Nursing Activities Score in the intensive care unit: analysis of the related factors.

BACKGROUND: High costs of intensive care as well as quality of care and patient safety demand measurement of nursing workload in order to determine nursing staff requirements. It is also important to be aware of the factors related to high patient care demands in order to help forecast staff requirements in intensive care units (ICUs). OBJECTIVES: To describe nursing workload using the Nursing Activities Score (NAS); to explore the association between NAS and patients variables, i.e. gender, age, length of stay (LOS), ICU discharge, treatment in the ICU, Simplified Acute Physiology Score II (SAPS II) and Therapeutic Interventions Scoring System-28 (TISS-28). METHODS: NAS, demographic data, SAPS II and TISS-28 were analysed among 200 patients from four different ICUs in a private hospital in S?o Paulo, Brazil. RESULTS: NAS median were 66.4%. High NAS scores (> 66.4%) were associated with death (p-value 0.006) and LOS (p-value 0.015). Logistic regression analysis demonstrated that TISS-28 scores above 23 and SAPS II scores above 46.5 points, classified as high, increased 5.45 and 2.78 times, respectively, the possibility of a high workload as compared to lower values of the same indexes. CONCLUSION: This study shows that the highest NAS scores were associated with increased mortality, LOS, severity of the patient illness (SAPS II), and particularly to TISS-28 in the ICU.     

Commentary: Hillman K, Chen J, et al. (2005). Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial

Patients with cardiac arrests or who die in general wards have often received delayed or inadequate care. We investigated whether the medical emergency team (MET) system could reduce the incidence of cardiac arrests, unplanned admissions to intensive care units (ICU) and deaths. We randomized 23 hospitals in Australia to continue functioning as usual (n= 11) or to introduce a MET system (n= 12). The primary outcome was the composite of cardiac arrest, unexpected death or unplanned ICU admission during the 6‐month study period after MET activation. Analysis was by intention to treat. Introduction of the MET increased the overall calling incidence for an emergency team (3·1 versus 8·7 per 1000 admissions, p= 0·0001). The MET was called to 30% of patients who fulfilled the calling criteria and who were subsequently admitted to the ICU. During the study, we recorded similar incidence of the composite primary outcome in the control and MET hospitals (5·86 versus 5·31 per 1000 admissions, p= 0·640), as well as of the individual secondary outcomes (cardiac arrests, 1·64 versus 1·31, p= 0·736; unplanned ICU admissions, 4·68 versus 4·19, p= 0·599; and unexpected deaths, 1·18 versus 1·06, p= 0·752). A reduction in the rate of cardiac arrests (p= 0·003) and unexpected deaths (p= 0·01) was seen from baseline to the study period for both groups combined. The MET system greatly increases emergency team calling but does not substantially affect the incidence of cardiac arrest, unplanned ICU admissions or unexpected death. Abstract reprinted from the The Lancet volume 365, Hillman K et al., ‘Introduction of the medical emergency team (MET) system…’, pages 2091–7. © 2005, with permission from Elsevier.     

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.     

Commentary: Knowles RE, Tarrier N (2009). Evaluation of the effect of prospective patient diaries on emotional well-being in intensive care unit survivors: a randomized control trial

Objective: To evaluate the effect of a prospective diary intervention on levels of anxiety and depression in a group of intensive care unit (ICU) survivors. Design: Pragmatic randomized controlled trial. Setting: Adult ICU, medical/surgical wards of a district general hospital and community bases. Patients: A total of 36 patients who were admitted to the ICU between March 2006 and March 2007 for a minimum of 48 h. Interventions: Prospective diary kept by nursing staff for the duration of the patient’s stay on ICU, containing daily information about their physical condition, procedures and treatments, events occurring on the unit, and significant events from outside the unit. Measurement and main results: At initial assessment, almost half of patients fell into the ‘disorder likely’ category on the Hospital Anxiety and Depression Scale (44% for anxiety and 47·2% for depression). Paired samples Student’s t‐tests to compare the Hospital Anxiety and Depression Scale scores at time 1 and time 2 in the two participant groups revealed that the experimental group displayed statistically significant decreases in both anxiety [t(1, 17) = 2·65, p < 0·05) and depression [t (1, 17) = 3·33, p < 0·005] scores, while the control group did not, a difference attributed to the diary intervention. Conclusions: Survivors of critical illnesses are likely to experience clinically significant symptoms of anxiety and depression following their discharge from hospital. The prospective diary intervention was designed to help patients understand what happened to them in intensive care, and it has a significant positive impact on anxiety and depression scores almost 2 months after patients’ discharge from ICU. Attempts to replicate these results using larger samples are therefore encouraged, with the aim of informing best practice guidelines. Abstract reprinted from the Critical Care Medicine, volume 37, Knowles and Tarrier, ‘(2009) Evaluation of the effect of prospective patient diaries on emotional well‐being in intensive care unit survivors: A randomized control trial’, pages 184–191. © 2009, reproduced with permission from Lippincott Williams & Wilkins.     

