Intensive care unit occupancy after introduction of the emergency department 4-hour discharge rule at a tertiary referral hospital in Western Australia.

BACKGROUND: The 4-hour rule has been introduced in Western Australia, requiring that emergency department (ED) patients be admitted to hospital or discharged from the ED within 4 hours of presentation. We hypothesised that this rule might have been associated with changes in medical emergency team (MET) calls and intensive care unit exit bed block. METHODS: Hospital databases were examined to determine compliance with the 4-hour rule, the effect on ICU exit bed block, and the number of MET calls, in 2008 (before introduction of the 4-hour rule) and 2011 (after introduction of the 4-hour rule). We also measured background ICU and hospital activity in 2008 and 2011. RESULTS: Monthly compliance with the 4-hour rule ranged from 35%-46% in 2008 to 64%-75% in 2011 (P < 0.0001). There was a marked increase in bed block days for patients in the ICU between 2008 (before introduction of the 4-hour rule) and 2011 (after introduction of the 4-hour rule) (P = 0.05). The increase in ICU bed block-days could not be explained by a difference in ICU occupancy, as there was a reduction in ICU bed-days between 2008 and 2011 (P = 0.014). There was a reduction in hospital mortality rate between 2008 and 2011 (P < 0.001). There was no significant increase in the number of MET calls from 2008 to 2011 (P = 0.221). Hospital activity (separations) increased from 2008 to 2011 (P < 0.0001). DISCUSSION: The introduction of the 4-hour rule was associated with increased exit block from the ICU, but not with increased MET calls to attend to unstable or deteriorating ward patients. Introduction of the 4-hour rule was associated with a small reduction in hospital mortality.

Factual memories of ICU: recall at two years post-discharge and comparison with delirium status during ICU admission--a multicentre cohort study.

AIMS AND OBJECTIVE: To examine the relationship between observed delirium in ICU and patients' recall of factual events up to two years after discharge. BACKGROUND: People, the environment, and procedures are frequently cited memories of actual events encountered in ICU. These are often perceived as stressors to the patients and the presence of several such stressors has been associated with the development of reduced health-related quality of life or post-traumatic stress syndrome. DESIGN: Prospective cohort study using interview technique. METHOD: The cohort was assembled from 152 patients who participated in a previously conducted multi-centre study of delirium incidence in Australian ICUs. The interviews involved a mixture of closed- and open-ended questions. Qualitative responses regarding factual memories were analysed using thematic analysis. A five-point Likert scale with answers from 'always' to 'never' was used to ask about current experiences of dream, anxiety, sleep problems, fears, irritability and/or mood swings. Scoring ranged from 6 to 30 with a mid-point value of 18 indicating a threshold value for the diagnosis of post-traumatic stress syndrome. A P-value of <0.05 was considered significant for all analyses. RESULTS: Forty-one (40%) out of 103 potential participants consented to take part in the follow-up interview; 18 patients (44%) had been delirious and 23 patients (56%) non-delirious during the ICU admission. The non-participants (n = 62) formed a control group to ensure a representative sample; 83% (n = 34) reported factual memories either with or without recall of dreaming. Factual memories were significantly less common (66% cf. 96%) in delirious patients (OR 0.09, 95%CI 0.01-0.85, p = 0.035). Five topics emerged from the thematic analysis: 'procedures', 'staff', 'comfort', 'visitors', and 'events'. Based on the current experiences, five patients (12%, four non-delirious and one delirious) scored > or =18 indicative of symptoms of post-traumatic stress syndrome; this did not reach statistical significance. Memory of transfer out of ICU was less frequent among the delirious patients (56%, n = 10) than among the non-delirious patients (87%, n = 20) (p = 0.036). CONCLUSION: Most patients have factual memories of their ICU stay. However, delirious patients had significantly less factual recall than non-delirious patients. Adverse psychological sequelae expressed as post-traumatic stress syndrome was uncommon in our study. Every attempt must be made to ensure that the ICU environment is as hospitable as possible to decrease the stress of critical illness. Post-ICU follow-up should include filling in the 'missing gaps', particularly for delirious patients. Ongoing explanations and a caring environment may assist the patient in making a complete recovery both physically and mentally. RELEVANCE TO CLINICAL PRACTICE: This study highlights the need for continued patient information, re-assurance and optimized comfort. While health care professionals cannot remove the stressors of the ICU treatments, we must minimize the impact of the stay. It must be remembered that most patients are aware of their surroundings while they are in the ICU and it should, therefore, be part of ICU education to include issues regarding all aspects of patient care in this particularly vulnerable subset of patients to optimize their feelings of security, comfort and self-respect.

