Improving the intensive care experience from the perspectives of different stakeholders.

The intensive care unit (ICU) is a complex environment where patients, family members and healthcare professionals have their own personal experiences. Improving ICU experiences necessitates the involvement of all stakeholders. This holistic approach will invariably improve the care of ICU survivors, increase family satisfaction and staff wellbeing, and contribute to dignified end-of-life care. Inclusive and transparent participation of the industry can be a significant addition to develop tools and strategies for delivering this holistic care. We present a report, which follows a round table on ICU experience at the annual congress of the European Society of Intensive Care Medicine. The aim is to discuss the current evidence on patient, family and healthcare professional experience in ICU is provided, together with the panel's suggestions on potential improvements. Combined with industry, the perspectives of all stakeholders suggest that ongoing improvement of ICU experience is warranted.

Prophylactic Intra-Aortic Balloon Counterpulsation in High Risk Cardiac Surgery: The PINBALL Pilot Multicentre, Registry-Linked, Randomised, Controlled Feasibility Trial.

BACKGROUND: Prophylactic intra-aortic balloon counterpulsation (IABC) is commonly used in selected patients undergoing coronary artery bypass graft (CABG) surgery, but definitive evidence is lacking. The aim of the multicentre PINBALL Pilot randomised controlled trial (RCT) was to assess the feasibility of performing a definitive trial to address this question. METHODS: Patients listed for CABG surgery with impaired left ventricular function and at least one additional risk factor for postoperative low cardiac output syndrome were eligible for inclusion if the treating surgical team was uncertain as to the benefit of prophylactic IABC. The primary outcome of feasibility was based on exceeding a pre-specified recruitment rate, protocol compliance and follow-up. RESULTS: The recruitment rate of 0.5 participants per site per month did not meet the feasibility threshold of two participants per site per month and the study was stopped early after enrolment of 24 out of the planned sample size of 40 participants. For 20/24 (83%) participants, preoperative IABC use occurred according to study assignment. Six (6)-month follow-up was available for all enrolled participants, [IABC 1 death (8%) vs. control 1 death (9%), p = 0.95]. CONCLUSION: The PINBALL Pilot recruitment rate was insufficient to demonstrate feasibility of a multicentre RCT of prophylactic IABC in high risk patients undergoing CABG surgery.

Perceived Discomfort in Patients admitted to Intensive Care (DETECT DISCOMFORT 1): a prospective observational study.

BACKGROUND: Discomfort experienced by patients admitted to intensive care units (ICUs) is an important indicator of the quality of care provided, but few studies have evaluated the incidence and magnitude of discomfort in critically ill patients. The IPREA (Inconforts des Patients de REAnimation) discomfort questionnaire is a tool developed by French intensivists and validated in the French language with good internal consistency (Cronbach's α, 0.78). OBJECTIVES: To translate and validate in English the IPREA discomfort questionnaire, to evaluate discomfort perceived by patients in intensive care, and to identify predictors of discomfort. DESIGN, SETTING AND PARTICIPANTS: After translating the IPREA questionnaire using published methods that use principles of good practice for translating and culturally adapting patient-reported outcomes measures, all eligible patients (aged > 18 years, Glasgow Coma Scale score of 15, English speaking) admitted to our ICU over the 6-month period from April 2017 to September 2017 were surveyed within 24 hours of ICU discharge. Patient-perceived discomfort was measured using the translated IPREA questionnaire. The patients were asked to score their discomfort for each of 16 items on a scale of 0 (no discomfort) to 100 (maximum discomfort). An overall discomfort score was computed as the mean score of the 16 individual discomfort scores. Multivariate analysis was performed to identify predictors of discomfort. MAIN OUTCOME MEASURES: Translated questionnaire internal consistency. Individual and overall discomfort scores. RESULTS: A total of 168 patients (58% men; mean age, 60.1 ± 14.8 years; mean APACHE [Acute Physiology and Chronic Health Evaluation] II score, 13.8 ± 5.6) completed the questionnaire. The translated questionnaire had good internal consistency (Cronbach's α, 0.82), and good content and construct validity (average inter-item correlation, 0.23). The mean overall discomfort score was 18.4 ± 12.5, and discomfort scores did not differ between men and women or between types of ICUs (general ICU, cardiothoracic ICU or high dependency unit). On multivariate analysis, increasing age was an independent predictor of a low discomfort score (ß, -0.27; 95% CI, -0.42 to -0.12; P = 0.001). CONCLUSION: Patients admitted to our ICU reported low overall discomfort. There was an inverse relationship between age and perceived discomfort. The translated questionnaire for measuring discomfort performed well in our setting and could be applied to the Australian population.

