Respiratory rate monitoring and early detection of deterioration practices.

BACKGROUND: Growing evidence points to respiratory rate (RR) being the most important vital sign for early detection of patient deterioration. However, RR is the vital sign most likely to be inaccurate or missed. AIMS: To measure prevalence of early detection of deterioration protocols, examine whether RR was perceived as the leading indicator of deterioration, and understand RR monitoring practices used by nurses around the world. METHODS: A double-blinded survey of nurses in Asia Pacific, Middle East, and Western Europe. FINDINGS: 161 nurses responded. Most (80%) reported having an initiative for early detection of patient deterioration; 12% indicated RR was the most important indicator of deterioration, 27% captured RR for all medical/surgical patients, and 56% take 60 seconds or longer to measure RR. CONCLUSION: Nurses across all regions generally underestimated the importance of capturing an accurate RR for all patients' multiple times per day. This study reinforces the need to enhance international nursing education regarding the importance of RR.

Single-center task analysis and user-centered assessment of physical space impacts on emergency Cesarean delivery.

OBJECTIVE: This study aimed to begin to address this gap using validated techniques in human factors to perform a participatory user-centered analysis of physical space during emergency Cesarean. METHODS: This study employed a mixed-methods design. Focus group interviews and surveys were administered to a convenience sample (n = 34) of multidisciplinary obstetric teams. Data collected from focus group interviews were used to perform a task and equipment analysis. Survey data were coded and mapped by specialty to identify reported areas of congestion and time spent, and to identify themes related to physical space of the OR and labor and delivery unit. RESULTS: Task analysis revealed complex interdependencies between specialties. Thirty task groupings requiring over 20 pieces of equipment were identified. Perceived areas of congestion and areas of time spent in the OR varied by clinical specialty. The following categories emerged as main challenges encountered during an emergency Cesarean: 1) size of physical space and equipment, 2) layout and orientation, and 3) patient transport. CONCLUSION: User insights on physical space and workflow processes during emergency Cesarean section at the institution studied revealed challenges related to getting the patients into the OR expediently and having space to perform tasks without crowding or staff injury. By utilizing human factors techniques, other institutions may build upon our findings to improve safety during emergency situations on labor and delivery.

Healthcare handoffs among lay caregivers.

BACKGROUND: Much of home healthcare is also performed by informal caregivers. This paper seeks to add understanding to the home healthcare field, specifically studying care handoffs between informal caregivers. This study included 16 trained and 20 lay participants to determine differences due to expertise. This comparison is useful because there is a lot of published research on healthcare handoff happenings involving healthcare professionals, and the results indicate how much of the published research can be applied to care handoffs between informal caregivers. OBJECTIVE: The primary objective of this study is to identify differences between lay and professional caregivers when there is uncertainty in a caregiving handoff from their fellow caregiver. METHODS: The study design included between-group analysis of Expertise (layman and expert) and within-group analysis of Task Difficulty and Communication Modality. Dependent variables included willingness to ask for help, confidence in handoff instructions, confidence in the ability to complete tasks and task accuracy. Both Expertise groups were given the same four scenarios in a repeated measures study design. RESULTS: The findings suggest statistically significant differences in how informal caregivers respond to unclear handoff instructions, where lay participants were more confident in understanding instructions, more confident in executing the tasks, less willing to ask for help and also less able to spot and resolve conflicting information compared to trained participants. Lower performance in resolving conflicting information was exhibited by the lay participants. However, when comparing with the syringes that were prepared correctly, it was observed that the accuracy of those prepared syringes was higher for lay participants than for trained participants. CONCLUSION: It was anticipated that lay participants would be more willing to ask for help due to lack of subject matter expertise and trained participants would be more confident in completing tasks due to their superior subject matter expertise, but the opposite was true in both cases. It was also anticipated that lay and trained participants would be equally confident of the instructions given by their fellow caregiver, yet trained participants were less confident. The results from this study have impacts on the design of instructions (often by formal caregivers) for informal caregivers.

Interactive tools for safety 4.0: virtual ergonomics and serious games in real working contexts.

