Family centeredness of care: a cross-sectional study in intensive care units part of the European society of intensive care medicine.

PURPOSE: To identify key components and variations in family-centered care practices. METHODS: A cross-sectional study, conducted across ESICM members. Participating ICUs completed a questionnaire covering general ICU characteristics, visitation policies, team-family interactions, and end-of-life decision-making. The primary outcome, self-rated family-centeredness, was assessed using a visual analog scale. Additionally, respondents completed the Maslach Burnout Inventory and the Ethical Decision Making Climate Questionnaire to capture burnout dimensions and assess the ethical decision-making climate. RESULTS: The response rate was 53% (respondents from 359/683 invited ICUs who actually open the email); participating healthcare professionals (HCPs) were from Europe (62%), Asia (9%), South America (6%), North America (5%), Middle East (4%), and Australia/New Zealand (4%). The importance of family-centeredness was ranked high, median 7 (IQR 6-8) of 10 on VAS. Significant differences were observed across quartiles of family centeredness, including in visitation policies availability of a waiting rooms, family rooms, family information leaflet, visiting hours, night visits, sleep in the ICU, and in team-family interactions, including daily information, routine day-3 conference, and willingness to empower nurses and relatives. Higher family centeredness correlated with family involvement in rounds, participation in patient care and end-of-life practices. Burnout symptoms (41% of respondents) were negatively associated with family-centeredness. Ethical climate and willingness to empower nurses were independent predictors of family centeredness. CONCLUSIONS: This study emphasizes the need to prioritize healthcare providers' mental health for enhanced family-centered care. Further research is warranted to assess the impact of improving the ethical climate on family-centeredness.

Prevalence of skin pressure injury in critical care patients in the UK: results of a single-day point prevalence evaluation in adult critically ill patients.

OBJECTIVES: Hospital-acquired pressure injuries (PIs) are a source of morbidity and mortality, and many are potentially preventable. DESIGN: This study prospectively evaluated the prevalence and the associated factors of PIs in adult critical care patients admitted to intensive care units (ICU) in the UK. SETTING: This service evaluation was part of a larger, international, single-day point prevalence study of PIs in adult ICU patients. Training was provided to healthcare givers using an electronic platform to ensure standardised recognition and staging of PIs across all sites. PARTICIPANTS: The characteristics of the ICUs were recorded before the survey; deidentified patient data were collected using a case report form and uploaded onto a secure online platform. PRIMARY AND SECONDARY OUTCOME MEASURES: Factors associated with ICU-acquired PIs in the UK were analysed descriptively and using mixed multiple logistic regression analysis. RESULTS: Data from 1312 adult patients admitted to 94 UK ICUs were collected. The proportion of individuals with at least one PI was 16% (211 out of 1312 patients), of whom 8.8% (n=115/1312) acquired one or more PIs in the ICU and 7.3% (n=96/1312) prior to ICU admission. The total number of PIs was 311, of which 148 (47.6%) were acquired in the ICU. The location of majority of these PIs was the sacral area, followed by the heels. Braden score and prior length of ICU stay were associated with PI development. CONCLUSIONS: The prevalence and the stage of severity of PIs were generally low in adult critically ill patients admitted to participating UK ICUs during the study period. However, PIs are a problem in an important minority of patients. Lower Braden score and longer length of ICU stay were associated with the development of injuries; most ICUs assess risk using tools which do not account for this. TRIAL REGISTRATION NUMBER: NCT03270345.

Ten areas for ICU clinicians to be aware of to help retain nurses in the ICU.

Shortage of nurses on the ICU is not a new phenomenon, but has been exacerbated by the COVID-19 pandemic. The underlying reasons are relatively well-recognized, and include excessive workload, moral distress, and perception of inappropriate care, leading to burnout and increased intent to leave, setting up a vicious circle whereby fewer nurses result in increased pressure and stress on those remaining. Nursing shortages impact patient care and quality-of-work life for all ICU staff and efforts should be made by management, nurse leaders, and ICU clinicians to understand and ameliorate the factors that lead nurses to leave. Here, we highlight 10 broad areas that ICU clinicians should be aware of that may improve quality of work-life and thus potentially help with critical care nurse retention.

Development of competencies for advanced nursing practice in intensive care units across Europe: A modified e-Delphi study.