Evaluation of cognitive load and emotional states during multidisciplinary critical care simulation sessions.

BACKGROUND: The simulation in critical care setting involves a heterogeneous group of participants with varied background and experience. Measuring the impacts of simulation on emotional state and cognitive load in this setting is not often performed. The feasibility of such measurement in the critical care setting needs further exploration. METHODS: Medical and nursing staff with varying levels of experience from a tertiary intensive care unit participated in a standardised clinical simulation scenario. The emotional state of each participant was assessed before and after completion of the scenario using a validated eight-item scale containing bipolar oppositional descriptors of emotion. The cognitive load of each participant was assessed after the completion of the scenario using a validated subjective rating tool. RESULTS: A total of 103 medical and nursing staff participated in the study. The participants felt more relaxed (-0.28±1.15 vs 0.14±1, P<0.005; d=0.39), excited (0.25±0.89 vs 0.55±0.92, P<0.005, d=0.35) and alert (0.85±0.87 vs 1.28±0.73, P<0.00001, d=0.54) following simulation. There was no difference in the mean scores for the remaining five items. The mean cognitive load for all participants was 6.67±1.41. There was no significant difference in the cognitive loads among medical staff versus nursing staff (6.61±2.3 vs 6.62±1.7; P>0.05). CONCLUSION: A well-designed complex high fidelity critical care simulation scenario can be evaluated to identify the relative cognitive load of the participants' experience and their emotional state. The movement of learners emotionally from a more negative state to a positive state suggests that simulation can be an effective tool for improved knowledge transfer and offers more opportunity for dynamic thinking.

Learning curve for cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal surface malignancy--a journey to becoming a Nationally Funded Peritonectomy Center.

BACKGROUND: Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) for peritoneal surface malignancy is associated with a morbidity rate of 30-50% and a mortality rate of 1-10%. Recently, the St George Hospital in Sydney has been commissioned as the Nationally Funded Center for treatment of peritoneal surface malignancy in Australia. METHODS: The clinical and treatment-related data regarding 140 consecutive patients were prospectively collected. A comparison between the initial 70 patients (Group I) and the subsequent 70 patients (Group II) was performed. Univariate and multivariate analyses were conducted to identify the significant risk factors for moderate to severe morbidity. RESULTS: The hospital mortality was 4%. Sixty-one patients (44%) had moderate morbidity. Twenty-eight patients (20%) experienced severe morbidity. The mean hospital stay was 30 days. Twenty-seven patients (19%) were readmitted after initial discharge for management of delayed complications. The severe morbidity rate reduced from 30% to 10%, and the delayed morbidity rate reduced from 29% to 10%, when comparing Groups I and II. There were also reduced transfusion requirement, duration of operation, and intensive care unit stay. In the multivariate analysis, Group I (vs Group II; P = .005), performing small bowel resection (P = .005), and >4 peritonectomy procedures (vs

Combinations of early signs of critical illness predict in-hospital death-the SOCCER study (signs of critical conditions and emergency responses).

