The characterisation of workloads and nursing staff allocation in intensive care units: A descriptive study using the Nursing Activities Score for the first time in Norway

Objective

This study compares the Nine Equivalents of Nursing Manpower Use Score (NEMS) to the Nursing Activities Score (NAS) in terms of characterising the nursing workload by examining and calculating the per-nurse NAS% over a 24-h period.

Method

The sample consisted of 235 patients from four volunteered for the study multidisciplinary ICUs in Norway. The daily NEMS, NAS and number of nurses who were involved in patient care per ICU were measured over one month from 2008 to 2009.

Results

The average length of stay for the included patients was 5 days, and the mean patient age was 52.8 years. The mean NEMS was 32.7 points (S.D., 8.98 points), and the mean NAS was 96.24% (S.D., 22.35%). Several nurses exhibited mean NEMS points that ranged from 16 to 39.7 per ICU per day. The correlation between the NEMS and NAS could only be separately determined for each ICU. The correlation was r = 0.16–0.40 [significant at the 0.01 level (2-tailed)] per unit. Depending on which unit was investigated, each nurse was observed to perform of capacity with a NAS as high as 75–90%.

Conclusion

The study suggests that the actual numbers of nurses might explain the calculated NAS of 75–90% per nurse.     

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.     

Resident productivity: trends over consecutive shifts

Background

It has been shown that residents’ ability to see more patients and patients of higher acuity improves with level of training.

Aims

No published study has reviewed whether residents become less productive with consecutive shifts. Determining peak resident productivity can optimize staffing to manage patient flow and enhance resident exposure to patients, which is critical to their education. We examine the relationship between resident productivity and number of consecutive shifts worked.

Methods

This is a retrospective review of emergency medicine (EM) resident productivity defined as patients evaluated per hour per shift. Data were collected utilizing patient tracker software which provides a record of physician assignment and checked against the computerized medical record. Residents were credited with a patient if they initiated the workup and dictated the chart. Productivity was tallied for 188 first-year shift strings, 303 second-year shift strings, and 224 third-year shift strings beginning 1 November 2006. Analysis of variance (ANOVA) was used to assess for productivity differences based on the shift number, with the first shift in a series being designated “1,” the second consecutive shift being designated “2,” and so on.

Results

First-year residents saw 0.82, 0.81, and 0.91 patients per hour on consecutive shifts (F _(2,175)=2.89, p?=?0.06), second-year residents saw 1.12, 1.08, 1.17, and 1.28 patients per hour on consecutive shifts (F _(3,292)=4.19, p?=?0.006), and third-year residents saw 1.19, 1.24, and 1.33 patients per hour on consecutive shifts (F _(2,211)=4.08, p?=?0.02).

Conclusions

Instead of tiring, residents maintain or improve productivity over consecutive shifts.     

Acute kidney injury in critically ill patients with 2009 influenza A (H1N1) viral pneumonia: an observational study

Objective

To describe the incidence, risk factors, and impact on mortality of acute kidney injury (AKI) in patients with 2009 influenza?A (H1N1) viral pneumonia requiring mechanical ventilation.

Design

Observational cohort study.

Patients and methods

AKI was defined as risk, injury or failure, according to the RIFLE classification. Early and late AKI were defined as AKI occurring on intensive care unit (ICU) day?2 or before, or after ICU day?2, respectively. Demographic data and information on organ dysfunction were collected daily.

Results

Of 84 patients, AKI developed in 43 patients (51%). Twenty (24%) needed renal replacement therapy. Early and late AKI were found in 28 (33%) and 15 (18%) patients, respectively. Patients with AKI, as compared with patients without AKI, had higher Acute Physiology and Chronic Health Evaluation (APACHE)?II score and ICU mortality (72% versus 39%, p?<?0.01) and presented on admission more marked cardiovascular, respiratory, and hematological dysfunction. Patients with early but not late AKI presented on admission higher APACHE?II score and more marked organ dysfunction, as compared with patients without AKI. ICU mortality was higher in late versus early AKI (93% versus 61%, p?<?0.001). On multivariate analysis, only APACHE?II score and late but not early AKI [odds ratio (OR) 1.1 (95% confidence interval 1.0?C1.1) and 15.1 (1.8?C130.7), respectively] were associated with mortality.

Conclusions

AKI is a frequent complication of 2009 influenza?A (H1N1) viral pneumonia. AKI developing after 2?days in ICU appears to be associated with different risk factors than early AKI, and is related to a higher mortality rate.     

