Development and implementation of a clinical information system-based protocol to improve nurse satisfaction of end-of-life care in a single intensive care unit.

BACKGROUND: Patients treated in Australian intensive care units (ICUs) have an overall mortality rate of 5.05%. This is due to the critical nature of their disease, the increasing proportion of patients with multiple comorbidities, and advanced age. This has made treating patients during the end of life an integral part of intensive care practice and requires a high quality of care. With the increased use of electronic clinical information systems, a standardised protocol encompassing end-of-life care may provide an efficient method for documentation, communication, and timely delivery of comfort care. OBJECTIVE: The aim of the study was to determine if an electronic clinical information system-based end-of-life care protocol improved nurses' satisfaction with the practice of end-of-life care for patients in the ICU. DESIGN: This is a prospective single-centre observational study. SETTING: The study was carried out at a 20-bed cardiothoracic and general ICU between 2015 and 2017. PARTICIPANTS: The study participants were ICU nurses. INTERVENTION: Electronic clinical information-based end-of-life care protocol was used in the study. OUTCOME: The primary outcome was nurse satisfaction obtained by a survey. RESULTS: The number of respondents for the before survey and after survey was 58 (29%) and 64 (32%), respectively. There was a significant difference between the before survey and the after survey with regard to feeling comfortable in transitioning from curative treatment (median = 2 [interquartile range {IQR} = 2, 3] vs 3 [IQR = 2, 3], p = 0.03), feeling involved in the decision to move from curative treatment to end-of-life care (median = 2 [IQR = 2, 2] vs 2 [IQR 2, 3], p = 0.049), and feeling religious beliefs/rituals should be respected during the end-of-life process (median = 4 [IQR = 3, 4] vs. 4 [IQR = 4, 4], p = 0.02). There were some practices that had a low satisfaction rate on both the before survey and after survey. However, a high proportion of nurses were satisfied with many of the end-of-life care practices. CONCLUSION: The nurses were highly satisfied with many aspects of end-of-life care practices in this unit. The use of an electronic clinical information system-based protocol improved nurse satisfaction and perception of quality of end-of-life care practices for three survey questions.

The importance of hyperosmolarity in diabetic ketoacidosis.

AIM: Diabetic ketoacidosis is a hyperglycaemic emergency that is often treated in intensive care units (ICUs) despite having a low mortality and good prognosis. Current risk stratification is based primarily on acidosis, but it has been suggested that hyperosmolarity may also be an important marker of increased severity. Our aim was to evaluate the relationship between raised serum osmolarity and adverse clinical outcomes in ICU admissions for ketoacidosis. METHODS: Retrospective review of prospectively collected data for adult admissions with ketoacidosis in the Australian and New Zealand Intensive Care Society Adult Patient Database over a 15-year period (2004-2018). Exclusions were readmissions and records with critical missing data. Serum hyperosmolarity was defined as > 320 mosm/l. The primary outcome was hospital mortality; secondary outcomes were ICU mortality and other adverse clinical events. RESULTS: Some 17 379 admissions were included in the study population. People with hyperosmolarity had fourfold increased mortality, a higher incidence of renal failure and need for mechanical ventilation, and prolonged ICU and hospital length of stay. The relationship with mortality remained highly significant even after adjusting for severity of acidosis, hospital type, year of admission, time to ICU, and a modified Australia and New Zealand Risk of Death propensity score. CONCLUSIONS: Although adults with ketoacidosis have a good prognosis overall, hyperosmolarity was independently associated with a significantly higher incidence of multiple adverse outcomes including mortality. Whether or not this is directly causal, it may have practical applications to improve risk stratification and identify individuals at risk of adverse outcomes.

Improved hospital mortality with a low MET dose: the importance of a modified early warning score and communication tool.

