Surveillance of bloodstream infections in intensive care units in England, May 2016-April 2017: epidemiology and ecology.

BACKGROUND: Bloodstream infections (BSIs) in patients in intensive care units (ICUs) are associated with increased morbidity, mortality and economic costs. Many BSIs are associated with central venous catheters (CVCs). The Infection in Critical Care Quality Improvement Programme (ICCQIP) was established to initiate surveillance of BSIs in English ICUs. METHODS: A web-based data capture system was launched on 1st May 2016 to collect all positive blood cultures (PBCs), patient-days and CVC-days. National Health Service (NHS) trusts in England were invited to participate in the surveillance programme. Data were linked to the antimicrobial resistance dataset maintained by Public Health England and to mortality data. FINDINGS: Between 1st May 2016 and 30th April 2017, 84 ICUs (72 adult ICUs, seven paediatric ICUs and five neonatal ICUs) based in 57 of 147 NHS trusts provided data. In total, 1474 PBCs were reported, with coagulase-negative staphylococci, Escherichia coli, Staphylococcus aureus and Enterococcus faecium being the most commonly reported organisms. The rates of BSI and ICU-associated CVC-BSI were 5.7, 1.5 and 1.3 per 1000 bed-days and 2.3, 1.0 and 1.5 per 1000 ICU-CVC-days in adult, paediatric and neonatal ICUs, respectively. There was wide variation in BSI and CVC-BSI rates within ICU types, particularly in adult ICUs (0-44.0 per 1000 bed-days and 0-18.3 per 1000 ICU-CVC-days). CONCLUSIONS: While the overall rates of ICU-associated CVC-BSIs were lower than 2.5 per 1000 ICU-CVC-days across all age ranges, large differences were observed between ICUs, highlighting the importance of a national standardized surveillance system to identify opportunities for improvement. Data linkage provided clinically important information on resistance patterns and patient outcomes at no extra cost to participating trusts.

Peer-led training and assessment in basic life support for healthcare students: synthesis of literature review and fifteen years practical experience.

BACKGROUND: In 1995, the University of Birmingham, UK, School of Medicine and Dentistry replaced lecture-based basic life support (BLS) teaching with a peer-led, practical programme. We present our 15-yr experience of peer-led healthcare undergraduate training and examination with a literature review. METHODS: A literature review of healthcare undergraduate peer-led practical skills teaching was performed though Pubmed. The development of the Birmingham course is described, from its inception in 1995-2011. Training methods include peer-led training and assessment by senior students who complete an European Resuscitation Council-endorsed instructor course. Student assessors additionally undergo training in assessment and communication skills. The course has been developed by parallel research evaluation and peer-reviewed publication. Course administration is by an experienced student committee with senior clinician support. Anonymous feedback from the most recent courses and the current annual pass rates are reported. RESULTS: The literature review identified 369 publications of which 28 met our criteria for inclusion. Largely descriptive, these are highly positive about peer involvement in practical skills teaching using similar, albeit smaller, courses to that described below. Currently approximately 600 first year healthcare undergraduates complete the Birmingham course; participant numbers increase annually. Successful completion is mandatory for students to proceed to the second year of studies. First attempt pass rate is 86%, and close to 100% (565/566 students, 99.8%) following re-assessment the same day. 97% of participants enjoyed the course, 99% preferred peer-tutors to clinicians, 99% perceived teaching quality as "good" or "excellent", and felt they had sufficient practice. Course organisation was rated "good" or "excellent" by 91%. Each year 3-4 student projects have been published or presented internationally. The annual cost of providing the course is currently £15,594.70 (Eur 18,410), or approximately £26 (Eur 30) per student. CONCLUSIONS: This large scale, peer-led BLS course demonstrates that such programmes can have excellent outcomes with outstanding participant satisfaction. Peer-tutors and assessors are competent, more available and less costly than clinical staff. Student instructors develop skills in teaching, assessment and appraisal, organisation and research. Sustainability is possible given succession-planning and consistent leadership.

Human factors in the management of the critically ill patient.