PURPOSE: The aim of this study was to identify and define core competencies for advanced nursing roles in adult intensive care units across Europe. METHODS: Three round electronic Delphi conducted between September 2018 and November 2019, with an expert panel of 184 nurses from 20 countries, supplemented by consensus meetings with 16 participants from 10 countries before each round. RESULTS: In Round 1, participants generated 275 statements across 4 domains (knowledge skills and clinical performance; clinical leadership, teaching and supervision; personal effectiveness; safety and systems management). These were re-worded as competency statements and refined at a consensus meeting resulting in 230 statements in 30 sub-domains. The expert panel rated the 'importance' of each statement in Round 2; further refinement at the consensus meeting and the addition of descriptors for sub-domains resulted in 95 competency statements presented to the panel in Round 3. These were all retained in the final set of competency statements. CONCLUSION: We have used consensus techniques to generate competencies for advanced practice in intensive care nursing that are relevant across European countries and available in eight languages. These have provided the basis for an outline curriculum from which education programmes can be developed within countries.

Epidemiology and outcome of pressure injuries in critically ill patients with chronic obstructive pulmonary disease: A propensity score adjusted analysis.

BACKGROUND: Pressure injuries are a frequent complication in intensive care unit (ICU) patients, especially in those with comorbid conditions such as chronic obstructive pulmonary disease (COPD). Yet no epidemiological data on pressure injuries in critically ill COPD patients are available. OBJECTIVE: To assess the prevalence of ICU-acquired pressure injuries in critically ill COPD patients and to investigate associations between COPD status, presence of ICU-acquired pressure injury, and mortality. STUDY DESIGN AND METHODS: This is a secondary analysis of prospectively collected data from DecubICUs, a multinational one-day point-prevalence study of pressure injuries in adult ICU patients. We generated a propensity score summarizing risk for COPD and ICU-acquired pressure injury. The propensity score was used as matching criterion (1:1-ratio) to assess the proportion of ICU-acquired pressure injury attributable to COPD. The propensity score was then used in regression modeling assessing the association of COPD with risk of ICU-acquired pressure injury, and examining variables associated with mortality (Cox proportional-hazard regression). RESULTS: Of the 13,254 patients recruited to DecubICUs, 1663 (12.5%) had documented COPD. ICU-acquired pressure injury prevalence was higher in COPD patients: 22.1% (95% confidence interval [CI] 20.2 to 24.2) vs. 15.3% (95% CI 14.7 to 16.0). COPD was independently associated with developing ICU-acquired pressure injury (odds ratio 1.40, 95% CI 1.23 to 1.61); the proportion attributable to COPD was 6.4% (95% CI 5.2 to 7.6). Compared with non-COPD patients without pressure injury, mortality was no different among patients without COPD but with pressure injury (hazard ratio [HR] 1.07, 95% CI 0.97 to 1.17) or COPD patients without pressure injury (HR 1.13, 95% CI 1.00 to 1.27). Mortality was higher among COPD patients with pressure injury (HR 1.35, 95% CI 1.15 to 1.58). CONCLUSION AND IMPLICATIONS: Critically ill COPD patients have a statistically significant higher risk of pressure injury. Moreover, those that develop pressure injury are at higher risk of mortality. As such, pressure injury may serve as a surrogate for poor prognostic status to help clinicians identify patients at high risk of death. Also, delivery of interventions to prevent pressure injury are paramount in critically ill COPD patients. Further studies should determine if early intervention in critically ill COPD patients can modify development of pressure injury and improve prognosis.

Management and outcomes in critically ill nonagenarian versus octogenarian patients.