Job satisfaction and importance for intensive care unit research coordinators: results from binational survey.

OBJECTIVE: To measure Intensive Care Unit Research coordinator job satisfaction and importance and to identify priorities for role development. BACKGROUND: Research coordinator numbers are growing internationally in response to increasing clinical research activity. In Australia, 1% of registered nurses work principally in research, many as Research coordinators. Internationally, the Association of Clinical Research Professionals currently has 6536 certified Research coordinators in 13 countries, with likely additional large numbers practicing without the voluntary certification. Research coordinators are almost always nurses, but little is know about this emerging specialty. Design. Cross-sectional study using anonymous self-report questionnaire. METHODS: After ethics approval, the McCloskey-Mueller Satisfaction Scale and McCloskey-Mueller Importance Scale were administered via the Internet. The sample was 49 (response rate 71%) Research coordinators from the Australia and New Zealand Intensive Care Unit Research coordinators' Interest Group. RESULTS: Research coordinators were satisfied with structural aspects of the position working business hours; flexibility of working hours; high levels of responsibility and control over their work. Dissatisfaction was expressed regarding: remuneration and recognition; compensation for weekend work; salary package; career advancement opportunities; and childcare facilities. CONCLUSIONS: High priorities for role development are those rated highly important but with much lower satisfaction. These are: compensation for weekend call-out work; salary and remuneration package; recognition by management and clinicians; career advancement opportunities; departmental research processes; encouragement and feedback; and number of working hours. RELEVANCE TO CLINICAL PRACTICE: Increasing numbers of nurses have been attracted to this clinically based research position. These data contribute to the understanding and development of the role.

Delirium in the intensive care unit: searching for causes and sources.

INTRODUCTION: Currently, diagnosis of delirium in theintensive care unit requires the use of one of a range of screening scales. Publications on delirium in the ICU are increasing, but most focus on psychological markers, with only limited data on physiological indicators of delirium. AIM: To assess the relationship between a range of physiological and treatment markers and the presence of delirium in an ICU cohort. METHODS: Patients admitted to the ICU of a metropolitan tertiary hospital between 1 August 2002 and 31 January 2003 were prospectively screened for delirium using the Intensive Care Delirium Screening Checklist (ICDSC). A retrospective chart review was undertaken to identify potential markers: raised white cell count, neutrophil count, and serum C-reactive protein concentration, lactic acidosis, low haemoglobin concentration, use of inotropic support, corticosteroids, or continuous venovenous haemodiafiltration (CVVHDF), and presence of systemic inflammatory response syndrome. Association of these markers with delirium was assessed using chi2 statistics. RESULTS: Of 56 ICU patients who were screened for delirium, charts could be retrieved for 44 (80%): 21 had delirium during the ICU admission, and 23 did not. CVVHDF was the only variable associated with an increased risk of delirium (P=0.03). CONCLUSIONS: Treatment with CVVHDF was the only factor associated with the presence of delirium. Further research is warranted into physiological indicators as adjuncts to psychological assessment scales for delirium. The quest to find a simple biomarker for delirium continues.

Intensive care research coordinators: who are they and what do they do? Results of a binational survey.