This paper presents an innovative safety training method based on digital ergonomics simulations and serious games, which are games that focus on education. Digital ergonomics is intended to disseminate the culture of safety among workers, while serious games are used to train the operators on specific safety procedures and verify their skills. The results of the experimentation in a real industrial environment showed that, compared to the traditional training methodology, multimedia contents and quantitative ergonomic analyses improve the level of attention and the awareness of the workers about their own safety. However, serious games turned out to be promising training tools with regard to standard operating procedures that are usually difficult or dangerous to simulate in a real working scenario without stopping production. Practitioner summary: Digital ergonomics and serious games are used to disseminate the culture of safety among the workers and for safety training. Our results show that the proposed methodology improves the level of attention and provides a better feedback about the actual skills of the workers than the standard educational strategies. Abbreviations.

Evaluation of Clinical Questions and Patient-Important Outcomes Associated With the Treatment of Age-Related Macular Degeneration.

Importance: Identifying and prioritizing unanswered clinical questions may help to best allocate limited resources for research associated with the treatment of age-related macular degeneration (AMD). Objective: To identify and prioritize clinical questions and outcomes for research associated with the treatment of AMD through engagement with professional and patient stakeholders. Design, Setting, and Participants: Multiple cross-sectional survey questions were used in a modified Delphi process for panel members of US and international organizations, the American Academy of Ophthalmology (AAO) Retina/Vitreous Panel (n=7), health care professionals from the American Society of Retinal Specialists (ASRS) (n=90), Atlantic Coast Retina Conference (ACRC) and Macula 2017 meeting (n=34); and patients from MD (Macular Degeneration) Support (n=46). Data were collected from January 20, 2015, to January 9, 2017. Main Outcomes and Measures: The prioritizing of clinical questions and patient-important outcomes for AMD. Results: Seventy clinical questions were derived from the AAO Preferred Practice Patterns for AMD and suggestions by the AAO Retina/Vitreous Panel. The AAO Retina/Vitreous Panel assessed all 70 clinical questions and rated 17 of 70 questions (24%) as highly important. Health care professionals assessed the 17 highly important clinical questions and rated 12 of 17 questions (71%) as high priority for research to answer; 9 of 12 high-priority clinical questions were associated with aspects of anti-vascular endothelial growth factor agents. Patients assessed the 17 highly important clinical questions and rated all as high priority. Additionally, patients identified 6 of 33 outcomes (18%) as most important to them (choroidal neovascularization, development of advanced AMD, retinal hemorrhage, gain of vision, slowing vision loss, and serious ocular events). Conclusions and Relevance: Input from 4 stakeholder groups suggests good agreement on which 12 priority clinical questions can be used to underpin research related to the treatment of AMD. The 6 most important outcomes identified by patients were balanced between intended effects of AMD treatment (eg, slowing vision loss) and adverse events. Consideration of these patient-important outcomes may help to guide clinical care and future areas of research.

Elaborating the Human Aspect of the NIST Framework for Cyber-Physical Systems.

The National Institute of Standards and Technology (NIST) has developed a Framework for Cyber-Physical Systems (CPS Framework) that supports system engineering analysis, design, development, operation, validation and assurance of CPS. Cyber-physical systems (CPS) comprise interacting digital, analog, physical, and human components engineered for function through integrated physics and logic. For instance, a city implementing an advanced traffic management system including real-time predictive analytics and adaptation/optimization must consider all aspects of such a CPS system of systems' functioning and integrations with other systems, including interactions with humans. One Aspect (or grouping of stakeholder concerns) of the CPS Framework is the Human Aspect. NIST is engaging HFES in a panel discussion to elaborate Human Aspect concerns, especially relevant constructs, measures, methods, and tools.

Population trends in substances used in deliberate self-poisoning leading to intensive care unit admissions from 2000 to 2010.