Rapid response systems have been mandated for the recognition and management of the deteriorating patient. Increasing medical emergency team (MET) dose may be associated with improved outcomes. Large numbers of MET calls may divert resources from the program providing the service unless additional personnel are provided. To describe the implementation and outcomes of a multifaceted rapid response system (RRS) in a teaching hospital, we conducted an observational study. The RRS consisted of the introduction of a MET together with 1) redesign of the ward observation chart with the vital sign variables colour-coded to identify variation from normal; 2) mandated minimum frequency of vital sign measurement; 3) three formal levels of escalation based on the degree of physiological instability as measured by a modified early warning score (MEWS); 4) COMPASS© education and e-learning package with a two-hour face-to-face small group tutorial; 5) practise in escalation and communication using the ISBAR (Identify, Situation, Background, Assessment, Response/Recommendation) communication tool. The primary outcome measures were all-cause hospital mortality rate and hospital standardised mortality ratio (HSMR) compared to peer hospitals calculated by the Health Round Table. There were 161,153 separations and 1,994 hospital deaths from July 2008 to December 2012. The MET call rate was 11.3 per 1000 separations in 2012. There was a decline in all-cause hospital mortality from 13.8 to 11 deaths/1000 separations. The HSMR decreased from 95.7 in 2008 to 66 in the second half of 2012 (below the three standard deviation control limit). A low MET dose may be associated with improved hospital mortality when combined with a MEWS and an intervention to improve communication.

Protocol guided bleeding management improves cardiac surgery patient outcomes.

BACKGROUND AND OBJECTIVES: Excessive bleeding is a risk associated with cardiac surgery. Treatment invariably requires transfusion of blood products; however, the transfusion itself may contribute to postoperative sequelae. Our objective was to analyse a quality initiative designed to provide an evidenced-based approach to bleeding management. MATERIALS AND METHODS: A retrospective analysis compared blood product transfusion and patient outcomes 15 months before and after implementation of a bleeding management protocol. The protocol incorporated point-of-care coagulation testing (POCCT) with ROTEM and Multiplate to diagnose the cause of bleeding and monitor treatment. RESULTS: Use of the protocol led to decreases in the incidence of transfusion of PRBCs (47·3% vs. 32·4%; P < 0·0001), FFP (26·9% vs. 7·3%; P < 0·0001) and platelets (36·1% vs. 13·5%; P < 0·0001). During the intra-operative period, the percentage of patients receiving cryoprecipitate increased (2·7% vs. 5·1%; P = 0·002), as did the number of units transfused (248 vs. 692; P < 0·0001). The proportion of patients who received tranexamic acid increased (13·7% to 68·2%; P < 0·0001). There were reductions in re-exploration for bleeding (5·6% vs. 3·4; P = 0·01), superficial chest wound (3·3% vs. 1·4%; P = 0·002), leg wound infection (4·6% vs. 2·0%; P < 0·0001) and a 12% reduction in mean length of stay from operation to discharge (95%: 9-16%, P < 0·0001). Acquisition cost of blood products decreased by $1 029 118 in the 15-month period with the protocol. CONCLUSIONS: The implementation of a bleeding management protocol supported by POCCT in a cardiac surgery programme was associated with significant reductions in the transfusion of allogeneic blood products, improved outcomes and reduced cost.

Resolution of severe ischemia-reperfusion injury post-lung transplantation after administration of endobronchial surfactant.

BACKGROUND: Ischemia-reperfusion injury (IRI) is a prominent cause of primary graft failure after lung transplantation and is associated with an altered surfactant profile. Experimental animal studies have found that replacement with exogenous surfactant administered via fiber-optic bronchoscopy (FOB) enhanced recovery from IRI with improved pulmonary compliance and gas exchange after lung transplantation. We report our clinical experience with FOB instillation of surfactant in severe IRI after human lung transplantation. METHODS: This study is a retrospective review of 106 consecutive lung or heart-lung transplants performed at a single institution. Severe IRI was defined as diffuse roentgenographic alveolar infiltrates, worsening hypoxemia and decreased lung compliance within 72 hours of lung transplantation. One vial of surfactant (20 mg/ml phospholipid) was instilled into each segmental bronchus upon diagnosis of IRI. RESULTS: Six patients (5 bilateral sequential and 1 re-do heart-lung transplant), mean age 46 years, were diagnosed with IRI and surfactant was administered at a mean of 37 hours (range 2.3 to 98) post-transplant. Mean graft ischemia time was 376 minutes (range 187 to 625) and cardiopulmonary bypass time 174 minutes (range 0 to 210). Mean Pao(2) [mm Hg]/Fio(2) ratio before and 48 hours after surfactant instillation was 70 and 223, respectively. Significant resolution of radiologic infiltrates was evident in all cases within 24 hours. Successful extubation occurred at a mean of 13.5 days and survival is presently 100% at 19 months (range 3 to 54). CONCLUSIONS: Bronchoscopic instillation of surfactant improves oxygenation and prognosis after severe IRI in lung transplant recipients. It represents a cost-effective, relatively non-invasive therapeutic alternative to extracorporeal membrane oxygenation.