BACKGROUND: Medical emergency team (MET) call criteria are late signs of a deteriorating clinical condition. Some early signs predict in-hospital death but have a high prevalence so their use as single sign call criteria could be wasteful of resources. This study searched a large database to explore the association of combinations of recordings of early signs (ES), or early with late signs (LS) with in-hospital death. METHODS: A cross-sectional survey was undertaken of 3046 non-do not attempt resuscitation adult admissions in 5 hospitals without MET over 14 days. The medical records were reviewed for recordings of 26 ES and 21 LS and in-hospital death. Combinations of ES with or without LS were examined as predictors of death. Global modified early warning scores (GMEWS) were calculated. FINDINGS: ES with LS, plus LS only, had higher odd ratios than ES alone. Four combinations of ES were strongly associated with death: cardiovascular plus respiratory with decrease in urinary output, cardiovascular plus respiratory with a decrease in consciousness, respiratory with decrease in urinary output, and cardiovascular plus respiratory. In other combinations, recordings of SpO2 90-95%, systolic blood pressure 80-100 mmHg or decrease in urinary output in turn occurring with one or more disturbed blood gas variable were associated with death. Compared with admissions whose GMEWS were 0-2, admissions with GMEWS 5-15 were 27.1 times more likely to die while those with GMEWS 3-4 were 6.5 times more likely. CONCLUSIONS: The results support the inclusion of early signs of a deteriorating clinical condition in sets of call criteria.

Audit of over 500 percutaneous dilational tracheostomies.

AIM: To review immediate procedure-related complications of percutaneous dilational tracheostomy (PDT) in relation to patient characteristics, technique and seniority of operator. DESIGN: Retrospective audit of all tracheostomies performed in our ICU over 10 years. METHOD: Data were derived from a prospectively maintained tracheostomy logbook and, when necessary, from patients' case notes. Data were compiled to determine demographic characteristics, diagnosis on admission, indication for tracheostomy, technique used, seniority of operator, and complications related to the procedure. RESULTS: 581 tracheostomies (501 PDT and 80 surgical) were performed between January 1995 and December 2004. A written protocol was followed with standardisation of indication, authorisation and supervision by consultant, antibiotic prophylaxis and anaesthetic technique. Mean patient age was 67.6 (SD, 15.7 years) (PDT group) and 52.1 (SD, 12.4) (surgical group). Mean Apache II score was 20.6 (SD, 7.9) (PDT) and 19.7 (SD, 6.8) (surgical). The PDT techniques used were Griggs' forceps dilatation (85%), Ciaglia's multiple sequential dilator technique (15%), and Ciaglia's Blue Rhino single dilator technique (0.2%). Prolonged respiratory weaning was the most common indication (42%), followed by head injury and other neurological causes (31%). The surgical group comprised patients with multiple trauma and those deemed to have difficult anatomy, with 11 PDTs being converted to surgical tracheostomies. In the PDT group, bleeding was the most common complication (4.3%), followed by desaturation (1.0%), bradycardia (1.0%) and hypotension (0.8%). Two patients in the PDT group needed surgical control of bleeding. There was one death, 11 days after PDT, caused by secondary haemorrhage. Complications were not related to operator seniority. CONCLUSION: Our findings are comparable with those of other published case studies, with low complication rates for PDT. This audit supports our structured training program, policies on procedure, and quality audit process.

Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting.