Increased nonbeneficial care in patients spending their birthday in the ICU

Objective

End-of-life decisions are based on objective and subjective criteria. Previous studies identified substantial subjective biases during end-of-life decision-making. We evaluated whether in-ICU patient’s birthday influenced management decisions.

Design

We used a case–control design in which patients spending their birthday in the ICU (cases) were matched to controls on center, gender, age, severity, type of admission, and length of ICU stay before birthday.

Setting

12 ICUs in French hospitals.

Patients

The cases and controls were patients with ICU admissions >48?h over a 10-year period.

Interventions

None.

Measurements and main results

Compared with the 1,042 controls, the 223 cases were more often trauma patients and received a larger number and longer durations of life-sustaining interventions. This increased intensity of life support occurred after, but not before, the birthday. The cases had longer ICU stay lengths. ICU and hospital mortality were not different between the two groups. End-of-life decisions were made in 22% and 24% of cases and controls, respectively. However, these decisions were made later in the cases than in the controls (18 [5–33] versus 9 [3–19]?days).

Conclusions

Our finding that patients who spent their birthday in the ICU received a higher intensity of life-sustaining care and had longer ICU stays but did not have significantly different mortality rates compared with the controls suggests the use of nonbeneficial interventions. Staff members caring for patients whose birthdays fall during the ICU stay should be aware that this feature can bias end-of-life decisions, leading to an inappropriate level of care.     

How to implement monitoring tools for sedation, pain and delirium in the intensive care unit: an experimental cohort study

Purpose

Systematic monitoring of sedation, pain and delirium in the ICU is of paramount importance in delivering adequate patient care. While the use of systematic monitoring instruments is widely agreed upon, these tools are infrequently implemented into daily ICU care. The aim of this study is to compare the effectiveness of two different training strategies (training according to the local standard vs. modified extended method) on the implementation rate of scoring instruments on the ICU.

Methods

In this experimental cohort study we analyzed the frequency of scoring on three surgical ICUs before and after training, and in a 1?year follow-up. A modified extended training included establishing a local support team helping to resolve immediate problems. In addition we evaluated the impact on patients’ outcome.

Results

ICUs trained by the modified extended method showed increased documentation rates of all scores per patient and day. In a 1?year follow-up, increased scoring rates for all scores were maintained. Scoring rates with training according to the local standard training protocol did not increase significantly. Implementation of delirium and pain monitoring were associated with a decrease in mortality [odds ratio (OR) 0.451; 95?% confidence interval (CI): 0.22–0.924, and, respectively, OR 0.348; 95?% CI: 0.140–0.863]. Monitoring had no significant influence on ventilation time or ICU length of stay.

Conclusions

A modified extended training strategy for ICU monitoring tools (sedation, pain, delirium) leads to higher intermediate and long-term implementation rates and is associated with improved patient outcome. However, these findings may have been biased by unmeasured confounders.     

Impact of hypoxic hepatitis on mortality in the intensive care unit

Purpose

Hypoxic hepatitis (HH) is a form of hepatic injury following arterial hypoxemia, ischemia, and passive congestion of the liver. We investigated the incidence and the prognostic implications of HH in the medical intensive care unit (ICU).

Methods

A total of 1,066 consecutive ICU admissions at three medical ICUs of a university hospital were included in this prospective cohort study. All patients were screened prospectively for the presence of HH according to established criteria. Independent risk factors of mortality in this cohort of critically ill patients were identified by a multivariate Poisson regression model.

Results

A total of 118 admissions (11%) had HH during their ICU stay. These patients had different baseline characteristics, longer median ICU stay (8 vs. 6?days, p?p?p?p?p?=?0.359).

Conclusions

Hypoxic hepatitis (HH) occurs frequently in the medical ICU. The presence of HH is a strong risk factor for mortality in the ICU in patients requiring vasopressor therapy.     

Intensive care unit environment may affect the course of delirium

Purpose

Delirium is a common disorder in intensive care unit (ICU) patients. It is unclear whether ICU environment affects delirium. We investigated the influence of ICU environment on the number of days with delirium during ICU admission.

Methods

In this prospective before–after study, ICU delirium was compared between a conventional ICU with wards and a single-room ICU with, among others, improved daylight exposure. We included patients admitted for more than 24 h between March and June 2009 (ICU with wards) or between June and September 2010 (single-room ICU). Patients who remained unresponsive throughout ICU admission were excluded. The presence of delirium in the preceding 24 h was assessed daily with the confusion assessment method for the ICU (CAM-ICU) by research physicians combined with evaluation of medical and nursing charts. The number of days with delirium was investigated with Poisson regression analysis.

