Improving the management of medical emergency team calls due to suspected infections: A before-after study.

Objective: To introduce a management guideline for sepsis-related MET calls to increase lactate and blood culture acquisition, as well as prescription of appropriate antibiotics. Design: Prospective before (Jun-Aug 2018) and after (Oct-Dec 2018) study was designed. Setting: A public university linked hospital in Melbourne, Australia. Participants: Adult patients with MET calls related to sepsis/infection were included. Main outcome measures: The primary outcome measure was the proportion of MET calls during which both a blood culture and lactate level were ordered. Secondary outcomes included the frequency with which new antimicrobials were commenced by the MET, and the presence and class of administered antimicrobials. Results: There were 985 and 955 MET calls in the baseline and after periods, respectively. Patient features, MET triggers, limitations of treatment and disposition after the MET call were similar in both groups. Compliance with the acquisition of lactates (p = 0.101), respectively. There was a slight reduction in compliance with lactate acquisition in the after period (97% vs 99%; p = 0.06). In contrast, there was a significant increase in acquisition of blood cultures in the after period (69% vs 78%; p = 0.035). Conclusions: Introducing a sepsis management guideline and enhanced linkage with an AMS program increased blood culture acquisition and decreased broad spectrum antimicrobial use but didn't change in-hospital mortality.

Critical care nurses' perceptions of essential elements for an intensive care liaison or critical care outreach nurse curriculum.

BACKGROUND: For over a decade, patients experiencing clinical deterioration have been attended to by specialised nurses, the most senior of which are intensive care unit liaison nurses (ICU LNs) or critical care outreach nurses. These roles have evolved without consistent and formal recognised educational preparation. To continue to advance patient safety, an understanding of the educational requirements for these vital roles is required. AIM: The aim of this study was to ascertain nurses' perceptions of the curriculum required to perform the roles of ICU LNs or critical care outreach nurses within an acute care sector rapid response system. METHODS: An exploratory descriptive study was conducted at an international rapid response system conference in 2016 following ethics approval. Using convenience sampling, extended response surveys were completed by nurses with rapid response system leadership experience and roles. Data were analysed using content analysis according to a priori themes of theoretical knowledge, skills, and attributes. RESULTS: Seventy-seven registered nurses volunteered to take part in the study, forming 14 groups, each with four to seven members. Participants identified key concepts for desired theoretical knowledge, practical skills, and personal attributes. Professional behaviours were more frequently emphasised than theoretical knowledge or practical skills, suggesting personal attributes were highly valued in these leadership roles. CONCLUSIONS: A curriculum designed to prepare patient safety leadership roles of the ICU LN or critical care outreach nurse has been identified. These findings can inform the development of postgraduate courses and training requirements, along with position descriptions and expectations of employers regarding the skill set expected in these leadership roles.

Differences in the characteristics, treatment, and outcomes of patient groups reviewed by intensive care liaison nurses in Australia: A multicentre prospective study.

BACKGROUND: There is a lack of knowledge about tasks intensive care unit liaison nurses (ICU LNs) perform during patient review, despite this role operating in at least 31 acute care hospitals in Australia. OBJECTIVES: To evaluate the tasks that ICU LNs perform during patient review in the following referral subcategories: review after ICU discharge, rapid response team (RRT) review, and ward referral. METHODS: A 2-month prospective observational study using standardised case report forms to collect data on patients reviewed by ICU LNs in 20 Australian hospitals was conducted. RESULTS: From 3799 patients screened, 3542 were included, among whom 1933 (54.6%) were men, and the mean (standard deviation) age was 63 (19.4) years. The admitting units were surgical 1765 (49.8%) and medical 1696 (47.9%), and the breakdown of referral types were routine review after ICU discharge (1732; 47.9%), RRT review (1208; 34.1%), and ward referral (602; 17.0%). Patients subject to ward and RRT reviews were older, more likely to be medical admissions with less favourable vital signs on the initial review, and less likely to have repeat reviews. Of note, ward reviews were more likely to receive palliative care. Intensive care liaison nurse-initiated medication prescription and investigation ordering was uncommon. The most common interventions included consultation with medical staff, bedside education, adjusting oxygen flow and patient position, and directing the change in frequency of vital sign measurement. In-hospital mortality was lower in patients reviewed after ICU discharge (2.3%), compared with those after RRT review (2.8%) and ward referral (4.4%). CONCLUSIONS: Most patients were reviewed after ICU discharge or in the context of the RRT. RRT and ward patients were less physiologically stable and more likely to die in hospital. The most common interventions performed by the ICU LN were nontechnical skills including clinical education, consultation with medical staff, and changes to vital sign frequency. Finally, the most common medication therapies administered related to intravenous therapy and electrolyte administration.

Characteristics and outcomes of patients reviewed by intensive care unit liaison nurses in Australia: a prospective multicentre study.