BACKGROUND: Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup and place a huge financial burden on health care resources despite the benefit being unclear. This leads to ethical problems. The present investigation assessed the differences in outcome between nonagenarian and octogenarian ICU patients. METHODS: We included 7900 acutely admitted older critically ill patients from two large, multinational studies. The primary outcome was 30-day-mortality, and the secondary outcome was ICU-mortality. Baseline characteristics consisted of frailty assessed by the Clinical Frailty Scale (CFS), ICU-management, and outcomes were compared between octogenarian (80-89.9 years) and nonagenarian (> 90 years) patients. We used multilevel logistic regression to evaluate differences between octogenarians and nonagenarians. RESULTS: The nonagenarians were 10% of the entire cohort. They experienced a higher percentage of frailty (58% vs 42%; p < 0.001), but lower SOFA scores at admission (6 + 5 vs. 7 + 6; p < 0.001). ICU-management strategies were different. Octogenarians required higher rates of organ support and nonagenarians received higher rates of life-sustaining treatment limitations (40% vs. 33%; p < 0.001). ICU mortality was comparable (27% vs. 27%; p = 0.973) but a higher 30-day-mortality (45% vs. 40%; p = 0.029) was seen in the nonagenarians. After multivariable adjustment nonagenarians had no significantly increased risk for 30-day-mortality (aOR 1.25 (95% CI 0.90-1.74; p = 0.19)). CONCLUSION: After adjustment for confounders, nonagenarians demonstrated no higher 30-day mortality than octogenarian patients. In this study, being age 90 years or more is no particular risk factor for an adverse outcome. This should be considered- together with illness severity and pre-existing functional capacity - to effectively guide triage decisions. TRIAL REGISTRATION: NCT03134807 and NCT03370692 .

Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs.

BACKGROUND: Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear. OBJECTIVE: To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function. DESIGN: Prospective cohort study. SETTING: 241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019. SUBJECTS: Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2. METHODS: Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected. RESULTS: Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001). CONCLUSIONS: There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study.

PURPOSE: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. METHODS: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. RESULTS: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9-27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6-16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score < 19, ICU stay > 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2-1.8), stage II (OR 1.6; 95% CI 1.4-1.9), and stage III or worse (OR 2.8; 95% CI 2.3-3.3). CONCLUSION: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat.

Sex-specific outcome disparities in very old patients admitted to intensive care medicine: a propensity matched analysis.

Female and male very elderly intensive patients (VIPs) might differ in characteristics and outcomes. We aimed to compare female versus male VIPs in a large, multinational collective of VIPs with regards to outcome and predictors of mortality. In total, 7555 patients were included in this analysis, 3973 (53%) male and 3582 (47%) female patients. The primary endpoint was 30-day-mortality. Baseline characteristics, data on management and geriatric scores including frailty assessed by Clinical Frailty Scale (CFS) were documented. Two propensity scores (for being male) were obtained for consecutive matching, score 1 for baseline characteristics and score 2 for baseline characteristics and ICU management. Male VIPs were younger (83 ± 5 vs. 84 ± 5; p < 0.001), less often frail (CFS > 4; 38% versus 49%; p < 0.001) but evidenced higher SOFA (7 ± 6 versus 6 ± 6 points; p < 0.001) scores. After propensity score matching, no differences in baseline characteristics could be observed. In the paired analysis, the mortality in male VIPs was higher (mean difference 3.34% 95%CI 0.92-5.76%; p = 0.007) compared to females. In both multivariable logistic regression models correcting for propensity score 1 (aOR 1.15 95%CI 1.03-1.27; p = 0.007) and propensity score 2 (aOR 1.15 95%CI 1.04-1.27; p = 0.007) male sex was independently associated with higher odds for 30-day-mortality. Of note, male gender was not associated with ICU mortality (OR 1.08 95%CI 0.98-1.19; p = 0.14). Outcomes of elderly intensive care patients evidenced independent sex differences. Male sex was associated with adverse 30-day-mortality but not ICU-mortality. Further research to identify potential sex-specific risk factors after ICU discharge is warranted.Trial registration: NCT03134807 and NCT03370692; Registered on May 1, 2017 https://clinicaltrials.gov/ct2/show/NCT03370692 .

The quality of intensive care unit nurse handover related to end of life: a descriptive comparative international study.