Results

We included 55 patients (449 observation days) in the ICU with wards and 75 patients (468 observation days) in the single-room ICU. After adjusting for confounding, the number of days with delirium decreased by 0.4 days (95 % confidence interval 0.1–0.7) in the single-room ICU (p = 0.005). The incidence of delirium during ICU stay was similar in the ICU with wards (51 %) and in the single-room ICU (45 %, p = 0.53).

Conclusions

This study is the first to show that ICU environment may influence the course of delirium in ICU patients.     

Early intervention on the outcomes in critically ill cancer patients admitted to intensive care units

Purpose

To determine whether earlier intervention was associated with decreased mortality in critically ill cancer patients admitted to an intensive care unit (ICU).

Methods

A retrospective observational study was performed of 199 critically ill cancer patients admitted to the ICU from the general ward between January 2010 and December 2010. A logistic regression model was used to adjust for potential confounding factors in the association between time to intervention and in-hospital mortality.

Results

In-hospital mortality was 52?%, with a median Simplified Acute Physiology Score 3 (SAPS 3) of 80 [interquartile range (IQR) 67–93], and a median Sequential Organ Failure Assessment (SOFA) score of 8 (IQR 5–11). Median time from physiological derangement to intervention (time to intervention) prior to ICU admission was 1.5 (IQR 0.6–4.3)?h. Median time to intervention was significantly shorter in survivors than in non-survivors (0.9 vs. 3.0?h; p?p?2/FiO₂ ratio. Even after adjusting for potential confounding factors, time to intervention was still significantly associated with hospital mortality (adjusted odds ratio 1.445, 95?% confidence interval 1.217–1.717).

Conclusions

Early intervention before ICU admission was independently associated with decreased in-hospital mortality in critically ill cancer patients admitted to the ICU.     

ICU admission characteristics and mortality rates among elderly and very elderly patients

Purpose

The effect of advanced age per?se versus severity of chronic and acute diseases on the short- and long-term survival of older patients admitted to the intensive care unit (ICU) remains unclear.

Methods

Intensive care unit admissions to the surgical ICU and medical ICU of patients older than 65?years were analyzed. Patients were divided into three age groups: 65–74, 75–84, and 85 and above. The primary endpoints were 28-day and 1-year mortality.

Results

The analysis focused on 7,265 patients above the age of 65, representing 45.7?% of the total ICU population. From the first to third age group there was increased prevalence of heart failure (25.9–40.3?%), cardiac arrhythmia (24.6–43.5?%), and valvular heart disease (7.5–15.8?%). There was reduced prevalence of diabetes complications (7.5–2.4?%), alcohol abuse (4.1–0.6?%), chronic obstructive pulmonary disease (COPD) (24.4–17.4?%), and liver failure (5.0–1.0?%). Logistic regression analysis adjusted for gender, sequential organ failure assessment, do not resuscitate, and Elixhauser score found that patients from the second and third age group had odds ratios of 1.38 [95?% confidence interval (CI) 1.19–1.59] and 1.53 (95?% CI 1.29–1.81) for 28-day mortality as compared with the first age group. Cox regression analysis for 1-year mortality in all populations and in 28-day survivors showed the same trend.

Conclusions

The proportion of elderly patients from the total ICU population is high. With advancing age, the proportion of various preexisting comorbidities and the primary reason for ICU admission change. Advanced age should be regarded as a significant independent risk factor for mortality, especially for ICU patients older than 75.     

Clinical impact and risk factors for colonization with extended-spectrum β-lactamase-producing bacteria in the intensive care unit

Purpose

The changed epidemiology of extended spectrum beta-lactamases (ESBL), the spread to the community and the need for prudent use of carbapenems require updated knowledge of risk factors for colonization with ESBL-producing enterobacteriaceae (ESBL-PE).

Methods

An 8-month prospective study in the medical ICU of an 850-bed general and university-affiliated hospital.

Results

Of 610 patients admitted, 531 (87?%) had a rectal swab obtained at admission, showing a 15?% (82 patients) ESBL-PE carriage rate, mostly of E. coli (n?=?51, 62?%); ESBL-PE caused 9 (3?%) infections on admission. By multivariable analysis, transfer from another ICU (OR?=?2.56 [1, 22]), hospital admission in another country [OR?=?5.28 (1.56–17.8)], surgery within the past year [OR?=?2.28 (1.34–3.86)], prior neurologic disease [OR?=?2.09 (1.1–4.0)], and prior administration of third generation cephalosporin (within 3–12?months before ICU admission) [OR?=?3.05 (1.21–7.68)] were independent predictive factors of colonization by ESBL-PE upon ICU admission. Twenty-eight patients (13?% of those staying for more than 5?days) acquired ESBL carriage in ICU, mostly with E. cloacae (n?=?13, 46?%) and K. pneumoniae (n?=?10, 36?%). In carriers, ESBL-PE caused 10 and 27?% of first and second episodes of ICU-acquired infections, respectively.