OBJECTIVE: To examine population trends in serious intentional overdoses leading to admission to intensive care units (ICUs) in Winnipeg, Manitoba, Canada. METHOD: Participants consisted of 1,011 individuals presenting to any of the 11 ICUs in Winnipeg, Canada, with deliberate self-poisonings from January 2000 to December 2010. Eight categories of substances were created: poisons, over-the-counter medications, prescription medications, tricyclic antidepressants (TCAs), sedatives and antidepressants, anticonvulsants, lithium, and cocaine. Using the population of Winnipeg as the denominator, we conducted generalized linear model regression analyses using the Poisson distribution with log link to determine significance of linear trends in overdoses by substance over time. RESULTS: Women accounted for more presentations than men (57.8%), and the largest percentage of overdoses occurred among individuals in the 35- to 54-year age range. A large proportion of admissions were due to multiple overdoses, which accounted for 65.7% of ICU admissions. At the population level, multiple overdoses increased slightly over time (incidence rate ratio [IRR] = 1.02, P < .05), whereas use of poisons (IRR = 0.897, P < .01), over-the-counter medications (IRR = 0.910, P < .01), nonpsychotropic prescription medications (IRR = 0.913, P < .01), anticonvulsants (IRR = 0.880, P < .01), and TCAs (IRR = 0.920, P < .01) decreased over time. Overdoses did not change over time as a function of age or sex. However, severity of overdoses classified by length of stay increased over time (IRR = 1.08, P < .01). CONCLUSIONS: It is important for physicians to exercise vigilance while prescribing medication, including being aware of other medications their patients have access to.

Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses.

RATIONALE: Around-the-clock intensivist presence in intensive care units (ICUs) has been promoted as necessary to optimize outcomes. Little data have addressed how it affects the multiple stakeholders in such care. OBJECTIVES: To assess effects of around-the-clock intensivist presence on intensivists, patients, families, housestaff, and nurses. METHODS: This 32-week, crossover pilot trial of two intensivist staffing models, performed in two Canadian ICUs, alternated 8-week blocks of two staffing models: the standard model, where one intensivist worked for 7 days, taking night call from home; and the shift work model, where one intensivist worked 7 day shifts, while other intensivists remained in the ICU at night. MEASUREMENTS AND MAIN RESULTS: Surveys scaled from 0-100 points assessed outcomes for 24 intensivists (primary outcome: burnout); 119 families (satisfaction); 74 nurses (satisfaction with collaboration and communications, role conflict); and 34 housestaff (autonomy, supervision, and learning opportunities). Outcomes for 501 patients included mortality, length of stay, and resource use. Intensivists doing shift work experienced less burnout (-6.9 points; P = 0.04). Adjusted hospital mortality (odds ratio, 1.22; P = 0.44), ICU length of stay (-6 h; P = 0.46), and family satisfaction (0.9 points; P = 0.79) did not differ between staffing models. Under shift work staffing, nurses reported more role conflict (9 points; P < 0.001), whereas nighttime housestaff reported less autonomy, more supervision, but no difference in learning opportunities. CONCLUSIONS: Shiftwork staffing was better for intensivists and most were receptive once they had experienced it. Although there were no evident negative outcomes for patients or families, further evaluation is needed to clarify how around-the-clock intensivist staffing influences the various stakeholders in ICU care, given power considerations in this study. Clinical trial registered with www.clinicaltrials.gov (NCT 01146691).

High rates of mortality and technique failure in peritoneal dialysis patients after critical illness.

INTRODUCTION: Little is known regarding the causes and outcomes of peritoneal dialysis (PD) patients admitted to the intensive care unit (ICU). We explored the outcomes of technique failure and mortality in a cohort of PD patients admitted to the ICU. METHODS: Using a provincial database of 990 incident PD patients followed from January 1997 to June 2009, we identified 90 (9%) who were admitted to the ICU. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. The Cox proportional hazards and competing risk methods were used to investigate associations. RESULTS: Compared with other patients, those admitted to the ICU had been on PD longer (p < 0.0001) and were more often on continuous ambulatory PD (74.2% vs 25.8%, p = 0.016). Cardiac problems were the most common admitting diagnosis (50%), followed by sepsis (23%), with peritonitis accounting for 69% of the sepsis admissions. The 1-year mortality was 53.3%, with 12% alive and converted to hemodialysis, and one third remaining alive on PD. In multivariate Cox modeling, age [hazard ratio (HR): 1.01; 95% confidence interval (CI): 0.99 to 1.03], white blood cell count (HR: 1.02; 95% CI: 1.00 to 1.04), temperature (HR: 0.75; 95% CI: 0.61 to 0.92), and peritonitis (1.64; 95% CI: 1.21 to 2.22) at admission to the ICU were associated with the composite outcome of technique failure or death. In a competing risk analysis, the risk for death was 30%, and for technique failure, 36% at 1 year. CONCLUSIONS: Patients on PD have high rates of death and technique failure after admission to the ICU.