Oral care and oropharyngeal and tracheal colonization by Gram-negative pathogens in children

Background: Critical care nursing interventions to oral care can reduce microorganisms in the oropharynx available for translocation. Objectives: To analyse the effect of 0·12% chlorhexidine digluconate on the colonization of oropharyngeal and tracheal secretions by Gram‐negative pathogens in mechanically ventilated children. Methods: A randomized, controlled and double‐blinded study was performed in the paediatric intensive care unit (PICU) of a Brazilian university hospital. Exclusion criteria included child age under 28 days, pneumonia diagnosis at admission, use of tracheostomy, PICU length of stay (LOS) less than 48 h and refusal to participate. Children were randomly allocated to the interventional group (IG), in which oral care with chlorhexidine was administered, or to the placebo group (PG), which received oral care without antiseptic use. The data were analysed through Pearson's χ² test, Fisher's exact and ANOVA tests with significance levels set at 0·05. Results: The demographic characteristics of the 74 children were not statistically different between groups. No between‐group differences in oropharyx colonization by Gram‐negative pathogens were identified (p = 0·316). Pathogens were isolated in the tracheal secretions of two (10·0%) children in the PG and four (19·0%) children in the IG (p = 0·355). Conclusion: The use of chlorhexidine did not significantly influence the colonization of oropharyngeal and tracheal secretions by Gram‐negative pathogens of the studied sample. Relevance to clinical practice: This study demonstrated no influence of a specific antiseptic agent on colonization profile of mechanically ventilated children in PICU. Further research in this field is necessary to promote evidence‐based nursing practice on oral care of critically ill children.     

Improved quality and comprehensiveness in nursing documentation of pressure ulcers after implementing an electronic health record in hospital care

Aims. One aim was to compare the quality and comprehensiveness in nursing documentation of pressure ulcers before and after implementation of an electronic health record in a hospital setting. Another aim was to investigate the use of preformulated templates for pressure ulcer recording in the electronic health record. Background. With the possibilities of the electronic health record to provide information and give accurate and reliable feedback to the healthcare organisation, it is of high priority to develop standardised documentation practices for various areas of care (e.g. such as pressure ulcer care). Design. A cross‐sectional retrospective review of health records. Methods. Three departments in a Swedish university hospital participated. In 2002, there were 413 patients, including 59 paper‐based records identified with notes on pressure ulcers and in 2006, 343 patients, including 71 electronic health records with pressure ulcer recording. Recorded data on pressure ulcers were retrospectively reviewed. Results. Significantly more patient records showed notes of pressure ulcer grade (p < 0·001), size (p = 0·004), risk assessment (p = 0·002), nursing history (p = 0·040), nursing diagnoses (p < 0·001), nursing goals (p < 0·001) and nursing outcomes (p = 0·016) in 2006 than in 2002. One third of the recordings used preformulated templates. Conclusions. Although there were significant improvements in pressure ulcer recording after the change to the electronic health record, several deficiencies remained. Due to the short time of our follow‐up after implementation of the electronic health record, we suspect that the quality of recording will improve when nurses become more familiar with the new system. Relevance to clinical practice. Education related to the use of the electronic health record and evidence‐based pressure ulcer prevention should be provided to the nurses. To facilitate documentation, the templates need to be refined to be more user‐friendly.     