Traumatic liver injury complicating cardio-pulmonary resuscitation. The value of a major intensive care facility: a report of two cases.

Complications associated with external cardiac compression include trauma to the heart, chest wall, lungs and gastrointestinal viscera, with gastrointestinal visceral injury including, ruptured stomach, liver, oesophagus, spleen and colon. However, the use of thrombolytics and anticoagulants in patients with an acute myocardial infarction increases the incidence of a visceral haemorrhage when these patients need cardiopulmonary resuscitation. We report two out-of-hospital cardiac arrest patients whose immediate post-resuscitation phase was complicated by hepatic injury and significant haemoperitoneum. Conservative management in a major intensive care unit of both the liver trauma and the induced coagulopathy was associated with a successful outcome in both cases.

Cerebrospinal fluid in critical illness.

OBJECTIVE: To detail the physiology, pathophysiology and recent advances in diagnostic analysis of cerebrospinal fluid (CSF) in critical illness, and briefly review the pharmacokinetics and pharmaco-dynamics of drugs in the CSF when administered by the intravenous and intrathecal route. DATA SOURCES: A review of articles published in peer reviewed journals from 1966 to 1999 and identified through a MEDLINE search on the cerebrospinal fluid. SUMMARY OF REVIEW: The examination of the CSF has become an integral part of the assessment of the critically ill neurological or neurosurgical patient. Its greatest value lies in the evaluation of meningitis. Recent publications describe the availability of new laboratory tests on the CSF in addition to the conventional cell count, protein sugar and microbiology studies. Whilst these additional tests have improved our understanding of the pathophysiology of the critically ill neurological/neurosurgical patient, they have a limited role in providing diagnostic or prognostic information. The literature pertaining to the use of these tests is reviewed together with a description of the alterations in CSF in critical illness. The pharmacokinetics and pharmacodynamics of drugs in the CSF, when administered by the intravenous and the intrathecal route, are also reviewed. CONCLUSIONS: The diagnostic utility of CSF investigation in critical illness is currently limited to the diagnosis of an infectious process. Studies that have demonstrated some usefulness of CSF analysis in predicting outcome in critical illness have not been able to show their superiority to conventional clinical examination. With further advances in our understanding of neurological function and refinement in biochemical analysis there remains the possibility of useful cerebrospinal fluid diagnostic and prognostic markers in the future.

Culturing and bioassay testing of Daphnia magna using Elendt M4, Elendt M7, and COMBO media.

A performance-based, tiered approach was used to evaluate survival, growth, and reproduction of Daphnia magna in three selected synthetic media: Elendt M4, Elendt M7, and COMBO. Both Elendt M4 and Elendt M7 are high-hardness media currently recommended for Organization for Economic Cooperation and Development (OECD) testing. COMBO is a softer medium similar in total hardness to natural water found in the environment. Tier I consistent of an acclimation phase; Tier II involved a 21-day evaluation of survival, growth, and reproduction; and Tier III used each medium in a 21-day chronic study using a reference toxicant, 3,4-dichloroaniline (3,4-DCA). The evaluation of the performance of each medium was based on acceptance criteria similar to those used by the U.S. Environmental Protection Agency and the European Commission. Tests were run concurrently at three laboratories to assess interlaboratory variability. Daphnids were acclimated to the media for less than 1 month. Daphnid performance in all media exceeded the European Economic Community (EEC) validity criteria; however, reproductive performance and growth were significantly greater in the Elendt media than in COMBO. 3,4-DCA exerted more toxicity to daphnids in COMBO medium [no-observed-effect concentration (NOEC), <3.1microg/liter] compared with those in the Elendt media (NOEC,

The efficacy of a limestone doser to mitigate stream acidification in a Maryland coastal plain stream: Implications for migratory fish species.

