The needs of babies discharged from special care baby units: a subject review

This subject review identifies issues of concern to primary health care nurses and parents or carers of babies discharged from special care baby units (SCBU). Common medical and developmental sequelae are discussed, and the literature on the community nursing care of these babies is reviewed. While there is a dearth of literature on this important area in nursing, there is evidence to suggest that some of these babies have particular nursing care needs requiring specific expertise.     

Socioeconomic status and outcome from intensive care in England and Wales

OBJECTIVE: The objective of this study was to estimate the association between socioeconomic status (SES) and outcome for admissions to intensive care. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: We studied 51,572 admissions to 99 intensive-care units in England and Wales between 1995 and 2000. MEASURES: The SES of admissions was measured using Carstairs deprivation scores. Outcome was hospital mortality after adjustment for case mix using the APACHE II method. RESULTS: Admissions of lower SES were, on average, younger and less likely to be following surgery. There was evidence of a SES gradient for hospital mortality in admissions after elective surgery after adjusting for case mix (test for trend P <0.001), with higher SES associated with lower mortality. In the least-deprived quintile of SES, the odds ratio for hospital mortality was 0.70 (95% confidence interval, 0.58-0.84) compared with the most deprived quintile. There was no evidence of a SES gradient for hospital mortality in nonsurgical or emergency surgical admissions, and the decision to withdraw active treatment did not differ by SES. CONCLUSIONS: There is a SES gradient for hospital mortality in elective surgical admissions that is not explained by differences in case mix or the withdrawal of active treatment. Further research is required to establish if this finding can be explained by unmeasured differences in health status at admission to an intensive-care unit or differences in care and to establish the potential impact these results may have on interpreting comparative surgical performance data.     

The association between deprivation and hospital mortality for admissions to critical care units in England

Introduction

Few studies have investigated the association between level of social deprivation and acute hospital outcome for admissions to adult general critical care units. It is important to be aware if an association exists because risk prediction models do not adjust for deprivation.

Materials and Methods

Deprivation was measured using the Index of Multiple Deprivation (IMD) 2004, developed using 2001 census data in England. Eighty-four thousand four hundred twenty-three admissions to 138 adult general critical care units in England were selected from the Case Mix Programme Database from 1 year before to 1 year after the census date and linked to the IMD using postcodes. Logistic regression analysis was used to investigate a possible association between quintile of IMD and acute hospital mortality.

Results

As deprivation increased, acute hospital mortality also increased (P < .001). This association remained after adjusting for age, sex, acute severity, medial history, source of admission, and reason for admission to critical care (adjusted odds ratio for most vs least deprived quintile, 1.19; 95% confidence interval, 1.10-1.28).

Conclusions

There is an association between increasing deprivation and increasing risk of mortality for admissions to adult general critical care unit units in England. Further research is required to identify other unmeasured potential confounders (eg, smoking, alcohol consumption) as possible explanations for this association.     

Mums and Dads need care too. Supporting parents of babies in neonatal units

New parenthood can be traumatic and stressful at the best of times, but for parents with a baby in a neonatal unit, the experience can be much more difficult to deal with. The support received from unit staff can make all the difference.     

Resident care needs and work stressors in special care units versus non-specialized long-term care units

Differences in how elderly residents' care needs affect staff's experiences of work stressors between special care units (SCUs) for dementia and psychiatric residents and non-SCUs were investigated. The data were drawn from 390 staff members in 38 long-term care SCUs, and 587 staff in 53 non-SCUs in Finland. Residents' care needs were based on the Resident Assessment Instrument (RAI) system measured by the Minimum Data Set 2.0. Work stressors (time-pressure and role-conflicts) were assessed with a staff survey questionnaire. Multiple-group regression analysis showed that residents' dependency in activities of daily living (ADL) was related to increased work stressors only in SCUs. A high proportion of behavioral problems was related to fewer work stressors for SCU staff, but more for non-SCU staff. Work stressors may be reduced by specializing, so that residents with similar care needs are placed together and care is focused.     

Lack of change in trauma care in England and Wales since 1994

Abstract: To demonstrate trends in trauma care in England and Wales from 1989 to 2000.

Study population: Database of the Trauma Audit and Research Network that includes hospital patients admitted for three days or more, those who died, were transferred or admitted to an intensive care or high dependency area.