Intensive care 1980–1995: change in patient characteristics, nursing workload and outcome

Objective: To assess temporal changes in patient characteristics, nursing workload and outcome of the patients and to compare the actual amount of available nursing staff with the estimated needs in a medical-surgical ICU. Design: Retrospective analysis of prospectively collected data. Setting: A medical-surgical adult intensive care unit (ICU) in a Swiss university hospital. Patients: Data of all patients staying in the ICU between January 1980 and December 1995 were included. Interventions: None. Measurements and results: The estimated number of nurses needed was defined according to the Swiss Society of Intensive Care Medicine (SGI) grading system: category I = one nurse/patient/shift ( = 8 h), category II = one nurse/two patients/shift, category III = one nurse/three patients/shift. An intervention score (IS) was obtained, based on a number of specific activities in the ICU. There was a total of 35,327 patients (32 % medical and 68 % postoperative/trauma patients). Over time, the number of patients per year increased (1980/1995: 1,825/2,305, p < 0.001) and the length of ICU stay (LOS) decreased (4.1/3.8 days, p < 0.013). There was an increase in the number of patients aged > 70 years (19 %/28 %, p < 0.001), and a decrease in the number of patients < 60 years (58 % /41 %, p < 0.001). During the same time period, the IS increased two-fold. Measurement of nursing workload showed an increase over time. The number of nursing days per year increased (1980/1995: 7454/8681, p < 0.019), as did the relative amount of patients in category I (49 %/71 %, p < 0.001), whereas the portion of patients in category II (41 %/28 %, p < 0.019) and category III (10 %/0 %) decreased. During the same time period, mortality at ICU discharge decreased (9.0 %/7.0 %, p < 0.002). Conclusions: During the last 16 years, there has been a marked increase in workload at this medical-surgical ICU. Despite an increase in the number of severely sick patients (as defined by the nursing grading system) and patient age, ICU mortality and LOS declined from 1980 to 1995. This may be ascribed to improved patient treatment or care. Whether an increasingly liberal discharge policy (transfer to newly opened intermediate care units, transfer of patients expected to die to the ward) or a more rigorous triage (denying admission to patients with a very poor prognosis) are confounding factors cannot be answered by this investigation. The present data provide support for the tenet that there is a trend toward more complex therapies in increasingly older patients in tertiary care ICUs. Calculations for the number or nurses needed in an ICU should take into account the increased turnover of patients and the changing patient characteristics. Received: 30. April 1997 / Accepted: 8 August 1997     

Factual memories of ICU: recall at two years post-discharge and comparison with delirium status during ICU admission--a multicentre cohort study

Aims and objective. To examine the relationship between observed delirium in ICU and patients’ recall of factual events up to two years after discharge. Background. People, the environment, and procedures are frequently cited memories of actual events encountered in ICU. These are often perceived as stressors to the patients and the presence of several such stressors has been associated with the development of reduced health‐related quality of life or post‐traumatic stress syndrome. Design. Prospective cohort study using interview technique. Method. The cohort was assembled from 152 patients who participated in a previously conducted multi‐centre study of delirium incidence in Australian ICUs. The interviews involved a mixture of closed‐ and open‐ended questions. Qualitative responses regarding factual memories were analysed using thematic analysis. A five‐point Likert scale with answers from ‘always’ to ‘never’ was used to ask about current experiences of dream, anxiety, sleep problems, fears, irritability and/or mood swings. Scoring ranged from 6 to 30 with a mid‐point value of 18 indicating a threshold value for the diagnosis of post‐traumatic stress syndrome. A P‐value of <0·05 was considered significant for all analyses. Results. Forty‐one (40%) out of 103 potential participants consented to take part in the follow‐up interview; 18 patients (44%) had been delirious and 23 patients (56%) non‐delirious during the ICU admission. The non‐participants (n = 62) formed a control group to ensure a representative sample; 83% (n = 34) reported factual memories either with or without recall of dreaming. Factual memories were significantly less common (66% cf. 96%) in delirious patients (OR 0·09, 95%CI 0·01–0·85, p = 0·035). Five topics emerged from the thematic analysis: ‘procedures’, ‘staff’, ‘comfort’, ‘visitors’, and ‘events’. Based on the current experiences, five patients (12%, four non‐delirious and one delirious) scored ≥18 indicative of symptoms of post‐traumatic stress syndrome; this did not reach statistical significance. Memory of transfer out of ICU was less frequent among the delirious patients (56%, n = 10) than among the non‐delirious patients (87%, n = 20) (p = 0·036). Conclusion. Most patients have factual memories of their ICU stay. However, delirious patients had significantly less factual recall than non‐delirious patients. Adverse psychological sequelae expressed as post‐traumatic stress syndrome was uncommon in our study. Every attempt must be made to ensure that the ICU environment is as hospitable as possible to decrease the stress of critical illness. Post‐ICU follow‐up should include filling in the ‘missing gaps’, particularly for delirious patients. Ongoing explanations and a caring environment may assist the patient in making a complete recovery both physically and mentally. Relevance to clinical practice. This study highlights the need for continued patient information, re‐assurance and optimized comfort. While health care professionals cannot remove the stressors of the ICU treatments, we must minimize the impact of the stay. It must be remembered that most patients are aware of their surroundings while they are in the ICU and it should, therefore, be part of ICU education to include issues regarding all aspects of patient care in this particularly vulnerable subset of patients to optimize their feelings of security, comfort and self‐respect.     