The role of functional status in discharge to assisted care facilities and in-hospital death among dialysis patients.

BACKGROUND: Functional status is an important component in the assessment of hospitalized patients. We set out to determine the scope, severity, and prognostic significance of impaired functional status in acutely hospitalized dialysis patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 1,286 hospitalized dialysis patients admitted and discharged from 1 of 11 area hospitals in Manitoba, Canada, from September 2003 to September 2010 with an activity of daily living (ADL) assessment within 24 hours of admission. PREDICTOR: The 12-point ADL score assesses 6 domains (bathing, toileting, dressing, incontinence, feeding, and transferring) and scores them as independent or supervision only (score, 0), partial assistance (1), and full assistance (2). Thus, higher score indicates worse functional status. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. OUTCOMES: Multivariable logistic regression and Cox proportional hazards assessed the association between functional status, in-hospital death, and discharge to an assisted care facility. RESULTS: During the study period, 250 (19.4%) and 72 (5.6%) patients experienced the outcomes of in-hospital death or discharge to an assisted care facility. Abnormalities in functional status were present in >70% of the cohort. ADL score within 24 hours of admission combined with age differentiated risks of death and discharge to an assisted care facility home, ranging from 4.8%-46.6% and 0.6%-17.8%, respectively. After adjustment, ORs of death and discharge to an assisted care facility were 1.16 (95% CI, 1.11-1.22; P < 0.001; C statistic = 0.79) and 1.25 (95% CI, 1.14-1.36; P < 0.001; C statistic = 0.91) per 1-point increase in ADL score, respectively. Findings were consistent after accounting for the competing outcomes of in-hospital death or discharge to an assisted care facility versus discharge to home. LIMITATIONS: A 1-time measurement of ADLs could not differentiate temporary from long-term deterioration in functional status. CONCLUSIONS: Impaired functional status is common at the time of admission in the dialysis population. A single ADL score measurement at admission combined with age is highly predictive of poor outcomes in the hospitalized dialysis population.

Long-term outcomes of end-stage renal disease patients admitted to the ICU.

BACKGROUND: End-stage renal disease (ESRD) patients admitted to the intensive care unit (ICU) have poor survival and high rates of readmission; however, little evidence exists on long-term outcomes. We set out to investigate the long-term (6 and 12 months) survival of ESRD patients admitted to the ICU and whether differential survival could be explained by dialysis modality and vascular access. METHODS: We compared the admission characteristics, outcomes and readmission rates of 619 ESRD [95 peritoneal dialysis (PD), 334 hemodialysis with a catheter (HD CVC), 190 hemodialysis with an AV fistula (HD AVF)] patients admitted to 11 ICU's in Winnipeg, Manitoba, Canada. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. Multivariable Cox and logistic regression was used to assess outcomes between the groups. RESULTS: The 6- and 12-month crude survival was 62 and 52%, respectively. In a univariate model, modality and vascular access were associated with an increased hazard ratio (HR) of death [PD HR 1.60 95% confidence interval (CI) 1.20-2.13, HD CVC HR 1.55 95% CI 1.25-1.93] compared to patients on HD with an AVF. In three different multivariate adjusted models, this association persisted with HRs for death of 1.63-1.75 for PD and 1.50-1.58 for HD CVC. CONCLUSIONS: Overall long-term survival of ESRD patients after admission to the ICU is poor. Being on PD or being dialyzed with a catheter was independently associated with an increased mortality.

End-stage renal disease status and critical illness in the elderly.