Unreliable delivery of best practice care is a major component of medical error. Critically ill patients are particularly susceptible to error and unreliable care. Human factors analysis, widely used in industry, provides insights into how interactions between organizations, tasks, and the individual worker impact on human behaviour and affect systems reliability. We adopt a human factors approach to examine determinants of clinical reliability in the management of critically ill patients. We conducted a narrative review based on a Medline search (1950-March 2010) combining intensive/critical care (units) with medical errors, patient safety, or delivery of healthcare; keyword and Internet search 'human factors' or 'ergonomics'. Critical illness represents a high-risk, complex system spanning speciality and geographical boundaries. Substantial opportunities exist for improving the safety and reliability of care of critically ill patients at the level of the task, the individual healthcare provider, and the organization or system. Task standardization (best practice guidelines) and simplification (bundling or checklists) should be implemented where scientific evidence is strong, or adopted subject to further research ('dynamic standardization'). Technical interventions should be embedded in everyday practice by the adjunctive use of non-technical (behavioural) interventions. These include executive 'adoption' of clinical areas, systematic methods for identifying hazards and reflective learning from error, and a range of techniques for improving teamworking and communication. Human factors analysis provides a useful framework for understanding and rectifying the causes of error and unreliability, particularly in complex systems such as critical care.

Central venous catheter-related bloodstream infections: improving post-insertion catheter care.

Patients with central venous catheters (CVCs) are at increased risk of bloodstream infections and sepsis-related death. CVC-related bloodstream infections (CRBSIs) are costly and account for a significant proportion of hospital-acquired infections. The aim of this audit was to assess current practice and staff knowledge of CVC post-insertion care and therefore identify aspects of CVC care with potential for improvement. We conducted a prospective audit over 28 consecutive days at a university teaching hospital investigating current practice of CVC post-insertion care in wards with high CVC usage. A multiple choice questionnaire on best practice of CVC insertion and care was distributed among clinical staff. Rates of breaches in catheter care and CRBSIs were calculated and statistical significance assumed when P<0.05. Data was recorded from 151 CVCs in 106 patients giving a total of 721 catheter days. In all, 323 breaches in care were identified giving a failure rate of 44.8%, with significant differences between intensive care unit (ICU) and non-ICU wards (P<0.001). Dressings (not intact) and caps and taps (incorrectly placed) were identified as the major lapses in CVC care with 158 and 156 breaches per 1000 catheter days, respectively. During the study period four CRBSIs were identified, producing a CRBSI rate of 5.5 per 1000 catheter days (95% confidence interval: 0.12-10.97). There are several opportunities to improve CVC post-insertion care. Future interventions to improve reliability of care should focus on implementing best practice rather than further education.

Development of core competencies for an international training programme in intensive care medicine.

OBJECTIVE: The aim of this study was to define the core (minimum) competencies required of a specialist in adult intensive care medicine (ICM). This is the second phase of a 3-year project to develop an internationally acceptable competency-based training programme in ICM for Europe (CoBaTrICE). METHODOLOGY: Consensus techniques (modified Delphi and nominal group) were used to enable interested stakeholders (health care professionals, educators, patients and their relatives) to identify and prioritise core competencies. Online and postal surveys were used to generate ideas. A nominal group of 12 clinicians met in plenary session to rate the importance of the competence statements constructed from these suggestions. All materials were presented online for a second round Delphi prior to iterative editorial review. RESULTS: The initial surveys generated over 5,250 suggestions for competencies from 57 countries. Preliminary editing permitted us to encapsulate these suggestions within 164 competence stems and 5 behavioural themes. For each of these items the nominal group selected the minimum level of expertise required of a safe practitioner at the end of their specialist training, before rating them for importance. Individuals and groups from 29 countries commented on the nominal group output; this informed the editorial review. These combined processes resulted in 102 competence statements, divided into 12 domains. CONCLUSION: Using consensus techniques we have generated core competencies which are internationally applicable but still able to accommodate local requirements. This provides the foundation upon which an international competency based training programme for intensive care medicine can be built.

An international survey of training in adult intensive care medicine.

OBJECTIVE: The aim of this international survey of training in adult intensive care medicine (ICM) was to characterise current structures, processes, and outcomes to determine the potential for convergence to a common competency-based training programme across national borders. This survey is the first phase of a 3 year project which will use consensus methods to build an international competency-based training programme in ICM in Europe (CoBaTrICE). METHODOLOGY: A survey by questionnaire, e-mail, and direct discussion was undertaken with national ICM representatives from seven geographical regions. RESULTS: Responses were obtained from 41 countries (countries which share common training programmes were grouped together; n=38). Fifty-four different training programmes were identified, 37 within the European region; three (6%) were competency-based. Twenty (53%) permitted multidisciplinary access to a common training programme; in nine (24%) training was only available within anaesthesia. The minimum duration of ICM training required for recognition as a specialist varied from 3 months to 72 months (mode 24 months). The content of most (75%) ICM programmes was standardised nationally. Work-based assessment of competence was formally documented in nineteen (50%) countries. An exam was mandatory in twenty-nine (76%). CONCLUSION: There are considerable variations in the structures and processes of ICM training worldwide. However, as competency-based training is an outcome strategy rather than a didactic process, these differences should not impede the development of a common international competency-based training programme in ICM.