Falls and fall risk among nursing home residents

Aim and objectives. The aim of this study was to identify risk factors for falls in older people living in nursing homes. Background. Impaired cognitive function and a poor sense of orientation could lead to an increase in falls among those with impaired freedom of movement. Many accidents occur while an older person is walking or being moved. Method. The study was carried out over four years (2000–2003) and 21 nursing home units in five municipal homes for older people in Stockholm, Sweden, participated. A questionnaire was sent to staff nurses, including questions on fall risk assessments, falls, fractures, medication and freedom‐restricting measures, such as wheelchairs with belts and bed rails. The data were aggregated and not patient‐bound. The study covered 2343 reported incidents. Results. There was a significant correlation between falls and fractures (r = 0·365, p = 0·004), fall risk and use of wheelchairs (r = 0·406, p = 0·001, safety belts (r = 0·403, p = 0·001 and bed rails (r = 0·446, p = 0·000) and between the occurrence of fractures and the use of sleeping pills with benzodiazepines (r = 0·352, p = 0·005). Associations were also found between fall risk and the use of anti‐depressants (r = 0·412, p = 0·001). Conclusion. In clinical practice, patient safety is very important. Preventative measures should focus on risk factors associated with individuals, including their environment. Wheelchairs with safety belts and bed rails did not eliminate falls but our results support the hypothesis that they might be protective when used selectively with less anti‐depressants and sleeping pills, especially benzodiazepines.     

Assessment of a training programme for the prevention of ventilator‐associated pneumonia

Background: Ventilator‐associated pneumonia (VAP) is the most frequent nosocomial infection in intensive care units (ICUs). Most published studies have analysed nurses' theoretical knowledge about a specific procedure; however, the transfer of this knowledge to the practice has received little attention. Aim: To assess the impact of training session on nurses' knowledge regarding VAP, compliance with VAP preventive measures, VAP incidence and determining whether nursing workload affects compliance. Method: A prospective, quasiexperimental, pre‐ and post‐study of the nursing team in a 16‐bed medical/surgical ICU. Pre‐intervention phase: a questionnaire to assess nurses' knowledge of VAP prevention measures, direct observation and review of clinical records to assess compliance. Intervention phase: eight training sessions for nurses. The post‐intervention phase mirrored the pre‐intervention phase. Findings: Nurses answered more questions correctly on the post‐intervention questionnaire than on the pre‐intervention (17·87 ± 2·69 versus 15·91 ± 2·68, p = 0·002). Compliance with the following measures was better during the post‐intervention period (p = 0·001): use of the smallest possible nasogastric tube, controlled aspiration of subglottic secretions and endotracheal tube cuff pressure, use of oral chlorhexidine and recording the endotracheal tube fixation number. VAP incidence remained unchanged throughout the study. However, a trend towards lower incidence of late (>4 days after intubation) VAP was observed (4·6 versus 3·1 episodes/1000 ventilation days, p = 0·37). Conclusion: The programme improved both knowledge of and compliance with VAP preventive measures, although improved knowledge did not always result in improved compliance.     

