STANDING Collaboration: a study protocol for developing clinical standards.

INTRODUCTION: Despite widespread availability of clinical practice guidelines (CPGs), considerable gaps continue between the care that is recommended ('appropriate care') and the care provided. Problems with current CPGs are commonly cited as barriers to providing 'appropriate care'.Our study aims to develop and test an alternative method to keep CPGs accessible and up to date. This method aims to mitigate existing problems by using a single process to develop clinical standards (embodied in clinical indicators) collaboratively with researchers, healthcare professionals, patients and consumers. A transparent and inclusive online curated (purpose-designed, custom-built, wiki-type) system will use an ongoing and iterative documentation process to facilitate synthesis of up-to-date information and make available its provenance. All participants are required to declare conflicts of interest. This protocol describes three phases: engagement of relevant stakeholders; design of a process to develop clinical standards (embodied in indicators) for 'appropriate care' for common medical conditions; and evaluation of our processes, products and feasibility. METHODS AND ANALYSIS: A modified e-Delphi process will be used to gain consensus on 'appropriate care' for a range of common medical conditions. Clinical standards and indicators will be developed through searches of national and international guidelines, and formulated with explicit criteria for inclusion, exclusion, time frame and setting. Healthcare professionals and consumers will review the indicators via the wiki-based modified e-Delphi process. Reviewers will declare conflicts of interest which will be recorded and managed according to an established protocol. The provenance of all indicators and suggestions included or excluded will be logged from indicator inception to finalisation. A mixed-methods formative evaluation of our research methodology will be undertaken. ETHICS AND DISSEMINATION: Human Research Ethics Committee approval has been received from the University of South Australia. We will submit the results of the study to relevant journals and offer national and international presentations.

Education for cardiac arrest--Treatment or prevention?

In-hospital cardiac arrests (IHCA) occur infrequently and individual staff members working on general wards may only rarely encounter one. Mortality following IHCA is high and the evidence for the benefits of many advanced life support (ALS) interventions is scarce. Nevertheless, regular, often frequent, ALS training is mandatory for many hospital medical staff and nurses. The incidence of pre-cardiac arrest deterioration is much higher than that of cardiac arrests, and there is evidence that intervention prior to cardiac arrest can reduce the incidence of IHCA. This article discusses a proposal to reduce the emphasis on widespread ALS training and to increase education in the recognition and response to pre-arrest clinical deterioration.

The ten barriers to appropriate management of patients at the end of their life.

The development of ICUs as the final option for seriously ill patients, especially the elderly frail patient at the end of his/her life, has meant that intensivists have increasingly taken on the role of diagnosing the dying. Our society, and even our medical colleagues, do not necessarily understand what we can achieve in ICUs, and even more importantly, what we cannot achieve. The next crucial step for us as individuals, and through our professional bodies, is to engage our society in discussions on our role and encourage debate and discussion, being aware of the controversies that will inevitably result. Birthing in the 1950s was medicalised without discussion with women and their families. In a similar manner, dying has been medicalised in the twenty-first century. It has not been a conspiracy and the use of futile and expensive treatment at the EoL transition is not necessarily anyone's choice. The specialty of intensive care has a particularly important role in facilitating discussions with our society in order to define different ways of managing dying.

Characteristics and outcomes of patients admitted to ICU following activation of the medical emergency team: impact of introducing a two-tier response system.

