Should the Placement of Carbon Monoxide (CO) Detectors be Influenced by CO’s Weight Relative to Air?

Background

Numerous states and localities have recently passed legislation mandating the installation and use of residential carbon monoxide (CO) detectors/alarms. Interestingly, there seems to be confusion about the optimal placement, if any, of CO alarms inside the home.

Objectives

It was the goal of this study to demonstrate the behavior of CO in air and to help provide a data-based recommendation for CO alarm placement.

Methods

CO was calculated to be slightly lighter than air. An 8-foot-tall airtight Plexiglas chamber was constructed and CO monitors placed within at the top, middle, and bottom. CO test gas (15 L, 3000 parts per million) was infused at each of the three heights in different trials and CO levels measured over time.

Results

Contrary to a significant amount of public opinion, CO did not layer on the floor, float at the middle of the chamber, or rise to the top. In each case, the levels of CO equalized throughout the test chamber. It took longer to equalize when CO was infused at the top of the chamber than the bottom, but levels always became identical with time.

Conclusions

As would have been predicted by the Second Law of Thermodynamics, CO infused anywhere within the chamber diffused until it was of equal concentration throughout. Mixing would be even faster in the home environment, with drafts due to motion or temperature. It would be reasonable to place a residential CO alarm at any height within the room.     

Acinetobacter baumannii infection was decreased by the structural renovation of a medical intensive care unit

Purpose

The study aimed to determine whether improvements in intensive care unit (ICU) structural environment affect the incidence of ICU-acquired infections (IAIs), particularly those caused by multidrug-resistant pathogens.

Methods

The incidence of IAI and the number of infections caused by organisms during the 6 months immediately before ICU renovation and during the 6 months immediately after ICU renovation were compared. The observational duration was prolonged for an additional 1 year after recruiting the after-renovation data to observe if the found effect of ICU structural renovation is maintained. The relevant data were prospectively gathered.

Results

The overall IAI incidence and distribution of infection site showed no difference in both periods. In IAI-causing pathogens, no considerable difference was found between before and after renovation, except for Acinetobacter baumannii. In comparison of the major pathogens’ identification rate between the entire hospital and the renovated ICU during the study periods, only A baumannii cases in the renovated ICU significantly decreased. However, the reduction of the IAI cases by A baumannii was not sustained for more than 1 year.

Conclusions

These results suggest that structural ICU renovations only may not improve overall IAI incidence, except for transient decrease in IAI by A baumannii.     

Rehabilitation therapy and outcomes in acute respiratory failure: An observational pilot project

Purpose

The aim of this study was to describe the frequency, physiologic effects, safety, and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation.

Materials and Methods

Prospective observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit (ICU) during a 13-week period was conducted.

Results

Of the 32 patients who met the inclusion criteria, only 21 (66%) received physician orders for evaluation by rehabilitation services (physical and/or occupational therapy). Fifty rehabilitation treatments were provided to 19 patients on a median of 12% of medical ICU days per patient, with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment. Physiologic changes during rehabilitation therapy were minimal. Joint contractures were frequent in the lower extremities and did not improve during hospitalization. In 53% and 79% of initial ICU assessments, muscle weakness was present in upper and lower extremities, respectively, with a decreased prevalence of 19% and 43% at hospital discharge, respectively. New impairments in physical function were common at hospital discharge.

Conclusions

This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength, range of motion, and functional outcomes at hospital discharge.     

Bedside Ultrasound for Hip Dislocations

Background

Bedside ultrasound in the emergency department is being used with increasing frequency and for an increasing scope of conditions.

Objectives

Demonstrate the use of bedside ultrasound as an adjunct for diagnosis of hip dislocation.

Case Report

A traumatic anterior hip dislocation was diagnosed with bedside ultrasound after an initial normal plain radiograph.

Conclusion

Although the current standard of care for diagnosis of hip dislocation is plain radiographs, this case demonstrates that bedside ultrasound may be used as a diagnostic adjunct in this time-sensitive and potentially catastrophic diagnosis.     

Motivation and job satisfaction of Tele-ICU nurses

Introduction

Although the first tele-ICU has been in existence for more than 12 years, little is known about the work of tele-ICU nurses. This study examines sources of motivation and satisfaction of tele-ICU nurses.