Conclusion

We found a high prevalence of ESBLE-PE colonization on admission to our ICU, even in the subgroup admitted from the community, but few first infections. Identifying risk factors for ESBL-PE colonization may help identifying which patients may warrant empiric ESBL-targeted antimicrobial drug therapy as a means to limit carbapenem use.     

Elevation of creatine kinase is associated with worse outcomes in 2009 pH1N1 influenza?A infection

Background

Current medical knowledge lacks specific information regarding creatine kinase (CK) elevation in influenza?A pH1N1 (2009) infection.

Objectives

Primary endpoints were correlation between CK at intensive care unit (ICU) admission and ICU mortality. Secondary endpoints were ICU length of stay (LOS), mechanical ventilation (MV), and requirement of renal replacement techniques (RRT).

Materials and methods

A prospective multicenter register included all adults admitted for severe acute respiratory insufficiency (SARI) with confirmed pH1N1 in 148 ICUs. Clinical data including demographics, comorbidities, laboratory information, organ involvement, and prognostic data were registered. Post?hoc classification of subjects was determined according to CK level. Data are expressed as median (interquartile range).

Results

Five hundred and five (505) patients were evaluable. Global ICU mortality was 17.8?% without documented differences between breakpoints. CK ≥500?UI/L was documented in 23.8?% of ICU admissions, being associated with greater renal dysfunction: acute kidney injury (AKI) was more frequent (26.1 versus 17.1?%, p?p?p?p?=?0.07) and duration of mechanical ventilation (median 15?days versus 11?days, p?Conclusions CK is a biomarker of severity in pH1N1 infection. Elevation of CK was associated with more complications and increased ICU LOS and healthcare resources.     

Six-month prognosis of patients with lung cancer admitted to the intensive care unit

Background

Intensive care unit (ICU) admission of patients with lung cancer remains debated because of the poor short-term prognosis. However, ICU admission of such patients should also be assessed on the possibility to administer specific anticancer treatment and the long-term outcome thereafter.

Objectives

To identify predictive factors of hospital and 6-month mortality in critically ill lung-cancer patients.

Design and setting

Retrospective study conducted in the ICU of a university hospital.

Patients

One hundred five consecutive lung-cancer patients included between 1 January 1997 and 31 December 2006.

Interventions

None.

Results

Of the 105 patients (mean age 64.8 years), 87 (83%) had a non-small cell lung cancer (NSCLC). Extensive disease was diagnosed in 85 patients (83%) (NSCLC stages IIIB and IV or disseminated small cell lung cancer). The main reasons for ICU admission were acute respiratory failure (59%) and/or hemoptysis (45%). Forty-three patients (41%) needed mechanical ventilation (MV). The ICU, hospital and 6-month mortality rates were 43, 54 and 73%, respectively. A performance status (PS) ≥2 [odds ratio OR = 3.6 (95% confidence interval CI (1.5–8.7)] and acute respiratory failure [OR = 3.5 (95% CI (1.5–8.4)] predicted hospital mortality. In a multivariate Cox model, the cancer progression [hazard ratio HR = 6.1 (95% CI 2.2–17)] and the need for MV [HR = 3.6 (95% CI 1.35–9.4)] were independently associated with 6-month mortality. Two-thirds of the ICU survivors were able to receive anticancer treatment.

Conclusions

ICU admission should be considered in selected patients with lung cancer (PS <2, no cancer disease progression).     

Using the improving palliative care in the intensive care unit (IPAL-ICU) project to promote palliative care consultation

Background

The Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) project is an initiative designed to improve the quality of palliative care in the intensive care unit. One of the problems to be addressed is the underutilization of palliative care.

Measures

The percentage change in number of palliative care consults in the Medical ICU (MICU) and Surgical ICU (SICU) compared with the same time period the previous year was used as an objective measure to indicate increased utilization of palliative care.

Intervention

Two hundred seventy-three patients were screened for potential palliative care consultation. After each patient screening, the attending physician was offered the opportunity to consult the palliative care consultation team.