Research coordinators in intensive care are a growing specialty about which little is known. This cross-sectional study surveyed the Australia and New Zealand Intensive Care Research Coordinators' Group (n = 49) regarding demographics, education, employment history, job structure, and role content. Most research coordinators were highly qualified and experienced nurses who undertake pharmaceutical trials, multicenter projects, departmental medical and nursing research, audits and data registries, and their own projects.

The best and worst aspects of the ICU research coordinator role.

BACKGROUND: The Research Coordinator (RC) role is a relative new addition to staffing profiles in Australasian Intensive Care Units (ICUs). The RC plays a pivotal role in conducting ethically and scientifically sound research. There have been anecdotal reports of the RC role in various speciality areas. However, limited research has been undertaken into the role, and only one study has been published from the intensive care setting. AIM: To evaluate which factors the RC found to be the best and worst attributes of the role. METHODS: A cross-sectional web-based cohort study was conducted in 2004 collecting free text information from RCs in ICUs in Australia and New Zealand. RESULTS: Forty-nine participants (71%) completed the study with 273 entries into the two categories of 'best' (60%) and 'worst' (40%) aspects of the role. We identified four thematic clusters in both categories: (1) 'How the job was structured' (2) 'The worth of the job' (3) 'What the work involves' and (4) 'Who I work with'. Both categories received proportionally the same number of responses in each theme with (1) the most frequent and (4) the least number of entries. CONCLUSION: There is much variation between RCs in almost every descriptor of the role. The Australasian Intensive Care RC values autonomy, respect and intellectual stimulation with the scope for extending the role to suit the individual and finds isolation, under-recognition and workload, often not sufficiently compensated, to be the worst aspects of the position.

Patients' dreams in ICU: recall at two years post discharge and comparison to delirium status during ICU admission. A multicentre cohort study.

Discharged intensive care unit (ICU) patients often recall experience vivid dreams, hallucinations or delusions. These may be persecutory in nature and are sometimes very frightening. It is possible that these memories stem from times when the patient was experiencing delirium, a common syndrome in the critically ill. Routine screening for delirium in ICU is becoming more prevalent, however, little has been published comparing the objective development of delirium (patient observations using screening tools) and patients' subjective recollection of dreams and unreal experiences in the ICU. This study describes the relationship between observed behaviour during ICU admission and the subjective memories of ICU experiences amongst 41 participants in three ICUs up to 24 months post discharge. Overall, 44% of patients (n=18) recalled dreams during their ICU admission. There was a trend to increased prevalence of dreaming (50% versus 39%) amongst the 18 patients who were delirious during their ICU admission than in the 23 non-delirious patients. Dreaming was significantly associated on logistic regression with increased length of stay (OR 1.39, 95% CI 1.08-1.79, p=0.01), but not delirium status (OR 1.56, 95% CI 0.45-5.41, p=0.49). A longer ICU stay was significantly associated with the experience of ICU dreaming. As many dreams are disturbing, we suggest providing information and counselling about delirium to patients who remain in ICU for longer periods.

A double-blind, randomized trial of intravenous versus intramuscular antivenom for red-back spider envenoming.

OBJECTIVE: To compare the efficacy of intravenous versus intramuscular antivenom (AV) in the treatment of Red-back spider (RBS) envenoming. METHODS: Randomized, double-dummy, double-blind, multicentre trial of patients with red-back spider envenoming requiring AV treatment recruited from five hospital EDs in Western Australia. RESULTS: Thirty-five patients were recruited; two were excluded; 33 were available for initial analysis, but two who were unblinded after one ampoule of trial AV and given i.v. AV had limited data; 31 remained in the study and had more complete data. After AV, pain scores for both i.m. and i.v. groups improved rapidly. At 24 h, the i.v. group was better with a 55% absolute difference (76% vs. 21%; 95% CI 25-85% difference) in the proportion pain-free. There were no safety issues. CONCLUSIONS: Red-back spider antivenom was initially effective by both i.m. and i.v. routes. The study generates the hypothesis that at 24 h, significantly more patients are pain-free with i.v. administration. Definitive recommendations on the optimal route of administration of RBS AV await the results of further studies.