Changes in the incidence and outcome of multiple organ failure in emergency non-cardiac surgical admissions: a 10-year retrospective observational study.

BACKGROUND: During the past decades, epidemiologic data of independent predictors of multiple organ failure (MOF), incidence, and mortality have changed. The aim of the study was to assess the potential changes in the incidence and outcomes of MOF for one decade (2008-2017). In addition, resource utilization was considered. METHODS: Patients were eligible for inclusion if they were adults, admitted to the ICU between January 1, 2008 and December 31, 2017, and had complete data sets regarding MOF. MOF was defined as organ failure separately with and without central nervous system (CNS) failure. The onset of MOF was defined as being early (≤48 h of ICU admission) and late (>48 h after ICU admission). RESULTS: Of a total of 13,270 patients enclosed in this study, 44.6% of the patients developed MOF with and 31.4% without CNS failure. MOF-related mortality decreased in patients with (adjusted IRR 0.972 [95% CI 0.948 to 0.996], P=0.022) and without (adjusted IRR 0.957 [95% CI 0.931 to 0.983], P=0.0013) CNS failure. In addition, the incidence (adjusted IRR 0.970 [95% CI 0.950 to 0.991], P=0.006) and mortality (adjusted IRR 0.968 [95% CI 0.940 to 0.996], P=0.025) of early-onset MOF decreased, while the incidence and mortality of late-onset MOF remained constant. The length of ICU (P=0.024) and hospital (P=0.032) stays decreased while the length of mechanical ventilation remained constant (P=0.41). CONCLUSIONS: Despite all improvements in intensive care during the last decades, the incidence of late-onset MOF remains a resource-intensive, morbid, and lethal condition. More research on etiologies, signs of organ failure, and where and when to start treatment is needed to improve the prognosis of late-onset MOF.

Implementation of strategies to liberate patients from mechanical ventilation in a tertiary-level medical center.

BACKGROUND: Considerable discrepancies have been observed in the implementation of strategies to liberate patients from mechanical ventilation. The aim of this study was to describe critical care nurses' knowledge of and self-reported and documented adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate and evaluate how these practices differ between patients with and without ventilator-associated pneumonia and between survivors and nonsurvivors. METHODS: The survey was conducted in a tertiary-level hospital in Finland from October 2014 to June 2015. Actual adherence was evaluated based on documentation of performed practices. RESULTS: A total of 86 critical care nurses responded to the survey, and 85 patients were followed. The levels of knowledge of and self-reported adherence to low tidal ventilation were 84.5% and 90.2%, respectively, and the median tidal volume was at a target level in 74.4% of patients. Regarding daily sedation interruption, the level of knowledge was 85.7%, the level of self-reported adherence was 77.3%, and documented adherence was 33.3%. The levels of knowledge and self-reported adherence regarding spontaneous breathing trials were 61.9% and 71.6%, respectively. Adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate did not differ between patients with (n = 20) and without (n = 65) ventilator-associated pneumonia and between survivors (n = 55) and nonsurvivors (n = 30). CONCLUSIONS: Lung-protective ventilation, including low-tidal ventilation and avoidance of high inspiratory plateau pressures, was well implemented and adhered to. The levels of knowledge and self-reported adherence versus documented adherence regarding daily sedation interruption and spontaneous breathing trial demonstrated insufficient implementation of local guidelines. There was no effect on the outcome.

Association of nurse staffing and nursing workload with ventilator-associated pneumonia and mortality: a prospective, single-center cohort study.