Methods

A total of 50 nurses in 5 tele-ICUs were interviewed about reasons for working as a tele-ICU nurse and sources of satisfaction and dissatisfaction in their job.

Results

Nurses have different motivations to work in the tele-ICU, including the challenges and opportunities for new learning that occur while interacting with clinicians in the tele-ICU and the various ICUs being monitored. Tele-ICU nurses also appreciate the opportunities for teamwork with tele-ICU physicians and nurses. The relationship and interactions with the ICUs is sometimes mentioned as a dissatisfier. Some nurses miss being physically at the bedside, as well as interacting with patients and families.

Conclusion

Most tele-ICU nurses are satisfied with their job. They like the challenge in their work and the opportunity to learn. For some nurses, the transition from a bedside caregiver to an information manager can be difficult. Other nurses have found a balance by working part-time in the tele-ICU and part-time in the ICU.     

Prognostic value of indocyanine green elimination assessed with LiMON in septic patients

Background

Sepsis is the most frequent infection with high mortality rates in intensive care units (ICUs), and the prediction of outcome is important in the decision-making process.

Objective

To assess the value of the Acute Physiology and Chronic Health Evaluation II (APACHE II) and indocyanin green (ICG) plasma disappearance rate (ICG-PDR) in septic patients.

Design

Retrospective analysis.

Measurements and Results

We analyzed 40 septic patients (17 female and 23 male; age range, 20-89 years) who were treated in our ICU. The ICG-PDR measurement and APACHE II score measurement were made within 24 hours after admission to the ICU. Indocyanine green elimination tests were conducted concurrently using the noninvasive liver function monitoring system (LiMON, Pulsion Medical Systems, Munich, Germany). A dose of 0.3 mg/kg ICG was given through a cubital fossa vein as a bolus.

Results

Statistical analysis showed that ICG-PDR was significantly lower in nonsurvivors (n = 18) than in survivors (n = 22) (mean, 12.1% ± 7.6%/min; median, 9%/min, vs mean, 21.2% ± 10.1%/min; median, 20%/min, respectively [P = .004]). The area under the curve as a measure of accuracy was 0.765 for ICG-PDR and 0.692 for APACHE II. Mortality was 80% in patients with ICG-PDR below 8% per minute, and survival was approximately 89% in patients with ICG-PDR above 24% per minute.

Conclusion

The results suggest that ICG-PDR, assessed with a user-friendly noninvasive bedside LiMON device, is a good predictor of survival in septic patients. Sensitivity and specificity of the noninvasive measurement of ICG-PDR on ICU admission was comparable to that obtained by APACHE II scores.     

ED bedside point-of-care lactate in patients with suspected sepsis is associated with reduced time to iv fluids and mortality

Objective

Early recognition and treatment of sepsis improves outcomes. We determined the effects of bedside point-of-care (POC) lactate measurement on test turnaround time, time to administration of IV fluids and antibiotics, mortality, and ICU admissions in adult ED patients with suspected sepsis. We hypothesized that bedside lactate POC testing would reduce time to IV fluids and antibiotics.

Methods

We compared 80 ED patients with suspected sepsis and a lactate level of 2 mmol/L or greater before and 80 similar patients after introduction of POC lactate measurements. Groups were compared with Χ² and Mann Whitney U tests. A sample size of 80 patients in each group had 85% power to detect a 30-minute difference in time to IV fluids or antibiotics.

Results

Study groups were similar in age, gender, baseline lactate levels, sepsis severity, and Sequential Organ Failure Assessment (SOFA) scores. Introduction of POC lactate was associated with significant reductions in test turnaround time (34 [26-55] vs. 122 [82-149] minutes; P < 0.001), time to IV fluids (55 [34-83] vs. 71 [42-110] minutes; P = 0.03), mortality (6% vs. 19%; P = 0.02), and ICU admissions (33% vs. 51%, P = 0.02), but not time to IV antibiotics (89 [54-156] vs. 88 [60-177] minutes; P = 0.35).

Conclusions

Implementation of bedside POC lactate measurement in adult ED patients with suspected sepsis reduces time to test results and time to administration of IV fluids but not antibiotics. A significant reduction in mortality and ICU admissions was also demonstrated, which is likely due, at least in part, to POC testing.     