OBJECTIVE: To determine the impact of introducing a two-tier system for responding to deteriorating ward patients on ICU admissions after medical emergency team review. DESIGN: Retrospective database review before (2006-2009) and after (2011-2013) the introduction of a two-tier system. SETTING: Tertiary, university-affiliated hospital. PATIENTS: A total of 1,564 ICU admissions. INTERVENTIONS: Two-tier rapid response system. MEASUREMENTS AND MAIN RESULTS: The median number of medical emergency team activations/1,000 hospitalizations increased from 22 to 31 (difference [95% CI], 9 [5-10]; p<0.0001) with a decreased rate of medical emergency team activations leading to ICU admission (from median 11 to 8; difference [95% CI], 3 [3-4]; p=0.03). The median proportion of medical emergency team reviews leading to ICU admission increased for those triggered by tachypnoea (from 11% to 15%; difference [95% CI], 4 [3-5]; p<0.0001) and by hypotension (from 27% to 43%; difference [95% CI], 15 [12-19]; p<0.0001) and decreased for those triggered by reduced level of consciousness (from 20% to 17%; difference [95% CI], 3 [2-4]; p<0.0001) and by clinical concern (from 18% to 9%; difference [95% CI], 10 [9-13]; p<0.0001). The proportions of ICU admissions following medical emergency team review did not change significantly for tachycardia, seizure, or cardiorespiratory arrest. The overall ICU mortality for admissions following medical emergency team review for tachypnoea, tachycardia, and clinical concern decreased (from 29% to 9%: difference [95% CI], 20 [11-29]; p<0.0001) but did not change for the other triggers. The Acute Physiology and Chronic Health Evaluation predicted and observed ICU mortality and the proportion of patients dying with a not-for-resuscitation order decreased. CONCLUSIONS: The introduction of a two-tier response to clinical deterioration increased ICU admissions triggered by cardiorespiratory criteria, whereas admissions triggered by more subjective criteria decreased. The overall ICU mortality for patients admitted following medical emergency team review decreased, suggesting that the two-tier system led to earlier recognition of reversible pathology or a decision not to escalate the level of care.

Central venous catheter placement by advanced practice nurses demonstrates low procedural complication and infection rates--a report from 13 years of service*.

OBJECTIVES: To report procedural characteristics and outcomes from a central venous catheter placement service operated by advanced practice nurses. DESIGN: Single-center observational study. SETTING: A tertiary care university hospital in Sydney, Australia. PATIENTS: Adult patients from the general wards and from critical care areas receiving a central venous catheter, peripherally inserted central catheter, high-flow dialysis catheter, or midline catheter for parenteral therapy between November 1996 and December 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Prevalence rates by indication, site, and catheter type were assessed. Nonparametric tests were used to calculate differences in outcomes for categorical data. Catheter infection rates were determined per 1,000 catheter days after derivation of the denominator. A total of 4,560 catheters were placed in 3,447 patients. The most common catheters inserted were single-lumen peripherally inserted central catheters (n = 1,653; 36.3%) and single-lumen central venous catheters (n = 1,233; 27.0%). A small proportion of high-flow dialysis catheters were also inserted over the reporting period (n = 150; 3.5%). Sixty-one percent of all catheters placed were for antibiotic administration. The median device dwell time (in d) differed across cannulation sites (p < 0.001). Subclavian catheter placement had the longest dwell time with a median of 16 days (interquartile range, 8-26 d). Overall catheter dwell was reported at a cumulative 63,071 catheter days. The overall catheter-related bloodstream infection rate was 0.2 per 1,000 catheter days. The prevalence rate of pneumothorax recorded was 0.4%, and accidental arterial puncture (simple puncture-with no dilation or cannulation) was 1.3% using the subclavian vein. CONCLUSIONS: This report has demonstrated low complication rates for a hospital-wide service delivered by advance practice nurses. The results suggest that a centrally based service with specifically trained operators can be beneficial by potentially improving patient safety and promoting organizational efficiencies.

Subglottic secretion drainage for preventing ventilator associated pneumonia: a meta-analysis.