Effects of a feeding skills training programme on nursing assistants and dementia patients

Aims and objectives. The purposes of this study were to develop a comprehensive feeding skills training programme for nursing assistants and to test the effects of this training programme on their knowledge, attitude and behaviour and the outcome of dementia patients including total eating time, food intake and feeding difficulty. Background. Dementia patients have a high probability of feeding problems that result in a substantial risk of malnutrition. Assisting residents with eating is a major task for nursing assistants and they require better training to provide adequate quality of nutritional care. Design methods. A quasi‐experimental study was conducted. Two convenience‐chosen dementia‐specialized long‐term care facilities in North Taiwan were randomly assigned into either a control or a treatment group. Sixty‐seven nursing assistants were enrolled (treatment: 31; control: 36). Twenty nursing assistants and the same number of dementia patients were observed during mealtime. The treatment group participated in a feeding skills training programme including three hours of in‐service classes and one hour of hands‐on training, whereas the control group did not receive any training. Results. The treatment group had significantly more knowledge (F = 47·7, P < 0·001), more positive attitude (F = 15·75, P = 0·001) and better behaviours (t = 6·0, P < 0·001) than the control group after the intervention. Dementia patients in the treatment group had significantly longer total eating time (t = 2·7, P < 0·05) and higher Edinburgh Feeding Evaluation in Dementia scores (more feeding difficulty) (t = 2·1, P < 0·05) than the control group. There was no significant difference on food intake between the two groups (t = 0·8, P = 0·49). Conclusion. This feeding skills training programme has been found to change nursing assistants’ knowledge, attitude, and behaviour as well as increasing the eating time for the dementia patients. Relevance to clinical practice. This study raises attention regarding on‐the‐job training for nursing assistants. Furthermore, the feeding problems among dementia patients should be further explored as well as the nutritional care.     

Nursing workload assessment in an intensive care unit: A retrospective observational study using the Nursing Activities Score

Background

Nursing Activities Score (NAS) is a promising tool for calculating the nursing workload in intensive care units (ICU). However, data on intensive care nursing activities in Portugal are practically non-existent.

Aim

To assess the nursing workload in a Portuguese ICU using the NAS.

Study Design

Retrospective cohort study developed throughout the analysis of the electronic health record database from 56 adult patients admitted to a six-bed Portuguese ICU between 1 June–31 August 2020. The nursing workload was assessed by the Portuguese version of the NAS. The study was approved by the Hospital Council Board and Ethics Committee. The study report followed the STROBE guidelines.

Results

The average occupancy rate was 73.55% (±16.60%). The average nursing workload per participant was 67.52 (±10.91) points. There was a correlation between the occupancy rate and the nursing workload. In 35.78% of the days, the nursing workload was higher than the available human resources, overloading nurse staffing/team.

Conclusions

The nursing workload reported follows the trend of the international studies and the results reinforce the importance of adjusting the nursing staffing to the complexity of nursing care in this ICU. This study highlighted periods of nursing workload that could compromise patient safety.

Relevance to Clinical Practice

This was one of the first studies carried out with the NAS after its cross-cultural adaptation and validation for the Portuguese population. The nursing workload at the patient level was higher in the first 24 h of ICU stays. Because of the ‘administrative and management activities’ related to the ‘patient discharge procedures’, the last 24 h of ICU stays also presented high levels of nursing workload. The implementation of a nurse-to-patient ratio of 1:1 may contribute to safer nurse staffing and to improve patient safety in this Tertiary (level 3) ICU.     

Commentary: Bouza C et al. (2007). Unplanned extubation in orally intubated medical patients in the ICU: a prospective cohort study

Background: Unplanned endotracheal extubation (UE) is recognized as the most common airway adverse event in the intensive care unit (ICU). Objectives: We examined the incidence, circumstances, and outcome of UE in orally intubated medical patients in the ICU. Methods: We performed a 12‐month prospective cohort study in a tertiary‐care medical ICU. Results: A total of 344 consecutive adults who were orally intubated and mechanically ventilated for 3710 days were included. The overall incidence density of UE was 0·92 of 100 days of ventilation. Eight episodes (24%) occurred in patients receiving mechanical ventilation (MV) and not in the weaning process versus 26 episodes (76%) in patients scheduled for weaning. UE was reported as intentional in 71% of cases and as accidental in 29% of cases. In 59% of UE cases, patients were without caregivers at the bedside when the episode took place, and 46% of cases occurred during the night shift. Reintubation was required in 41% of patients and was strongly associated with the accidental nature of the episode [odds ratio (95% confidence interval): 4.3 (1.9–9.6)]. Compared with patients without UE, patients with UE had a lower mortality rate [odds ratio (95% confidence interval): 0·21 (0·6–0·8)] but longer days on MV (11.5 versus 5, P _ 0·09) and ICU stay (13.5 versus 6, P _ 0·08). Conclusions: This study does not confirm the highest rates of UE previously reported in orally intubated medical patients in the ICU or the association with mortality in this scenario. However, UE increased the need for MV and ICU care. We found a moderate to high prevalence of potentially modifiable risk factors for UE, suggesting unsatisfactory ICU practices. Abstract reprinted from Heart & Lung, volume 36, Bouza C et al., ‘Unplanned extubation in orally intubated medical patients in the ICU: a prospective cohort study.’, pages 270–276. ©2007, reproduced with permission from Elsevier Limited.     