Accelerometer-based devices can be used to monitor sedation/agitation in the intensive care unit

Purpose

Monitoring sedation/agitation levels in patients in the intensive care unit (ICU) are important to direct treatment and to improve outcomes. This study was designed to determine the potential use of accelerometer-based sensors/devices to objectively measure sedation/agitation in patients admitted to the ICU.

Materials and methods

Accelerometer-based devices (actigraphs) were placed on nondominant wrists of 86 patients in the ICU after informed consent. The sedation/agitation levels were classified as deep sedation, light sedation, alert and calm, mild agitation and severe agitation, and measured at regular intervals. The sedation/agitation levels were correlated with the accelerometer data (downloaded raw actigraphy data).

Results

The sedation/agitation levels correlated strongly with the accelerometer readings represented by mean actigraphy counts (r = 0.968; P = .007) and the proportion of time spent moving as determined by actigraphy (r = 0.979; P = .004).

Conclusions

Accelerometer data correlate strongly with the sedation/agitation levels of patients in the ICUs, and appropriately designed accelerometer-based sensors/devices have the potential to be used for automating objective and continuous monitoring of sedation/agitation levels in patients in the ICU.     

Pulse oximetry desaturation alarms on a general postoperative adult unit: A prospective observational study of nurse response time

Background

Continuous pulse oximetry monitoring is recommended to improve safety during postoperative opioid use, however concerns with monitoring on general care units remain, given potential system barriers to alarm transmission, recognition, and nursing response.

Methods

This prospective, observational study evaluated unit and hospital-level factors affecting nurses’ response to monitor desaturation alarms in postoperative patients on a general postoperative unit. With exemption and waiver of consent granted from the Institutional Review Board, monitoring data were downloaded from bedside monitors of postoperative patients. Alarm notification data and response times were recorded from the continuous capture of institutional surveillance data. Paging notifications were coded as clinically relevant (i.e., true oxygen desaturation with SpO₂ < 89 for > 15 s) or irrelevant (i.e., artifact, inappropriate alarm threshold, or failure to delay page). Linear mixed models, and correlation coefficients were used to examine the relationships between unit staffing, shift, paging burden and response time. Means and [95% confidence intervals] are presented.

Results

1616 monitoring hours in 103 patients yielded 342 desaturation events (duration 23.6 s [20.99, 26.1]) and 710 notification pages, 36% of which were for clinically relevant desaturation. Nursing response time was 52.1 s [46.4, 57.7], which was longer at night (63.8 [51.2, 76.35]; p = 0.035), but not related to unit staffing. Missed alarm events (i.e., no notification page transmitted) occurred for 26% of the clinically relevant events, and were associated with higher paging burden (p = 0.04), lower SpO₂ values (81.8 [80.5, 83.0] vs. 83.2 [82.6, 83.8]; p = 0.026), and higher odds of intervention (OR 3.5 [1.38, 8.9]). 65% of patients with desaturation events received interventions which correlated with the number of pages (rho = 0.422; p < 0.01) and events (rho = 0.57; p < 0.01), desaturation duration (rho = 0.505; p < 0.01), and SpO₂ (rho = −0.324; p < 0.01).

Conclusions

One-third of pulse oximetry alarm notifications were for clinically relevant oxygen desaturation, facilitating timely nursing response and intervention for most patients. Unit staffing and false alarm frequency were not associated with response time, suggesting a high level of attention on this unit. The nature and degree of missed alarm events suggests patient safety concerns posed by hospital-level transmission systems warranting further strategies to ensure monitoring safety.     

Location of patients before transfer to a tertiary care intensive care unit: Impact on outcome

Objective

To evaluate the impact of the source of patients transferred to a tertiary care intensive care unit (ICU) (referring hospital ICU vs referring hospital emergency department [ED]) on outcomes of transferred patients.

Design and Setting

We performed a retrospective review of data contained in the Project Impact database of a medical-surgical ICU at a university hospital.

Patients and Participants

A total of 503 patients transferred from local community hospitals, 283 from EDs and 220 from ICUs, were identified and included. In addition to comparing all ED transfers with all ICU transfers, comparisons between the 2 populations were made for the subgroups of patients with intracranial hemorrhage (group 1), nonhemorrhagic stroke (group 2), and all other patients (group 3).