BACKGROUND: Emergency response systems (ERS) are based on a set of triggers used to identify patients "at risk". This study aimed to establish the association between recordings of disturbed physiological variables and adverse events. METHODS: A cross-sectional survey of 3,046 non Do Not Attempt Resuscitation (non DNAR) adult admissions in five hospitals over 14 days. Medical records were reviewed for 26 early signs (ES) and 21 late signs (LS) of critical conditions and serious adverse events (SAE): death, cardiac arrest, severe respiratory problems, or transfer to a critical care area. The LS included published medical emergency team (MET) call criteria. FINDINGS: There were 12,384 ES and 1,410 LS. The 'top five' ES and the odds (OR) for death were: base deficit -5 to -8 mmol/L=40.2 (95% C.I. 7.7-208.8), partial airway obstruction OR=38.7 (3.9-64.4), poor peripheral circulation OR=34.4 (6.8-174.0), >expected drain fluid loss OR=30.1 (6.1-148.9), pH <7.3 >7.2 OR=29.0 (3.1-268.3). For LS: urine output <200 mL in 24 h OR=188.6 (95% C.I. 30.1-1179.8), pH <7.2 OR=116.1 (7.1-1906.1), unresponsive to voice OR=34.8 (10.7-113.0), anuric OR=29.0 (3.1-268.3), base deficit <-8.0 mmol/L OR=29.0 (3.1-268.3). OR for the other SAE were similar. Pulse oximetry abnormalities were associated with all SAE. The risk for death for ES: SpO2 90-95% OR=8.1 (3.0-21.3) and LS: SpO2 <90% OR=9.0 (4.2-19.4). INTERPRETATION: Both ES and LS were associated with adverse events. This study confirms the validity of current MET call criteria but points to the need to expand them. It provides a possible explanation for the failure to demonstrate efficacy of a MET in some trials because current call criteria maybe too late in the progress of the patient's critical condition. It allows the modelling of ERS and education programmes focused on signs of critical conditions. It potentially brings together ICU outreach and ward based responses. Broader use of clinical signs, monitoring such as pulse oximetry and objective data such as blood gas results may assist early intervention and help prevent loss of life.

Enteral nutrition versus glucose-based or lipid-based parenteral nutrition and tight glycaemic control in critically ill patients.

OBJECTIVE: Early administration of nutrition and attention to tight glycaemic control are both associated with improved outcomes in critically ill patients. We hypothesized that blood glucose control would be better achieved in patients receiving enteral rather than parenteral nutrition and, in the latter group, would be better achieved using a "balanced" glucose plus lipid solution than a dextrose-based solution as calorie source. METHODS: We conducted a retrospective interrogation of the intensive care database as part of a clinical audit of a 12-bed mixed medical and surgical ICU in a tertiary referral teaching hospital between September 2003 and March 2004. Patients expected to stay in the ICU for longer than 48 hours were treated according to an intensive insulin therapy protocol. They received enteral nutrition (EN) or, if EN was not tolerated, parenteral nutrition (PN) or combined EN and PN. PN comprised a glucose-based solution (GluPN) during the first 3 months of the study and a balanced glucose plus lipid solution (LipPN) during the second 3 months. RESULTS: 96 patients were treated according to the protocol. Patients receiving PN (n = 26) had significantly longer ICU length of stay and greater daily caloric intake than did those receiving EN (n = 70) during both study periods. Mean blood glucose, percentage of blood glucose measurements within the target range, and daily insulin dose did not differ significantly between patients receiving EN and PN or GluPN and LipPN. CONCLUSION: When used in association with a tight glycaemic control regimen, PN is not associated with poorer glycaemic control in critically ill patients than EN.

The prevalence of recordings of the signs of critical conditions and emergency responses in hospital wards--the SOCCER study.

OBJECTIVE: To estimate the prevalence of recordings in case notes of disturbed physiological variables in adult admissions in general hospital wards. DESIGN AND SETTING: Retrospective cross-sectional survey of 3160 admissions in general wards in five hospitals in a 14-day period. MAIN OUTCOME MEASURES: Recordings of 26 potential early signs (ES) and 21 potential late signs (LS) of critical conditions. Eight late signs were classified as Liverpool Hospital Equivalent Calling Signs (LES). RESULTS: 54.7% admissions had at least one recording of early signs, 16.0% late signs and 6.4% LES. When ranked in order of recordings per 100 admissions, the top five ES were SpO(2) 90-95% (193.7), systolic blood pressure (SBP) 80-100 mmHg (85.2), pulse rate 40-49 or 121-140 b/min (32.0), SBP 181-240 mmHg (23.0) and "Other" (22.1) (mainly breathlessness or temperature > 38 degrees C). The top five LS were SpO2 < 90% (31.5), pulse rate < 40 or > 140 /min (6.6), SBP < 80 mmHg (4.2), GCS < or = 8 (3.8) and unresponsiveness to verbal commands (2.4). There were average signs per admission of ES 4.4, LS 0.6 and LES 0.19. Although there were differences in rates of recordings of signs across the five hospitals, the patterns of top 10 most frequent were similar. CONCLUSIONS: There was a high incidence of recordings of disturbed physiological variables in general ward patients. Changes to hospital emergency response systems to include rapidly responding teams to patients with the signs of developing critical conditions should be supported by training programmes for ward staff on the early recognition and management of patients with the warning signs.