Assessing predictive validity of the modified Braden scale for prediction of pressure ulcer risk of orthopaedic patients in an acute care setting

Aims and objectives. To assess and compare the predictive validity of the modified Braden and Braden scales and to identify which of the modified Braden subscales are predictive in assessing pressure ulcer risk among orthopaedic patients in an acute care setting. Background. Although the Braden scale has better predictive validity, literature has suggested that it can be used in conjunction with other pressure ulcer risk calculators or that some other subscales be added. To increase the predictive power of the Braden scale, a modified Braden scale by adding body build for height and skin type and excluding nutrition was developed. Design. A prospective cohort study. Method. A total of 197 subjects in a 106‐bed orthopaedic department of an acute care hospital in Hong Kong were assessed for their risk for pressure ulcer development by the modified Braden and Braden scales. Subsequently, daily skin assessment was performed to detect pressure ulcers. Cases were closed when pressure ulcers were detected. Results. Out of 197 subjects, 18 patients (9·1%) developed pressure ulcers. The area under the receiver operating characteristic curve for the modified Braden scale was 0·736 and for the Braden scale was 0·648. The modified Braden cut‐off score of 19 showed the best balance of sensitivity (89%) and specificity (62%). Sensory perception (Beta = ?1·544, OR=0·214, p = 0·016), body build for height (Beta = ?0·755, OR = 0·470, p = 0·030) and skin type (Beta = ?1·527, OR = 0·217, p = 0·002) were significantly predictive of pressure ulcer development. Conclusion. The modified Braden scale is more predictive of pressure ulcer development than the Braden scale. Relevance to clinical practice. The modified Braden scale can be adopted for predicting pressure ulcer development among orthopaedic patients in an acute care setting. Specific nursing interventions should be provided, with special attention paid to orthopaedic patients with impaired sensory perception, poor skin type and abnormal body build for height.     

Commentary: Hugonnet S et al. (2007). The effect of workload on infection risk in critically ill patients

Objective: There is growing evidence that low nurse staffing jeopardizes quality of patient care. The objective of the study was to determine whether low staffing level increases the infection risk in critical care. Design: Observational, single‐centre, prospective cohort study. Setting: Medical intensive care unit of the University of Geneva Hospitals, Switzerland. Patients: All patients admitted over a 4‐year period. Interventions: None. Measurements and main results: Study variables included all infections acquired in critical care, daily nurse‐to‐patient ratio, demographic characteristics, admission diagnosis and severity score, comorbidities, daily individual exposure to invasive devices and selected drugs. Of a cohort of 1883 patients totalling 10 637 patient‐days, 415 (22%) developed at least one health care‐associated infection (HCAI) while in critical care. Overall infection rate was 64·5 episodes per 1000 patient‐days. Infected patients experienced higher mortality with a longer duration of stay both in critical care and in the hospital than non‐infected patients (all p < 0·001). Median 24‐h nurse‐to‐patient ratio was 1·9. Controlling for exposure to central venous catheter, mechanical ventilation, urinary catheter and antibiotics, we found that higher staffing level was associated with a >30% infection risk reduction (incidence rate ratio, 0·69; 95% CI: 0·50–0·95). We estimated that 26·7% of all infections could be avoided if the nurse‐to‐patient ratio was maintained >2·2. Conclusions: Staffing is a key determinant of HCAI in critically ill patients. Assuming causality, a substantial proportion of all infections could be avoided if nurse staffing were to be maintained at a higher level. Abstract reprinted from Critical Care Medicine, volume 35, Hugonnet S et al., ‘The effect of workload on infection risk in critically ill patients.’, pages 76–81. © 2007, reproduced with permission from Lippincott Williams & Wilkins.