BACKGROUND: Nurse understaffing and increased nursing workload have been associated with increased risk of adverse patient outcomes and even mortality. AIM: To determine whether nurse staffing and nursing workload are associated with ventilator-associated pneumonia and mortality. METHODS: This prospective, observational cohort study was conducted in a single tertiary-level teaching hospital in Finland during 2014-2015. The association between nurse staffing, nursing workload and prognosis was determined using daily nurse-to-patient ratios, Therapeutic Intervention Scoring System and Intensive Care Nursing Scoring System scores, and Intensive Care Nursing Scoring System indices. Ventilator-associated pneumonia was defined according to the Centers for Disease Control and Prevention criteria. FINDINGS: Evaluable data was available for 85 patients. The overall ventilator-associated pneumonia and 28-day mortality rates were 23.5% and 35.3%, respectively. Nurse staffing, measured as the daily lowest nurse-to-patient ratio (P = 0.006) and median Intensive Care Nursing Scoring System index (P = 0.046), were significantly lower in patients with ventilator-associated pneumonia. In addition, nursing workload, measured as median scores obtained by the Therapeutic Intervention Scoring System (P = 0.009) and Intensive Care Nursing Scoring System (P = 0.03), was significantly higher in infected patients. The median (P = 0.02) and daily highest (P = 0.03) Intensive Care Nursing Scoring System scores were significantly higher in non-survivors. CONCLUSIONS: Lower nurse staffing and increased nursing workload are associated with ventilator-associated pneumonia and mortality, demonstrating that adequate staffing is a prerequisite for the availability and quality of critical care services.

Critical care nurses' knowledge of, adherence to, and barriers toward institution-specific ventilator bundle.

BACKGROUND: Although evidence-based practices are known to improve the quality of care, making it cost-efficient and improving clinical results, barriers to transferring research into clinical practice have hindered this process. AIMS: To evaluate critical care nurses' knowledge of, adherence to, and barriers toward institution-specific ventilator bundle. MATERIAL AND METHODS: In 2015, we conducted an institution-specific, cross-sectional study in a 26-bed adult mixed medical-surgical intensive care unit (ICU) in Finland using quantitative survey of knowledge and self-reported adherence with qualitative gathering of barrier data. A pre-validated multiple-choice Ventilator Bundle Questionnaire was distributed to all registered nurses who were direct care providers (n = 155). RESULTS: The final response rate was 55.5% (n = 86), and 47.2% (n = 34) of respondents had more than 10 years of ICU experience. The levels of knowledge and self-reported adherence were 71.1% and 65.8% of the total score, respectively. The level of knowledge was higher among respondents who had received in-service education about ventilator bundle compared with respondents who had not received in-service education (27.0 vs 24.0 [P = .012]). Less experienced nurses reported significantly higher adherence than nurses with more ICU experience (29.0 vs 25.0 [P = .034]). The correlation between knowledge and adherence scores was low (ρ 0.48 [P <.001]). The most well-known and adhered-to guidelines described patient positioning, daily chlorhexidine-based oral care, and strict hand hygiene. The least-known guidelines and those least adhered to described respiratory equipment, management of sedation and analgesia, and practices prior to and during endotracheal suctioning. The main barriers were related to the nurse respondents (e.g., lack of education [25.9%]), environment (e.g., role ambiguities [36.4%] and inadequate resources [21.1%]), and patients (e.g., patient discomfort [4.8%] and fear of adverse effects [4.6%]). CONCLUSIONS: Self-reported adherence did not correlate with knowledge and was not related to work experience. Most of the barriers toward evidence-based guidelines indicated a need for changes that are beyond the control of individual nurses.

Effects of simulation education on oral care practices - a randomized controlled trial.

BACKGROUND: Implementation of evidence-based oral care protocols, nurse education programmes and assessment tools may reduce the risk of developing ventilator-associated pneumonia by increasing critical care nurses' knowledge and skills in adhering to current oral care recommendations. AIMS: To evaluate the longitudinal effects of single-dose simulation education with structured debriefing and verbal feedback on critical care nurses' knowledge and skills in adhering to current oral care recommendations. DESIGN: A randomized controlled trial with repeated measurements. METHOD: The data for the study were collected in a single academic centre in a 22-bed adult, mixed, medical-surgical intensive care unit in Finland from February 2012 to March 2014. The effectiveness of simulation education was evaluated through the validated Ventilator Bundle Questionnaire and Observation Schedule at baseline (n = 30) and 24 months (n = 17) after simulation education. Data were analysed using a linear mixed model and intention-to-treat analyses. RESULTS: During the study period, the average knowledge score in the intervention group increased significantly (44·0% to 56·0% of the total score) in the final post-intervention measurement (pt = 0·51, pg = 0·002, pt*g = 0·023). However, single-dose simulation education with structured debriefing and verbal feedback had no impact on critical care nurses' skill scores. CONCLUSION: Single-dose simulation education had only a minimal effect on critical care nurses' knowledge and skills in adhering to current oral care recommendations. Despite increased awareness, there was no significant difference in oral care practices between the study groups after simulation education. RELEVANCE FOR CLINICAL PRACTICE: The need for regularly repeated educational sessions with theoretical training and practical exercises and direct feedback is evident. Certain aspects of oral care, such as prevention of microaspiration of oropharyngeal secretions and moistening of oral mucosa and lips, require more reinforcement than others.