BACKGROUND AND OBJECTIVES: Elderly patients (> 65 years old) are a rapidly growing demographic in the ESRD and intensive care unit (ICU) populations, yet the effect of ESRD status on critical illness in elderly patients remains unknown. Reliable estimates of prognosis would help to inform care and management of this frail and vulnerable population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The effect of ESRD status on survival and readmission rates was examined in a retrospective cohort of 14,650 elderly patients (>65 years old) admitted to 11 ICUs in Winnipeg, Manitoba, Canada between 2000 and 2006. Logistic regression models were used to adjust odds of mortality and readmission to ICU for baseline case mix and illness severity. RESULTS: Elderly ESRD patients had twofold higher crude in-hospital mortality (22% versus 13%, P < 0.0001) and readmission rate (6.4 versus 2.7%, P = 0.001). After adjustment for illness severity alone or illness severity and case mix, the odds ratio for mortality decreased to 0.85 (95% CI: 0.57 to 1.25) and 0.82 (95% CI: 0.55 to 1.23), respectively. In contrast, ESRD status remained significantly associated with readmission to ICU after adjustment for other risk factors (OR 2.06 [95% CI: 1.32, 3.22]). CONCLUSIONS: Illness severity on admission, rather than ESRD status per se, appears to be the main driver of in-hospital mortality in elderly patients. However, ESRD status is an independent risk factor for early and late readmission, suggesting that this population might benefit from alternative strategies for ICU discharge.

Acute kidney injury in critically ill patients infected with 2009 pandemic influenza A(H1N1): report from a Canadian Province.

BACKGROUND: 2009 pandemic influenza A(H1N1) has led to a global increase in severe respiratory illness. Little is known about kidney outcomes and dialytic requirements in critically ill patients infected with pandemic H1N1. STUDY DESIGN: Prospective observational study. SETTING & PARTICIPANTS: 50 patients with pandemic H1N1 admitted to any of 7 intensive care units in Manitoba, Canada, were prospectively followed. OUTCOME & MEASUREMENTS: Outcomes were kidney injury and kidney failure defined using RIFLE (risk, injury, failure, loss, end-stage disease) criteria or need for dialysis therapy. RESULTS: The pandemic H1N1 group was composed of 50 critically ill patients with pandemic H1N1 with severe respiratory syndrome (47 confirmed cases, 3 probable). Kidney injury, kidney failure, and need for dialysis occurred in 66.7%, 66%, and 11% of patients, respectively. Mortality was 16%. Kidney failure was associated with increased death (OR, 11.29; 95% CI, 1.29-98.9), whereas the need for dialysis was associated with an increase in length of stay (RR, 2.38; 95% CI, 2.13-25.75). LIMITATIONS: Small population studied from single Canadian province; thus, limited generalizability. CONCLUSIONS: In critically ill patients with pandemic H1N1, kidney injury, kidney failure, and the need for dialysis are common and associated with an increase in mortality and length of intensive care unit stay.

Outcomes of chronic dialysis patients admitted to the intensive care unit.

Admission rates and outcomes of patients who have ESRD and are admitted to an intensive care unit (ICU) are not well defined. We conducted a historical cohort study using a prospective regional ICU database that captured all 11 adult ICUs in Winnipeg, Canada. Between 2000 and 2006, there were 34,965 total admissions to the ICU, 1173 (3.4%) of which were patients with ESRD. The main admission diagnoses among patients with ESRD were cardiac disease (31%), sepsis (15%), and arrest (10%). Compared with other patients in the ICU, those with ESRD were significantly younger but had more diabetes, peripheral arterial disease, and higher APACHE II (Acute Physiology and Chronic Health Evaluation II) scores; mean length of stay in the ICU was similar, however, between these two groups. Restricting the analysis to first admissions to the ICU, unadjusted in-hospital mortality was higher for patients with ESRD (16 versus 11%; P < 0.0001), but this difference did not persist after adjustment for baseline illness severity. In conclusion, although ESRD associates with increased mortality among patients who are admitted to the ICU, this effect is mostly a result of comorbidity.

Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock.