BACKGROUND: Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it. OBJECTIVE: The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries. DESIGN: This was a descriptive comparative study. SETTINGS: The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units). PARTICIPANTS: A convenience sample of 157 handovers was studied. METHODS: Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors. RESULTS: The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154)=25.97, p=<.001; unit: F(6,150)=58.24, p=<.001), for the end of life subscale (country: F(2, 154)=28.23, p<.001; unit: F(6,150)=25.25, p=<.001), the family communication subscale (country: F(2,154)=15.04, p=<.001; unit: F(6,150)=27.38, p=<.001), the family needs subscale (F(2,154)=22.33, p=<.001; unit: F(6,150)=42.45, p=<.001) but only for units on the process subscale (F(6,150)=8.98, p=<.001. The total handover score was higher if the oncoming RN did not know the patient (F(1,155)=6.51, p=<.05), if the patient was expected to die during the shift (F(1,155)=89.67, p=<.01) and if the family were present (F(1,155)=25.81, p=<.01). CONCLUSIONS: Practices of end-of-life-handover communication vary greatly between units. However, room for improvement exists in all areas in all of the units studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool.

Non-therapeutic omission of medications in acutely ill patients.

AIMS AND OBJECTIVES: To examine documentation of medication administration in medical and surgical patients. STUDY OBJECTIVES: (1) Determine the point prevalence of non-therapeutic medication omissions; (2) identify documented reasons for non-therapeutic medication omissions; (3) examine the relationship between length of stay and medication omissions; and (4) explore the impact of outlier status (e.g. medical patients managed on surgical wards) on medication administration. BACKGROUND: Acutely ill patients are particularly sensitive to health care errors. We previously identified a 26% rate of non-therapeutic medication omissions in patients admitted unexpectedly to intensive care unit (ICU) from medical and surgical wards. DESIGN: A point prevalence survey of 162 medical and surgical patients across four sites in the South West of England. METHOD: Data collected included: all instances of, and reasons for, non-therapeutic medication omission. We also recorded whether the patient was an 'outlier' and examined nursing documentation where no reason for medication omission was given on the drug chart. RESULTS: The number of patients who missed at least one medication was high across all sites (n = 129/162; 79.6%, range 60-88%), with a total of 1077 doses omitted. Patients who were outliers (e.g. surgical patients on a medical ward) were more likely to miss medications (100% versus 74%, p < 0.001). The most common missed medications were analgesia and anti-inflammatory drugs (28%, 299/1077); 203 of these were due to patient refusal. CONCLUSIONS: The extent of medications omitted for non-therapeutic reasons in medical and surgical patients is of concern. None were recorded as an adverse drug event; however, the extent of omitted or refused medications suggests the need for a review of prescribing and drug administration processes. These findings have important implications for the role of ICU outreach and liaison services, for example, including medication management in the monitoring of patients pre/post-ICU admission and support/education provided for ward staff. RELEVANCE TO CLINICAL PRACTICE: Detailed analysis of medication records suggests a number of areas of medication administration that would benefit from review.

Prospective observational measurement of tracheal tube cuff pressures in the emergency department.

BACKGROUND: Tracheal mucosal blood flow is impaired when tracheal tube cuff pressure is above 30 cm of water, with the potential for tracheal mucosal necrosis. Previous studies have found excessive cuff pressures in simulated patients intubated by North American emergency physicians as well as patients intubated in the prehospital setting and emergency department (ED). This study assessed whether patients intubated in a UK prehospital setting or ED had excessive cuff pressures. METHOD: Prospective observational study in five ED in southwest England over a 2-month period. All patients over 18 years and intubated in the prehospital setting or in the ED were included. Clinical staff independent of the patients' care recorded the following: age, sex, presenting complaint and indication for intubation, tube size and cuff pressure. Neither the paramedics nor the participating ED staff were aware of the study purpose. Cuff pressure measurements were recorded using a standardised cuff inflator pressure gauge. RESULT: 61 patients were recruited. The median and mean cuff pressures were 58 and 62 cm of water, respectively. 75% of patients had a cuff pressure greater than 30 cm of water. The median cuff pressures in those patients intubated by senior emergency physicians, junior emergency physicians and paramedics were 70, 46 and 79 cm of water, respectively. CONCLUSION: Excessive tracheal tube cuff pressures were demonstrated in the majority of patients intubated both in the prehospital setting and ED. This is in keeping with existing evidence. Early measurement and adjustment of cuff pressures is recommended for those patients who require ongoing care.

How to measure and record vital signs to ensure detection of deteriorating patients.

This article aims to provide registered nurses with knowledge, skills and practical advice to improve the assessment, recording and reporting of patient observations. Using guidance from Patient Safety First's intervention on reducing harm from deterioration, common issues forward staff are illustrated and practical advice is given.