BACKGROUND: Ventilator associated pneumonia (VAP) in the intensive care unit (ICU) has been shown to be associated with significant morbidity and mortality.(1-3) It has been reported to affect between 9 and 27% of intubated patients receiving mechanical ventilation.(4-6) OBJECTIVE: A meta-analysis was undertaken to combine information from published studies of the effect of subglottic drainage of secretions on the incidence of ventilated associated pneumonia in adult ICU patients. DATA SOURCES: Studies were identified by searching MEDLINE (1966 to January 2011), EMBASE (1980-2011), and CINAHL (1982 to January 2011). REVIEW METHODS: Randomized trials of subglottic drainage of secretions compared to usual care in adult mechanically ventilated ICU patients were included in the meta-analysis. RESULTS: Subglottic drainage of secretions was estimated to reduced the risk of VAP by 48% (fixed-effect relative risk (RR)=0.52, 95% confidence interval (CI), 0.42-0.65). When comparing subglottic drainage and control groups, the summary relative risk for ICU mortality was 1.05 (95% CI, 0.86-1.28) and for hospital mortality was 0.96 (95% CI, 0.81-1.12). Overall subglottic drainage effect on days of mechanical ventilation was -1.04 days (95% CI, -2.79-0.71). CONCLUSION: This meta-analysis of published randomized control trials shows that almost one-half of cases of VAP may be prevented with the use of specialized endotracheal tubes designed to drain subglottic secretions. Time on mechanical ventilation may be reduced and time to development of VAP may be increased, but no reduction in ICU or hospital mortality has been observed in published trials.

Nurse-led central venous catheter insertion-procedural characteristics and outcomes of three intensive care based catheter placement services.

BACKGROUND: Nurse-led central venous catheter placement is an emerging clinical role internationally. Procedural characteristics and clinical outcomes is an important consideration in appraisal of such advanced nursing roles. OBJECTIVES: To review characteristics and outcomes of three nurse-led central venous catheter insertion services based in intensive care units in New South Wales, Australia. DESIGN: Using data from the Central Line Associated Bacteraemia project in New South Wales intensive care units. Descriptive statistical techniques were used to ascertain comparison rates and proportions. PARTICIPANTS: De-identified outcome data of patients who had a central venous catheter inserted as part of their therapy by one of the four advanced practice nurses working in three separate hospitals in New South Wales. RESULTS: Between March 2007 and June 2009, 760 vascular access devices were placed by the three nurse-led central venous catheter placement services. Hospital A inserted 520 catheters; Hospital C with 164; and Hospital B with 76. Over the study period, insertion outcomes were favourable with only 1 pneumothorax (1%), 1 arterial puncture (1%) and 1 CLAB (1%) being recorded across the three groups. The CLAB rate was lower in comparison to the aggregated CLAB data set [1.3 per 1000 catheters (95% CI=0.03-7.3) vs. 7.2 per 1000 catheters (95% CI=5.9-8.7)]. CONCLUSION: This study has demonstrated safe patient outcomes with nurse led CVC insertion as compared with published data. Nurses who are formally trained and credentialed to insert CVCs can improve organisational efficiencies. This study adds to emerging data that developing clinical roles that focus on skills, procedural volume and competency can be a viable option in health care facilities.

The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study.

OBJECTIVE: To investigate the role of medical emergency teams in end-of-life care planning. DESIGN: One month prospective audit of medical emergency team calls. SETTING: Seven university-affiliated hospitals in Australia, Canada, and Sweden. PATIENTS: Five hundred eighteen patients who received a medical emergency team call over 1 month. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 652 medical emergency team calls in 518 patients, with multiple calls in 99 (19.1%) patients. There were 161 (31.1%) patients with limitations of medical therapy during the study period. The limitation of medical therapy was instituted in 105 (20.3%) and 56 (10.8%) patients before and after the medical emergency team call, respectively. In 78 patients who died with a limitation of medical therapy in place, the last medical emergency team review was on the day of death in 29.5% of patients, and within 2 days in another 28.2%.Compared with patients who did not have a limitation of medical therapy, those with a limitation of medical therapy were older (80 vs. 66 yrs; p < .001), less likely to be male (44.1% vs. 55.7%; p = .014), more likely to be medical admissions (70.8% vs. 51.3%; p < .001), and less likely to be admitted from home (74.5% vs. 92.2%, p < .001). In addition, those with a limitation of medical therapy were less likely to be discharged home (22.4% vs. 63.6%; p < .001) and more likely to die in hospital (48.4% vs. 12.3%; p < .001). There was a trend for increased likelihood of calls associated with limitations of medical therapy to occur out of hours (51.0% vs. 43.8%, p = .089). CONCLUSIONS: Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals, and to confirm our findings in other organizations.