The objective of this two-year study was to determine the efficacy of an automated limestone slurry doser to neutralize acidic pulses and improve water quality conditions for enhancing survival of early life stages of migratory fish species in a Maryland coastal plain stream. Implications for survival of early life stages of migratory fish species such as yellow perch (Perca flavescens), white perch (Morone americana), blueback herring (Alosa aestivalis) and alewife (Alosa pseudoharengus) are discussed based on the improved chemical conditions in the dosed area of the stream. Despite problems with overdosing in 1991 and failure of the stage transducer to work properly in 1992, the doser was generally effective in neutralizing acidic pulses (pH depressions) in the stream during three major rain events in both years. Chemical conditions (pH and inorganic monomeric aluminum) reported in the non-dosed area during major rainfall events were potentially stressful to both alewife and blueback herring although neither species was reported spawning in the stream during either year. Mitigating the potential impact of acidic conditions on early life stages of important migratory fish species was not sufficient to ensure spawning. It is therefore recommended that habitat improvement measures and well designed fish stocking programs be implemented concurrently with doser operations if the goal is to create optimum spawning conditions for migratory species.

Butyltin and copper monitoring in a Northern Chesapeake Bay marina and river system in 1989: An assessment of tributyltin legislation.

This study was designed to: (1) evaluate dibutyltin (DBT) and tributyltin (TBT) bi-weekly in the water column for four months during the peak boating season (June-September, 1989) at seven stations in the Back Creek and Severn River area of Maryland waters of Chesapeake Bay; (2) compare butyltin values from the 1989 study with values obtained from a similar butyltin monitoring study conducted in 1988 (after Maryland TBT legislation) and 1986 (before Maryland TBT legislation); (3) determine the extent of TBT paint use in the Back Creek area by surveying boat owners; (4) determine dissolved copper concentrations from three of the seven stations bi-weekly during the four-month study; and (5) compare dissolved copper concentrations at these stations with previous copper data collected in 1988.Mean four-month DBT concentrations ranged from 10 to 73 ng/L at the seven stations. Highest DBT concentrations occurred at Station 1 in a marina; lowest concentrations occurred at Station 7 in the Severn River. Mean four-month TBT concentrations ranged from 177 ng/L at Station 1 (marina) to 21 ng/L at Station 7 (Severn River). Maximum TBT concentrations of 361 and 570 ng/L occurred at marina SDtations 1 and 3, respectively. Temporal trends in both DBT and TBT (station mean concentrations by date) showed that peak concentrations occurred during the early part of the boating season followed by reductions in late summer and early fall. Spike concentrations of both DBT (117 and 62 ng/L) and TBT (308 and 366 ng/L) were reported on two sampling dates near a boat maintenance facility in Back Creek.There was a significant reduction in DBT concentrations from 1986 to 1989 when date was treated as a fixed effect. However, TBT concentrations were not significantly reduced between 1986 and 1989 when mean concentrations of TBT were averaged across stations and dates for each year. A significant reduction was reported at Station 1 (marina station) when each station was examined for differences between years. TBT was also reported to significantly decrease (p=0.0442) at Station 7 between 1988 and 1989. A boat owner survey in the study area showed that 6% of the recreational boats that were surveyed were painted with TBT paint in 1989. This was a significant decrease in TBT paint use from the previous year when 31% of recreational boat owners surveyed used TBT paints.An evaluation of dissolved copper concentrations at three stations in the study area in 1989 showed that mean concentrations from bi-weekly sampling for four months was 10 µg/L at Station 1, 7.8 µg/L at Station 4 and 2.7 µg/L at Station 7. Copper concentrations decreased with distance away from the Back Creek marinas. Copper concentrations at all three stations were significantly lower in 1989 than in 1988.