Analysis of blood glucose measurements using capillary and arterial blood samples in intensive care patients.

OBJECTIVE: To analyse agreement between two methods for blood glucose measurement in intensive care patients: capillary blood using a reagent strip and glucometer with arterial blood using a blood gas analyser. DESIGN AND SETTING: Prospective, single-centre, observational study in a 12-bed tertiary referral intensive care unit. MEASUREMENTS: Blood glucose levels were measured in consecutive patients using simultaneous measurements of capillary blood samples using glucometry and from a multi-electrode arterial blood gas analyser. An a priori subgroup of patients with tissue hypoperfusion was identified (defined as systolic blood pressure <90 mmHg or vasopressor dependency). A total of 493 paired measurements were obtained; 75 of these were from patients with systemic hypoperfusion. RESULTS: Overall, the mean difference (bias) was 0.12 mmol/l (2.15 mg/dl) and precision 0.77 mmol/l (13.8 mg/dl); 95% limits of agreement were -0.14 and 1.66 mmol/l (-2.5 and 29.8 mg/dl). In patients with systemic hypoperfusion the bias was 0.24 mmol/l (4.0 mg/dl) and precision 0.9 mmol/l (16.2 mg/dl); 95% limits of agreement -2.05 and 1.58 mmol/l (36.8 and 28.4 mg/dl). CONCLUSIONS: In a general population of intensive care patients, there is statistical agreement between blood glucose measured from capillary blood glucometry and arterial blood gas analysis. However, in patients with systemic hypoperfusion, the accuracy of agreement between these two measurement techniques may be such that that biochemical hypoglycaemia (<2.5 mmol/l, 44.9 mg/dl) may go undetected if used interchangeably.

Duration of life-threatening antecedents prior to intensive care admission.

OBJECTIVE: To document the characteristics and incidence of serious abnormalities in patients prior to admission to intensive care units. DESIGN AND SETTING: Prospective follow-up study of all patients admitted to intensive care in three acute-care hospitals. PATIENTS: The study population totalled 551 patients admitted to intensive care: 90 from the general ward, 239 from operating rooms (OR) and 222 from the Emergency Department (ED). MEASUREMENTS AND RESULTS: Patients from the general wards had greater severity of illness (APACHE II median 21) than those from the OR (15) or ED (19). A greater percentage of patients from the general wards (47.6%) died than from OR (19.3%) and ED (31.5%). Patients from the general wards had a greater number of serious antecedents before admission to intensive care 43 (72%) than those from OR 150 (64.4%) or ED 126 (61.8%). Of the 551 patients 62 had antecedents during the period 8-48 h before admission to intensive care, and 53 had antecedents both within 8 and 48 h before their admission. The most common antecedents during the 8 h before admission were hypotension (n=199), tachycardia (n=73), tachypnoea (n=64), and sudden change in level of consciousness (n=42). Concern was expressed in the clinical notes by attending staff in 70% of patients admitted from the general wards. CONCLUSIONS: In over 60% of patients admitted to intensive care potentially life-threatening abnormalities were documented during the 8 h before their admission. This may represent a patient population who could benefit from improved resuscitation and care at an earlier stage.