Rapid response systems: you won't know there is a problem until you measure it.

The rapid response system concept is one of the first patient-centered and organizational-wide systems aimed at preventing deaths and serious adverse events. It has been strongly argued that we need a benchmark that reflects the care of a deteriorating patient across the organization using a 'score to door time'; that is, the time from the first vital sign abnormality to admission to the ICU. The study by Oglesby and colleagues highlights serious issues, especially delays, which could adversely impact on patient care, and the study proposes that we concentrate more on measuring patient care from a broad perspective.

Readmission to intensive care: development of a nomogram for individualising risk.

BACKGROUND: Readmission to intensive care during the same hospital stay has been associated with a greater risk of in-hospital mortality and has been suggested as a marker of quality of care. There is lack of published research attempting to develop clinical prediction tools that individualise the risk of readmission to the intensive care unit during the same hospital stay. OBJECTIVE: To develop a prediction model using an inception cohort of patients surviving an initial ICU stay. DESIGN, SETTING AND PARTICIPANTS: The study was conducted at Liverpool Hospital, Sydney. An inception cohort of 14 952 patients aged 15 years or more surviving an initial ICU stay and transferred to general wards in the study hospital between 1 January 1997 and 31 December 2007 was used to develop the model. Binary logistic regression was used to develop the prediction model and a nomogram was derived to individualise the risk of readmission to the ICU during the same hospital stay. MAIN OUTCOME MEASURE: Readmission to the ICU during the same hospital stay. RESULTS: Among members of the study cohort there were 987 readmissions to ICU during the study period. Compared with patients not readmitted to the ICU, patients who were readmitted were more likely to have had ICU stays of at least 7 days (odds ratio [OR], 2.2 [95% CI, 1.85- 2.56]); non-elective initial admission to the ICU (OR, 1.7 [95% CI, 1.44-2.08]); and acute renal failure (OR, 1.6 [95% CI, 0.97-2.47]). Patients admitted to the ICU from the operating theatre or recovery ward had a lower risk of readmission to ICU than those admitted from general wards, the emergency department or other hospitals. The maximum error between observed frequencies and predicted probabilities of readmission to ICU was estimated to be 3%. The area under the receiver operating characteristic curve of the final model was 0.66. CONCLUSION: We have developed a practical clinical tool to individualise the risk of readmission to the ICU during the same hospital stay in patients who survive an initial episode of intensive care.

Central venous catheter insertion by a clinical nurse consultant or anaesthetic medical staff: a single-centre observational study.

OBJECTIVE: To compare clinical outcomes of elective central venous catheter (CVC) insertions performed by either a clinical nurse consultant (CNC) or anaesthetic medical staff (AMS). DESIGN, SETTING AND PARTICIPANTS: Prospective audit of a convenience sample of consecutive CVC insertions between July 2005 and October 2007 at a metropolitan teaching hospital in Sydney, Australia. The sample included all outpatients and inpatients requiring a CVC for either acute or chronic conditions. MAIN OUTCOME MEASURES: Number of CVC lines inserted; differences between outcomes in the CNC and AMS groups; complications during and after insertion. RESULTS: Over a 28-month period, 245 CVCs were inserted by AMS and 123 by the CNC. The most common indications for CVC placement in both groups were for the treatment of oncology and autoimmune disorders (61%) and for antibiotic therapy (27%). Other indications were parenteral nutrition (2%) and other therapies (10%). There was no significant difference in complications on insertion between the CNC and AMS groups. AMS failed to obtain access in 12 attempted procedures compared with eight by the CNC. The rate of CVCs investigated for infection was twice as high in the AMS group as in the CNC group (19% v 8%). The confirmed catheter-related bloodstream infection (CRBSI) rate was 2.5/1000 catheters in the AMS group and 0.4/1000 catheters in the CNC group (P = 0.04). CONCLUSION: Insertion outcomes were favourable in both the AMS and CNC groups. Infection outcomes differed between groups, with a higher rate of CRBSI in the AMS group.