Measurements and Results

Patients were evaluated for a variety of outcome parameters, including mortality and ICU and hospital length of stay (LOS) according to their location at the referring hospital at the time of transfer: ICU (ICUtx) or ED (EDtx). Mortality was significantly lower among EDtx in all transferred patients as well as in groups 2 and 3 with no difference in mortality identified in group 1. Intensive care unit LOS was shorter for EDtx and the 3 groups, and hospital LOS was shorter among all EDtx and those in group 3. Group 3 EDtx also had lower than predicted mortality.

Conclusions

Transfer of patients to a tertiary care ICU from the ED of a referring hospital is associated with significantly better outcomes than transfers from referring hospital ICUs.     

Middle-Aged Man with Left Neck Pain and Swelling

Background

Disorders of the salivary glands can be evaluated by bedside ultrasonography and should be considered in patients presenting with undifferentiated neck swelling.

Objective

Our aim was to describe the sonographic findings present in sialolithiasis and sialadenitis.

Case Report

A 61-year-old man presented to the emergency department with 2 days of neck swelling. Initial evaluation included a bedside ultrasound that demonstrated sialolithiasis, which was later confirmed by computed tomography.

Conclusions

Bedside ultrasound can be a useful imaging modality in the evaluation of the patient with neck swelling.     

Delirium in patients admitted to a step-down unit: Analysis of incidence and risk factors

Background

Delirium is a rather common complication among patients admitted in intensive care units (ICUs), and rather than a single entity, it can be considered a spectrum of diseases where, besides overt cases, there are also many subsyndromal forms. Although there are many data about ICU delirium, there are few data concerning this complication in patients transferred from the ICU to a step-down unit (SDU) once clinically stable.

Objectives

With the present study, we wanted to assess the incidence of and risk factors for delirium and subsyndromal forms and their impact on clinical outcome in a group of patients transferred from an ICU to an SDU.

Methods

All patients transferred from an ICU to our SDU over a 2-year period were screened for delirium and subsyndromal delirious forms using the Intensive Care Delirium Screening Checklist, a simple tool already validated in the ICU. The following data were also recorded: demographic data, severity score (SAPS II), reason for admission to the SDU, length of stay, death rate, use of sedatives, impact of delirium on weaning from mechanical ventilation (MV).

Results

Among the 234 patients, the incidence of delirium and subsyndromal forms was 7.6% and 20%, respectively. Subsyndromal forms diagnosed at admission represented a risk factor for the subsequent development of delirium (odds ratio [OR], P < .0001). A previous episode of brain failure during ICU stay and older age were risks factors for the development of subsyndromal forms, whereas not needing MV was a protective factor. Delirium significantly prolonged the stay in the SDU but did not influence survival and the process of weaning from MV. Overall, the percentage of patients with an abnormal Intensive Care Delirium Screening Checklist score at discharge (5%) was reduced compared with that recorded at admission (18%).

Conclusions

Delirium may still occur after discharge from an ICU in patients who are transferred to an SDU. The strategy of care adopted in the SDU seems to positively affect the recovery from a delirious state. Patients with subsyndromal forms should be promptly recognized and treated because of the risk of developing delirium. Weaning from MV is not hindered by delirium.     

Revised Acute Physiology and Chronic Health Evaluation score as a predictor of neurosurgery intensive care unit readmission: A case-controlled study

Purpose

Patients with neurologic system problems are among the most common patients readmitted to the intensive care unit (ICU). Readmission predictors for neurologic ICU patients have not been established. Previous research suggests that the Revised Acute Physiology and Chronic Health Evaluation (APACHE II) score is one indication of the critical status of ICU-admitted patients; however, the ability of the discharge APACHE II to predict readmission to the ICU requires further study. The purpose of this study was to investigate the ability of the APACHE II scoring system to predict ICU readmission of neurosurgical and ICU patients.

Materials and Methods

A retrospective case-controlled comparison study and a review of patient records for all patients admitted to 8 ICUs from January 2003 to June 2005 (N = 753) were conducted. Readmitted neurosurgery ICU patients were matched with 58 randomly selected nonreadmitted patients.

Results

Nine variables were significantly different between the readmission and case-controlled group. The APACHE II discharge score was the only significant predictor and was able to predict 18.6% of neurologic ICU readmissions. The risk of ICU readmission increased when the APACHE II score at the time of discharge exceeded 8.5 points.