Longitudinal effects of single-dose simulation education with structured debriefing and verbal feedback on endotracheal suctioning knowledge and skills: A randomized controlled trial.

We evaluated the longitudinal effects of single-dose simulation education with structured debriefing and verbal feedback on critical care nurses' endotracheal suctioning knowledge and skills. To do this we used an experimental design without other competing intervention. Twenty-four months after simulation education, no significant time and group differences or time × group interactions were identified between the study groups. The need for regularly repeated educational interventions with audiovisual or individualized performance feedback and repeated bedside demonstrations is evident.

Simulation education as a single intervention does not improve hand hygiene practices: A randomized controlled follow-up study.

BACKGROUND: To evaluate how critical nurses' knowledge of and adherence to current care hand hygiene (HH) guidelines differ between randomly allocated intervention and control groups before and after simulation education in both a simulation setting and clinical practice during a 2-year follow-up period. It was hypothesized that intervention group knowledge of and adherence to current HH guidelines might increase compared with a control group after simulation education. METHODS: A prospective, parallel, randomized controlled trial with repeated measurements was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Oulu, Finland. Thirty out of 40 initially randomized critical care nurses participated in the baseline measurements; of these, 17 completed all the study procedures. Participants' HH adherence was observed only in high-risk contact situations prior to and postendotracheal suctioning events using a direct, nonparticipatory method of observation. Participants' HH knowledge was evaluated at the end of each observational session. RESULTS: The overall HH adherence increased from a baseline value of 40.8% to 50.8% in the final postintervention measurement at 24 months (P = .002). However, the linear mixed model did not identify any significant group (P = .77) or time-group interactions (P = .17) between the study groups after 2 years of simulation education. In addition, simulation education had no impact on participants' HH knowledge. CONCLUSIONS: After a single simulation education session, critical care nurses' knowledge of and adherence to current HH guidelines remained below targeted behavior rates.

Randomized, controlled trial of the effectiveness of simulation education: A 24-month follow-up study in a clinical setting.

BACKGROUND: Critical care nurses' knowledge and skills in adhering to evidence-based guidelines for avoiding complications associated with intubation and mechanical ventilation are currently limited. We hypothesized that single simulation education session would lead to a long-lasting higher level of skills among critical care nurses. MATERIAL AND METHODS: A randomized controlled trial was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Finland during the period February 2012-March 2014. Thirty out of 40 initially randomized critical care nurses participated in a 24-month follow-up study. Behavior and cognitive development was evaluated through a validated Ventilator Bundle Observation Schedule and Questionnaire at the baseline measurement and repeated 3 times during simulation and real-life clinic settings. RESULTS: After simulation education, the average skills score increased from 46.8%-58.8% of the total score in the final postintervention measurement (Ptime < .001, Ptime × group = .040, and Pgroup = .11). The average knowledge scores within groups did not change significantly. The average between-group difference in skills scores was significant only at the measurement taken at 6 months (P = .006). CONCLUSIONS: Critical care nurses' skills in adhering to evidence-based guidelines improved in both groups over time, but the improvements between the study groups was significantly different only at 6 months and was no longer evident after 2 years following a single simulation education.

Development and psychometric testing of ventilator bundle questionnaire and observation schedule.