OBJECTIVE: Our goal was to determine the impact of the initiation of inappropriate antimicrobial therapy on survival to hospital discharge of patients with septic shock. METHODS: The appropriateness of initial antimicrobial therapy, the clinical infection site, and relevant pathogens were retrospectively determined for 5,715 patients with septic shock in three countries. RESULTS: Therapy with appropriate antimicrobial agents was initiated in 80.1% of cases. Overall, the survival rate was 43.7%. There were marked differences in the distribution of comorbidities, clinical infections, and pathogens in patients who received appropriate and inappropriate initial antimicrobial therapy (p < 0.0001 for each). The survival rates after appropriate and inappropriate initial therapy were 52.0% and 10.3%, respectively (odds ratio [OR], 9.45; 95% CI, 7.74 to 11.54; p < 0.0001). Similar differences in survival were seen in all major epidemiologic, clinical, and organism subgroups. The decrease in survival with inappropriate initial therapy ranged from 2.3-fold for pneumococcal infection to 17.6-fold with primary bacteremia. After adjustment for acute physiology and chronic health evaluation II score, comorbidities, hospital site, and other potential risk factors, the inappropriateness of initial antimicrobial therapy remained most highly associated with risk of death (OR, 8.99; 95% CI, 6.60 to 12.23). CONCLUSIONS: Inappropriate initial antimicrobial therapy for septic shock occurs in about 20% of patients and is associated with a fivefold reduction in survival. Efforts to increase the frequency of the appropriateness of initial antimicrobial therapy must be central to efforts to reduce the mortality of patients with septic shock.

The effects of split keyboard geometry on upper body postures.

Split, gabled keyboard designs can prevent or improve upper extremity pain among computer users; the mechanism appears to involve the reduction of awkward wrist and forearm postures. This study evaluated the effects of changes in opening angle, slope and height (independent variables) of a gabled (14 degrees) keyboard on typing performance and upper extremity postures. Twenty-four experienced touch typists typed on seven keyboard conditions while typing speed and right and left wrist extension, ulnar deviation, forearm pronation and elbow position were measured using a motion tracking system. The lower keyboard height led to a lower elbow height (i.e. less shoulder elevation) and less wrist ulnar deviation and forearm pronation. Keyboard slope and opening angle had mixed effects on wrist extension and ulnar deviation, forearm pronation and elbow height and separation. The findings suggest that in order to optimise wrist, forearm and upper arm postures on a split, gabled keyboard, the keyboard should be set to the lowest height of the two heights tested. Keyboard slopes in the mid-range of those tested, 0 degrees to -4 degrees, provided the least wrist extension, forearm pronation and the lowest elbow height. A keyboard opening angle in the mid-range of those tested, 15 degrees, may provide the best balance between reducing ulnar deviation while not increasing forearm pronation or elbow separation. These findings may be useful in the design of computer workstations and split keyboards. The geometry of a split keyboard can influence wrist and forearm postures. The findings of this study are relevant to the positioning and adjustment of split keyboards. The findings will also be useful for engineers who design split keyboards.

Response of ventilator-dependent patients to delayed opening of exhalation valve.

In conventional mechanical ventilation, the inflation cycle often extends into neural expiration (TEN), potentially exacerbating dynamic hyperinflation (DH). We wished to determine the extent to which patients defend against DH when this happens. Such defense may include prolongation of TEN (timing response) and/or expiratory muscle recruitment (neuromuscular response). Fifty patients were ventilated in the Proportional Assist mode, allowing us to infer these responses noninvasively. At random intervals, exhalation of single breaths was delayed by briefly delaying the opening of exhalation valve (occlusion) (T(occ) = 0.78 +/- 0.34 seconds). Timing response was assessed from the change in TEN. Neuromuscular response was assessed from the difference between volume exhaled after release of occlusion and volume exhaled in unoccluded breaths over a similar expiratory flow duration (DeltaV(iso-time)). There was no evidence of an acute neuromuscular response; DeltaV(iso-time) averaged 0.005 +/- 0.023 L (NS). Forty-five of 50 patients significantly lengthened TEN. However, the timing response offset only 36 +/- 20% of the delay in expiration. Because of absent neuromuscular responses and weak timing responses, DH increased in most patients in postocclusion breaths (DeltaDH = 0.10 +/- 0.08 L, p = 2E-10). We conclude that acute compensatory responses to delays in opening of exhalation value are weak in ventilator-dependent patients. As a result, such nonsynchrony tends to exacerbate DH.