Conclusions

The risk of ICU readmission of neurologic ICU patients can be predicted by determining APACHE II score upon ICU discharge.     

Emergency Bedside Ultrasound Diagnosis of Superior Mesenteric Artery Dissection Complicating Acute Aortic Dissection

Background

A timely diagnosis of aortic dissection is associated with lower mortality. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, there is limited literature regarding the use of bedside ultrasound to identify superior mesenteric artery dissection, a known high-risk feature of aortic dissection.

Objective

Our aim was to present a case of superior mesenteric artery dissection identified by bedside ultrasound and review the utility of bedside ultrasound in the diagnosis of aortic emergencies.

Case Report

We report a case of superior mesenteric artery dissection found on emergent bedside ultrasound in a 46-year-old male complaining of abdominal pain with a history of cocaine abuse and prior aortic dissection. Bedside ultrasound in the emergency department revealed an intimal flap in the descending aorta with extension into the superior mesenteric artery prompting early surgical consultation before computed tomography because of concern for acute mesenteric ischemia.

Conclusion

Superior mesenteric artery dissection is a high-risk feature of aortic dissection and can be identified with emergent bedside ultrasound.     

Comparison of circuit patency and exchange rates between 2 different continuous renal replacement therapy machines

Background

Continuous renal replacement therapy (CRRT) is an important tool in the care of critically ill patients. However, the impact of a specific CRRT machine type on the successful delivery of CRRT is unclear. The purpose of this study was to evaluate the effectiveness of CRRT delivery with an intensive care unit (ICU) bedside nurse delivery model for CRRT while comparing circuit patency and circuit exchange rates in 2 Food and Drug Administration–approved CRRT devices. This article presents the data comparing circuit exchange rates for 2 different CRRT machines.

Materials and Methods

A group of ICU nurses were selected to undergo expanded training in CRRT operation and empowered to deliver all aspects of CRRT. The ICU nurses then provided all aspects of CRRT on 2 Food and Drug Administration–approved CRRT devices for 6 months. Each device was used exclusively in the designated ICU for a 2-week run-in period followed by 3-month data collection period. The primary end point for the study was the differences in average number of filter exchanges per day during each CRRT event.

Results

A total of 45 unique patients who underwent 64 separate CRRT treatment periods were included. Four CRRT events were excluded (see text for details). Twenty-eight CRRT events occurred in the NxStage System One arm (NxStage Medical, Lawrence, Mass) and 32 events in the Gambro Prismaflex arm (Gambro Renal Products, Boulder, Colo). Average (SD) filter exchanges per day was 0.443 (0.60) for the NxStage System One machine and 0.553 (0.65) for Gambro Prismaflex machine (P = .09).

Conclusions

There was no demonstrable difference in circuit patency as defined by the rate of filter exchanges per day of CRRT therapy.     

Unplanned admission to intensive care after emergency hospitalisation: Risk factors and development of a nomogram for individualising risk

Background and aims

Unplanned admission to an intensive care unit (ICU) is associated with high mortality, having the highest incidence among patients who are emergency admissions to the hospital. This study was designed to identify factors associated with unplanned ICU admission in emergency admissions to hospital and develop an absolute risk tool to individualise the risk of an event during a hospital stay.

Methods

Emergency department (ED) and in-patient hospital data from a large teaching hospital of consecutive admissions from 1 January 1997 to 31 December 2007 aged over 14 years was included in this study. Patient data extracted from 126 826 emergency presentations admitted as in-patients consisted of demographic and clinical variables.

Results

During an 11-year period 1582 incident unplanned ICU admissions occurred. Predictors of unplanned ICU admission included older age, being male, having a higher acuity triage category and a history of co-morbid conditions. Emergency department diagnostic groups associated with higher incidence of unplanned ICU admission included: sepsis, acute renal failure, lymphatic–hematopoietic tissue neoplasms, pneumonia, chronic-airways disease and bowel obstruction. The final model used to develop the nomogram had an ROC curve AUC of 0.7.

Conclusion

This study identified factors associated with unplanned ICU admission and developed a nomogram to individualise risk prior to a patient being transferred from the ED. This nomogram provides clinicians the opportunity prior to transfer from the ED, to either (1) review the appropriateness of the ward level of planned transfer or (2) flag patients for follow-up on the general ward to assess for deterioration.