BACKGROUND: Intensive care unit liaison nurse (ICU LN) services are one strategy to manage deteriorating hospital patients. Studies on the characteristics and outcomes of patients reviewed by ICU LNs have been from single centres and surveys. OBJECTIVES AND METHODS: To conduct a 20-hospital, prospective observational study on the characteristics and outcomes of patients reviewed by Australian ICU LNs over 2 months. PARTICIPANTS AND OUTCOME MEASURES: All patients screened by ICU LNs over the study period were included. Details included the source of initial review, patient demographics and initial physiological parameters, case load, interventions and patient outcome. RESULTS: Only two hospitals provided a 24-hour, 7-day service, and in 14 hospitals, an ICU LN participated in the rapid response team (RRT). There were 3799 patients screened (54.6% men, mean age 62.9 years [SD, 19.4 years]), of whom 1330 (35%) had no interventions (were screened only). The remaining 2469 patients received interventions; 978 (39.6%) were reviewed once, and 1491 (60.4%) were reviewed multiple times. The three commonest reasons for screening patients were after ICU discharge (1734 [45.6%]), as part of the RRT review (914 [24.1%]), or for a ward patient review meeting with a "worried" criterion (412 [10.8%]). Patients who did not receive interventions were younger, more likely to be surgical patients, less likely to have dementia, less likely to be seen during an RRT review, had more favourable vital signs and were less likely to be discharged to a nursing home or die in hospital. The commonest interventions included ordering a diagnostic test, administration of medication, initiating an interprofessional referral and increasing limitations of therapy. The inhospital mortality was 10.2% overall, and 4.6% in patients who were screened but did not receive any interventions. Several predictors of inhospital mortality were identified. CONCLUSIONS: Most ICU LN reviews occur after ICU discharge or in association with an RRT review. The inhospital mortality of ICU LN-reviewed patients is high (about 10%). ICU LNs effectively screen patients and often participate in end-of-life care planning.

Characteristics and outcomes of patients subject to intensive care nurse consultant review in a teaching hospital.

OBJECTIVE: To describe the evolution of our Intensive Care Nurse Consultant (ICNC) service, the characteristics and outcomes of the patients reviewed, and interventions performed. DESIGN, SETTING AND PARTICIPANTS: Retrospective observational study in a tertiary referral university-affiliated teaching hospital among all patients reviewed by the ICNC service between September 2007 and December 2009. MAIN OUTCOME MEASURES: Number and characteristics of patients reviewed, source of referral, interventions performed, inhospital mortality and hospital length of stay. RESULTS: Since August 2006, operating hours have increased and provision has been made for senior ICU nurses to undertake 6-month developmental allocations to the role. The name of the service was changed and a weekly report was commenced to capture patient referral source, and subsequent ICU medical referral. Additional changes included provision of an administration day, and use of an ICU discharge scoring tool. A total of 3118 (2278 post-ICU and 840 non-ICU) care episodes were provided by the ICNC service between September 2007 and December 2009. Median patient age was 64 years, inhospital mortality was about 9% and most reviews occurred in surgical patients and after ICU discharge. Most new ward referrals came from an ICU doctor or ward nurse, with few referrals from ward doctors. Communication with ward nurses was more common than with ward doctors. A common recommendation involved fluid and electrolyte management. In-hospital mortality was higher among patients entering the service after review by a medical emergency team or de-novo referral than in patients after ICU discharge. CONCLUSIONS: Most interventions are relatively simple, and the ICNC role may be augmented by limited rights to prescribe electrolyte replacement. The effect of the intervention on patient outcomes and the reproducibility of our findings in other hospitals remain to be determined.

A survey of ward nurses attitudes to the Intensive Care Nurse Consultant service in a teaching hospital.

The aim of an Intensive Care Nurse Consultant (ICNC) service is to optimise care of complex ward patients and reduce adverse events. Despite their widespread implementation, specific assessment of ward nurses' attitudes towards such is lacking. Accordingly, we surveyed ward nurses' attitudes towards our ICNC service in five domains: (a) accessibility and approachability; (b) perceived ICNC skill and knowledge; (c) perceived influence on patient management; (d) usefulness as a resource of clinical information; (e) impact upon adverse outcomes. To achieve this, an anonymous Liker-type questionnaire was distributed to 208 ward nurses in our hospital. We also included space for free text. Completed questionnaires were entered manually into a SURVEYMONKEY™ pro-forma to permit automatic report generation and results summary. The major findings were that ICNC staff were perceived as being approachable and good communicators, were skilled at early detection of deteriorating patients, and that they reduce serious adverse events. In addition, nurses believe the ICNC service provides continuity of care post discharge from the intensive care unit (ICU), as well as assisting staff to prioritise clinical issues following medical emergency team (MET) review or ICU discharge. The ward nurses did not believe that the ICNC service reduced their skills in managing ward patients. In contrast, respondents stated that the ICNC service needed to improve the processes of referral to allied health and education of ward staff regarding deteriorating patients. Finally, ward nurses suggest they would call the MET service rather than the ICNC service for patients who had already deteriorated. This survey suggests that the ICNC service is valued, and is perceived to prevent the development of adverse events, rather than playing a major role in the management of the deteriorating patient. There is a need to improve referrals to allied health and further educate ward nurses.