BACKGROUND: There is a current lack of valid and reliable instruments that can be used to examine critical care nurses' knowledge and skills in adhering to ventilator bundles. The aim of this study was to develop and psychometrically test a ventilator bundle questionnaire (VBQ) and ventilator bundle observation schedule (VBOS). METHODS: The VBQ and VBOS consisted of a list of pharmacologic and nonpharmacologic nurse-led interventions taken from the literature and supported by various levels of evidence. After content validation, stability and equivalence reliabilities of the VBOS were determined in a randomly selected sample of critical care nurses from a single academic center in Finland. RESULTS: The final VBQ contained 49 multiple-choice questions, and the VBOS had 86 dichotomous items, whose overall content validity ranged from 0.99 to 1.0. The overall intraclass correlation coefficient of the VBOS ranged from 0.93 to 1.0. CONCLUSIONS: The VBQ and VBOS have acceptable psychometric properties and could be used to objectively assess whether evidence-based guidelines regarding ventilator bundles are being used in clinical practice. Further testing with diverse samples is needed to strengthen the validity and reliability of these instruments.

Human patient simulation education in the nursing management of patients requiring mechanical ventilation: a randomized, controlled trial.

BACKGROUND: Knowledge among critical care nurses and their adherence to evidence-based guidelines for preventing ventilator-associated pneumonia is reported to be low. The aim of our study was to evaluate the effectiveness of human patient simulation (HPS) education in the nursing management of patients requiring mechanical ventilation. METHODS: A prospective, parallel, randomized controlled trial with repeated measurements was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Finland from February-October 2012. Thirty critical care nurses were allocated evenly to intervention and control groups (n = 15 each). The effectiveness of HPS education was evaluated through the validated Ventilator Bundle Questionnaire and Ventilator Bundle Observation Schedule at baseline and repeated twice-after the clinical and simulation settings, respectivley. RESULTS: After HPS education, the average skill scores (Ventilator Bundle Observation Schedule) in the intervention group increased significantly (46.8%-60.0% of the total score) in the final postintervention observation. In the average skill scores, a linear mixed model identified significant time (Pt < .001) and group (P(g) = .03) differences and time-group interactions (P(t*g) = .02) between the study groups after the HPS education. In contrast, the model did not identify any significant change over time (P(t) = .29) or time-group interactions (P(t) = .69) between groups in average knowledge scores (Ventilator Bundle Questionnaire). CONCLUSIONS: Our study identified significant transfer of learned skills to clinical practice following HPS education but no influence on the level of participants' factual knowledge.

Two-stage revision for prosthetic joint infection: outcome and role of reimplantation microbiology in 107 cases.

Two-stage revision is widely used for the treatment of prosthetic joint infections. However, the duration of antibiotic treatment between stages and role of reimplantation microbiology are controversial. The purpose of this study was to evaluate the outcome and influence of the reimplantation microbiology of two-staged revisions with 6 weeks of antibiotic treatment. We retrospectively reviewed 107 patients treated with two-stage revision between 2001 and 2009. The overall treatment success rate was 94.4%. The reimplantation cultures were positive in 5/97 (5.2%) cases, and only one of them failed. Therefore, we achieved excellent results with a 6-week course of antibiotics between stages in two-stage revision. Positive reimplantation cultures do not seem to be associated with worse outcomes.

Increased postoperative concentrations of tenascin-C in wound fluid.

BACKGROUND: Tenascin-C (Tn-C) is the most studied member of a family comprising large oligomeric glycoproteins in the extracellular matrix. The function of Tn-C still is unclear, and the levels of Tn-C in human wound fluid have not been studied. METHODS: The participants in this study were 24 patients referred for elective major gastrointestinal surgery. Concentrations of Tn-C and procollagen propeptides type 1 and type 3 in serum and wound fluid were measured after surgery. RESULTS: In wound fluid, Tn-C was present on postoperative day 1, and the concentration increased from day 5 up to day 7. CONCLUSIONS: The concentration of Tn-C increases postoperatively in wound fluid. The concentration of Tn-C in wound fluid is markedly higher than that of serum. The differences in expression between Tn-C and the procollagen propeptides may reflect different tasks of these extracellular matrix proteins.