Unplanned admission to the intensive care unit in the very elderly and risk of in-hospital mortality.

BACKGROUND: Unplanned admission to the intensive care unit has been shown to significantly increase the risk of inhospital mortality. Medical advances and increased expectations have resulted in a greater number of very elderly patients (80 years and over) being admitted to the ICU. The risk of in-hospital death associated with unplanned admission to the ICU in very elderly patients has not been clearly defined. OBJECTIVE: To estimate the risk of in-hospital mortality associated with unplanned admission to the ICU in patients aged 80 years and over. DESIGN, SETTING AND PARTICIPANTS: Retrospective review of an adult intensive care database. The setting was Liverpool Hospital, a large teaching hospital in Sydney, Australia, with a 28-bed ICU that has about 2000 admissions per year. We analysed data on very elderly patients (n = 1680), aged 80 years or more, admitted to the ICU between 1 January 1997 and 31 December 2007. MAIN OUTCOME MEASURES: Baseline risk factors for inhospital mortality. RESULTS: Mortality among patients with unplanned ICU admissions was 47%, compared with 25% in patients with planned admissions (adjusted rate ratio [RR], 1.92 [95% CI, 1.59-2.32]). An estimated 50% of the overall risk of inhospital death among very elderly patients was attributable to a combination of unplanned admission to the ICU, the presence of at least one comorbid condition, acute renal failure and respiratory failure requiring intubation. CONCLUSION: Unplanned admission to the ICU increases the risk of in-hospital mortality in very elderly patients. At least 50% of the risk of in-hospital death in this age group is attributable to a combination of unplanned ICU admission, comorbidity (≥1 comorbid condition), acute renal failure and respiratory failure.

Severity of illness and risk of readmission to intensive care: a meta-analysis.

BACKGROUND: Almost one in every 10 patients who survive intensive care will be readmitted to the intensive care unit (ICU) during the same hospitalisation. The association between increasing severity of illness (widely calculated in ICU patients) with risk of readmission to ICU has not been systematically summarized. OBJECTIVE: The meta-analysis was designed to combine information from published studies to assess the relationship between severity of illness in ICU patients and the risk of readmission to ICU during the same hospitalisation. DATA SOURCES: Studies were identified by searching MEDLINE (1966 to August 2008), EMBASE (1980-2008), and CINAHL (1982 to August 2008). REVIEW METHODS: Studies included only adult populations, readmissions to ICU during the same hospitalisation and reports of valid severity of illness index. RESULTS: Eleven studies (totaling 220000 patients) were included in the meta-analysis. Severity of illness (APACHE II, APACHE III, SAPS and SAPS II) measured at the time of ICU admission or discharge, was higher in patients readmitted to the ICU during the same hospitalisation compared to patients not-readmitted (both p-values<0.001). The risk of readmission to ICU increased by 43% with each standard deviation increase in severity of illness score (regardless if measured on admission to, or discharge from the ICU) (odds ratio (OR)=1.43, 95% confidence interval (CI)=1.3-1.6). CONCLUSIONS: A relationship between increasing intensive care severity of illness and risk of readmission to ICU was found. The effect was the same regardless of the time of measurement of severity of illness (at admission to ICU or the time of discharge from ICU). However, further research is required to develop more comprehensive tools to identify patients at risk of readmission to ICU to allow the targeted interventions, such as ICU-outreach to follow-up these patients to minimize adverse events.