continuity of family physician care and reductions in likelihood of death and hospitalizations in older people with diabetes.     

Changes in vital signs as predictors of bacterial infection in home care: a multi-center prospective cohort study

Objectives: To explore whether the combination of changes in heart rate and body temperature can predict bacterial infection in home care patients.

Methods: This multicenter, prospective cohort study was conducted in Japan from March 2012 through December 2013 and involved three clinics. The study population comprised all patients who received regular home visit services for at least 3 months and met one of the following inclusion criteria: 1) fever over 37.5°C at home visit, 2) physician’s clinical suspicion of fever, or 3) physician’s suspicion of bacterial infection. We collected temperature and heart rate data on the day of enrollment, and determined the probable causes of fever after treatment of febrile episodes. We defined the combination of changes in heart rate and body temperature as delta HR/BT. We calculated two types of delta HR/BT, averaged and assumed, using different baseline values for heart rate and body temperature.

Results: A total of 124 patients were enrolled and 194 episodes of fever were analyzed during the study period. The sensitivity, specificity, positive predictive value, and negative predictive value for the average delta HR/BT with a cut-off ≥ 20 were 20.4% (95% CI, 16.7–23.3), 84.2% (95% CI, 75.2–91.0), 75.7% (95% CI, 61.8–86.2), and 30.6% (95% CI, 27.3–33.0), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the assumed delta HR/BT with a cut-off ≥ 5 was 91.2% (95% CI, 89.2–94.0), 8.9% (95% CI, 4.1–15.7), 70.9% (95% CI, 69.3–73.0), and 29.4% (95% CI, 13.6–51.8), respectively.

Conclusions: The combination of changes in heart rate and body temperature could help physicians determine whether home care patients have bacterial infections.     

Nucleated red blood cells in the blood of medical intensive care patients indicate increased mortality risk: a prospective cohort study

Introduction  

In critically ill patients, the appearance of nucleated red blood cells (NRBCs) in blood is associated with a variety of severe diseases. Generally, when NRBCs are detected in the patients' blood, the prognosis is poor.