Method: To demonstrate trends in outcome, severity adjusted odds of death per year of admission to hospital were calculated for all hospitals (n=99) and 20 hospitals who had participated since 1989 (adjustments are for Injury Severity Score, age, and Revised Trauma Score). The grade of doctor initially seeing the injured patient in accident and emergency and median prehospital times per year of admission were calculated to demonstrate trends in the process of care. Trend analyses were carried out using simple linear regression (odds ratio versus year).

Results: The analysis shows a significant reduction in the severity adjusted odds of death of 3% per year over the 1989–2000 time period (p=0.001). During the period 1989–1994 the odds of death declined most steeply (on average 6% per year p=0.004). Between 1994 to 2000 no significant change occurred (p=0.35). This pattern was mirrored by the 20 permanent members where the odds of death also declined more steeply over the 1989–1994 period. The percentage of severely injured patients (ISS >15) seen by a consultant increased from 29 to 40 from 1989–1994 but has remained static subsequently. Median prehospital times for severely injured patients have not changed significantly since 1994 (51 to 45 minutes).

Conclusion: Most of the case fatality reduction for trauma patients reaching hospital over the 1989–2000 time period occurred before 1995 when there was most marked change in the initial care of severely injured patients.

     

The link between teamwork and patients' outcomes in intensive care units.

BACKGROUND: Links between teamwork and outcomes have been established in a number of fields. Investigations into this link in healthcare have yielded equivocal results. OBJECTIVE: To examine the relationship between the level of self-identified teamwork in the intensive care unit and patients' outcomes. METHOD: A total of 394 staff members of 17 intensive care units completed the Group Development Questionnaire and a demographic survey. The questionnaire is a reliable and valid measure of team development and effectiveness. Each unit's predicted and actual mortality rates for the month in which data were collected were obtained. Pearson product moment correlations and analyses of variance were used to analyze the data. RESULTS: Staff members of units with mortality rates that were lower than predicted perceived their teams as functioning at higher stages of group development. They perceived their team members as less dependent and more trusting than did staff members of units with mortality rates that were higher than predicted. Staff members of high-performing units also perceived their teams as more structured and organized than did staff members of lower-performing units. CONCLUSIONS: The results of this study and other establish a link between teamwork and patients' outcomes in intensive care units. The evidence is sufficient to warrant the implementation of strategies designed to improve the level of teamwork and collaboration among staff members in intensive care units.     

Epidemiology of severe sepsis occurring in the first 24 hrs in intensive care units in England, Wales, and Northern Ireland

OBJECTIVE: To investigate the numbers, clinical characteristics, resource use, and outcomes of admissions who met precise clinical and physiologic criteria for severe sepsis (as defined in the PROWESS trial) in the first 24 hrs in the intensive care unit. DESIGN: Observational cohort study, with retrospective analysis of prospectively collected data. SETTING: Ninety-one adult general intensive care units in England, Wales, and Northern Ireland between 1995 and 2000. PATIENTS: Patients were 56,673 adult admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We found that 27.1% of adult intensive care unit admissions met severe sepsis criteria in the first 24 hrs in the intensive care unit. Most were nonsurgical (67%), and the most common organ system dysfunctions were seen in the cardiovascular (88%) and respiratory (81%) systems. Modeling the data for England and Wales for 1997 suggested that 51 (95% confidence interval, 46-58) per 100,000 population per year were admitted to intensive care units and met severe sepsis criteria in the first 24 hrs.Of the intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, 35% died before intensive care unit discharge and 47% died during their hospital stay. Hospital mortality rate ranged from 17% in the 16-19 age group to 64% in those >85 yrs. In England and Wales in 1997, an estimated 24 (95% confidence interval, 21-28) per 100,000 population per year died after intensive care unit admissions with severe sepsis in the first 24 hrs.For intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, median intensive care unit length of stay was 3.56 days (interquartile range, 1.50-9.32) and median hospital length of stay was 18 days (interquartile range, 8-36 days). These admissions used 45% of the intensive care unit and 33% of the hospital bed days used by all intensive care unit admissions. CONCLUSIONS: Severe sepsis is common and presents a major challenge for clinicians, managers, and healthcare policymakers. Intensive care unit admissions meeting severe sepsis criteria have a high mortality rate and high resource use.