Outcomes

In comparison with the same time period the previous year, an increase in palliative care consults of 113% in the MICU and of 51% in the SICU was noted during the screening period.

Conclusions/Lessons Learned

The IPAL-ICU project framework and recommendations can be effectively used to increase the number of palliative care consults in the ICU.     

Survival in solid cancer patients following intensive care unit admission

Purpose

One in seven patients admitted to intensive care units (ICU) has a cancer diagnosis but evidence on their expected outcomes after admission has not been synthesised.

Methods

Systematic literature review of solid cancer adult patients admitted to ICU from 2000 onwards using EMBASE and MEDLINE electronic databases.

Results

There were 48 papers identified that reported survival in ICU patients with solid cancers. ICU mortality was reported in 35 studies comprising a total sample of 25,339 patients and ranging from 4.5 to 85 %. The average mortality of the distribution of reported mortality rates within ICU was 31.2 % (95 % CI 24.0–39.0 %). Hospital mortality was reported in 31 studies across a total sample of 74,061 patients. The average hospital mortality was 38.2 % (33.8–42.7 %) and ranged from 4.6 to 76.8 %. Poorer physiological score, invasive mechanical ventilation and poor functional status were associated with higher mortality.

Conclusions

Several factors have been associated with poor survival in ICU cancer patients; however, primary research is still needed to describe outcomes in cancer patients with sufficient case mix and treatment details to be of prognostic value to clinicians.     

Safety of nicotine replacement therapy in critically ill smokers: a retrospective cohort study

Purpose

Nicotine replacement therapy (NRT) has been used to ameliorate nicotine withdrawal in the intensive care unit (ICU). Previous cohort studies have suggested an increased mortality with NRT use: methodological problems may call into question the validity of these findings. We undertook a retrospective cohort study to determine if NRT use was associated with adverse outcomes.

Methods

This retrospective cohort study was conducted in a 30-bed, university affiliated, teaching hospital ICU.

Results

We identified 423 smokers admitted over 2?years, of whom 73 received transdermal NRT. Cox proportional hazard regression models, with NRT modelled as a time-varying covariate, were used to test the hypothesis that NRT was associated with an altered ICU or hospital mortality. A second analysis utilized propensity scores. The unadjusted ICU and hospital mortalities were lower for the NRT group; although both differences were non-significant. The Cox models showed that, after adjustment for APACHE risk, age, sex and alcohol use, risk associated with NRT administration was not statistically different than non-administration for both ICU (hazard ratio 0.50, [95?% CI 0.20–1.24], p?=?0.14) and hospital (hazard ratio 0.95, [95?% CI 0.52–1.75], p?=?0.88) mortality. Similar findings occurred with the propensity matched analysis.

Conclusion

We were unable to demonstrate any harm associated with NRT, with the ICU model actually trending towards benefit. We conclude that a randomised, blinded, placebo controlled trial is required to assess adequately the safety and efficacy of NRT as a treatment in critically ill smokers.     

Invasive pulmonary aspergillosis is a frequent complication of critically ill H1N1 patients: a retrospective study

Purpose

Despite their controversial role, corticosteroids (CS) are frequently administered to patients with H1N1 virus infection with severe respiratory failure secondary to viral pneumonia. We hypothesized that invasive pulmonary aspergillosis (IPA) is a frequent complication in critically ill patients with H1N1 virus infection and that CS may contribute to this complication.

Methods

We retrospectively selected all adult patients with confirmed H1N1 virus infection admitted to the intensive care unit (ICU) of two tertiary care hospitals from September 2009 to March 2011. Differences in baseline factors, risk factors, and outcome parameters were studied between patients with and without IPA.

Results

Of 40 critically ill patients with confirmed H1N1, 9 (23?%) developed IPA 3?days after ICU admission. Five patients had proven and four had probable IPA. Significantly more IPA patients received CS within 7?days before ICU admission (78 versus 23?%, p?=?0.002). IPA patients also received significantly higher doses of CS before ICU admission [hydrocortisone equivalent 800 (360–2,635) versus 0 (0–0)?mg, p?=?0.005]. On multivariate analysis, use of CS before ICU admission was independently associated with IPA [odds ratio (OR) 14.4 (2.0–101.6), p?=?0.007].

Conclusions

IPA was diagnosed in 23?% of critically ill patients with H1N1 virus infection after a median of 3?days after ICU admission. Our data suggest that use of CS 7?days before ICU admission is an independent risk factor for fungal superinfection. These findings may have consequences for clinical practice as they point out the need for increased awareness of IPA, especially in those critically ill H1N1 patients already receiving CS.