The association of intensive care capacity transfers with survival in COVID-19 patients from a Scottish district general hospital: A retrospective cohort study.

Background: During the second wave of COVID-19 cases within Scotland, local evidence suggested that a large number of interhospital transfers occurred due to both physical capacity and staff shortages. Although there are inherent risks with transferring critically ill patients between hospitals, there are signals in the literature that mortality is not affected in COVID-19 patients when transferred between intensive care units. With a lack of evidence in the Scottish population, and as the greatest source of capacity transfers in our critical care network at that time, we sought to determine whether these transfers impacted on survival to hospital discharge.Methods: We conducted a retrospective cohort study of all patients admitted to our unit between the 1st October 2020 and the 31st March 2021 with a primary diagnosis of COVID-19 pneumonia. Patients were grouped according to whether they underwent an interhospital capacity transfer or not, either for unit shortage of beds or unit shortage of staff. The primary outcome measure was survival to ultimate hospital discharge, and secondary outcomes included total ventilator days and total intensive care unit length of stay. Baseline characteristic data were also collected for all patients. Survival data were entered into a backward stepwise logistic regression analysis that included transfer status, and coefficients transformed into odds ratios and 95% confidence intervals.Results: A total of 108 patients were included. Of these, 30 were transferred to another intensive care unit due to capacity issues at the base hospital. From the baseline characteristic data, age was significantly higher in those transferred out, while other characteristics were similar. Unadjusted mortality rates were 30.8% for those not transferred, and 40% for those transferred out. However, when entered into a logistic regression analysis to attempt to control for confounders in the baseline characteristics, being transferred had an odds ratio of 1.14 (95% confidence interval 0.43-3.1) for survival to hospital discharge. Total ventilator days and total ICU length of stay were both higher in the transferred patients.Conclusion: This unique study of COVID-19 patients transferred from a Scottish district general hospital did not show an association between transfer status and survival to hospital discharge. However, the study was likely underpowered to detect small differences. As the situation continues to evolve, a prospective regional multi-centre study may help to provide more robust findings.

A team approach to the introduction of safe early mobilisation in an adult critical care unit.

Delirium and intensive care unit acquired weakness are common in patients requiring critical care and associated with higher mortality and poor long-term outcomes. Early mobilisation has been shown to reduce the duration of both conditions and is recommended as part of a strategy of rehabilitation of critically ill patients starting during their stay in intensive care. Our aim was to achieve 95% reliability with a standardised mobilisation process. Multidisciplinary involvement through the use of regular focus groups lead to the development of a standardised process of sitting a ventilated or non-ventilated patient at the side of the bed for a set period of time, which was called the daily dangle. Team learning from Plan, Do, Study, Act (PDSA)cycles, as well as feedback from both staff and patients, allowed us to develop the process and achieve a median 87% reliability. Delirium rates fell from 54.1% to 28.8%. There was no change in average length of stay, and no adverse events. Ownership by the staff, development of the process by staff, iterative testing and learning, and designs for reliability were the factors behind the successful adoption of a new and challenging process. Particular changes which drove reliability were standardisation of the criteria for a dangle, standardisation of the dangle itself and a reminder included on the daily goals checklist.

Collaborative approach to reducing cardiac arrests in an acute medical unit.

Cardiac arrests are often preceded by a period of physiological deterioration. Preventing potentially avoidable cardiac arrests therefore depends on reliable recognition of, and response to, those deteriorations. Our hospital's acute medical unit had one of the highest rates of cardiac arrest in our organisation at baseline. The aim was to reduce our unit's cardiac arrest rate by over 50%. Pareto chart analysis identified unreliable processes in the recognition and response to deteriorating patients. Process mapping exercises were performed, then the model for improvement and rapid cycle tests of change were used to develop standardised processes for clinical observations, recognising deteriorating patients and responding to hypoxia. Multidisciplinary learning from what went well, incorporating resilience engineering principles, helped to identify good practice and then test ways of making good practice happen more reliably. Learning from success also addressed some of the psychological barriers to change by encouraging pride in work and a positive focus within our unit. The cardiac arrest rate reduced from 4.3/1000 (October 2014 to February 2016) to 1.1/1000 (March 2016 to end of 2016), associated with improved reliability of the following process measures: reliability of clinical observations, documentation of target oxygen saturations, identification of hypoxia and completion of structured response to hypoxia. This study is an example of a multidisciplinary team engaging in quality improvement, identifying their own local problems and testing their solutions scientifically. Learning from what went well had a positive impact on the project, and the team plans to spread the successful interventions across the organisation.

Utility of the PRE-DELIRIC delirium prediction model in a Scottish ICU cohort.

The PREdiction of DELIRium for Intensive Care (PRE-DELIRIC) model reliably predicts at 24 h the development of delirium during intensive care admission. However, the model does not take account of alcohol misuse, which has a high prevalence in Scottish intensive care patients. We used the PRE-DELIRIC model to calculate the risk of delirium for patients in our ICU from May to July 2013. These patients were screened for delirium on each day of their ICU stay using the Confusion Assessment Method for ICU (CAM-ICU). Outcomes were ascertained from the national ICU database. In the 39 patients screened daily, the risk of delirium given by the PRE-DELIRIC model was positively associated with prevalence of delirium, length of ICU stay and mortality. The PRE-DELIRIC model can therefore be usefully applied to a Scottish cohort with a high prevalence of substance misuse, allowing preventive measures to be targeted.