Challenges in the care of the acutely ill.

Health care providers, hospital administrators, and politicians face competing challenges to reduce clinical errors, control expenditure, increase access and throughput, and improve quality of care. The safe management of the acutely ill inpatient presents particular difficulties. In the first of five Lancet articles on this topic we discuss patients' safety in the acute hospital. We also present a framework in which responsibility for improvement and better integration of care can be considered at the level of patient, local environment, hospital, and health care system; and the other four papers in the series will examine in greater detail methods for measuring, monitoring, and improving inpatient safety.

Research priorities in critical care medicine in the UK.

OBJECTIVES: To establish priorities for research in critical care medicine in the UK using survey and nominal group (NG) techniques. DESIGN: The senior doctor and nurse from 325 intensive care units (ICUs) in the UK were invited to contribute up to ten research questions relevant to intensive care organisation, practice or outcomes. These were then ranked twice using a Likert scale by a panel (nominal group) consisting of ten doctors (two trainees) and two nurses from university teaching and district general (community) hospitals. The first ratings were performed privately, and the second after group discussion. Thirty questions, ten each with strong, moderate or weak support, were then returned for rating by the originating ICU staff and the results compared with those of the NG. RESULTS: One hundred eighty-five respondents (35.6 % university teaching, 62.1% district general, 2.3 % not stated) provided 811 questions of which 722 were research hypotheses. The most frequently identified topics were the evaluation of high dependency care, ICU characteristics, treatments for acute lung injury and acute renal failure, nurse:patient ratios, pulmonary artery catheterisation, aspects of medical and nursing practice, protocol evaluation, and interhospital transfers. These were condensed into 100 topics for consideration by the NG. Discussion and re-rating by the group resulted in strong support being offered for 37 topics, moderate support for 48, and weak support for 21. Following circulation of ten questions from each category, nine questions achieved strong support from both ICU staff and the NG. These were the effect on outcomes from critical illness of early intervention, high dependency care, nurse:patient ratios, interhospital transfers, early enteral feeding, optimisation of perioperative care, hospital type, regionalisation of paediatric intensive care and the use of pulmonary artery catheters. The absence of any questions relating to interventions targetting mediators of the immuno-inflammatory response could be a consequence of the failure of recent studies in sepsis to demonstrate benefits in outcome. CONCLUSIONS: The intensive care community in the UK appears to prioritise research into organisational aspects of clinical practice and practical aspects of organ-system support. Health services research and the biological sciences need to develop collaborative methods for evaluating interventions and outcomes.

Susceptibility to critical illness: reserve, response and therapy.

Risk of critical illness is determined both by genetic and environmental influences, particularly those relating to infectious and cardiovascular diseases. Physiologically-based scoring systems cannot measure prior risk because they do not quantify physiological reserve independently of the acute illness. Genetic profiling could be useful for risk assessment. Early detection of critical illness involves identifying physiological 'triggers' for referral; this requires the education of nursing and medical staff in their significance. Analysis of the relationship between risk factors and interventions may need complex modelling techniques. Therapeutic strategies depend on the nature of the underlying problem: the most useful are likely to be those which enhance tissue oxygen delivery and resistance to infection.

Pharmacokinetics and dynamics of atracurium infusions after paediatric orthotopic liver transplantation.

We examined the pharmacokinetics and pharmacodynamics of atracurium besylate and its metabolites in children after orthotopic liver transplantation (OLT), as a suitable model for critically ill children. Ten children were studied after OLT on return to the intensive care unit (ICU). The mean (range) age was 36 (7-78) months, and weight 6-24.2 kg. Atracurium was started at induction of anaesthesia and adjusted in the ICU according to clinical need. Neuromuscular block was measured using accelerometry (TOFguard) and the train-of-four (TOF) ratio or count. Arterial plasma samples for atracurium and metabolites taken before, 12-hourly during, and at frequent intervals after the infusion were analysed by HPLC. The mean (range) maximum infusion rate during steady-state conditions was 1.44 (0.48-3.13) mg kg(-1) h(-1) and the duration of infusion 36.9 (22.5-98.4) h. Tachyphylaxis was not observed. The mean terminal half-life (t1/2) for atracurium was 18.8 (12-32.3) min. The steady-state plasma clearance (CLss) was 13.9 (7.9-20.3) ml min(-1) kg(-1) and the terminal volume of distribution (Vz) 390 (124-551) ml kg(-1); both were higher than in adults after successful OLT. The maximum concentration (Cmax) of laudanosine was 1190 (400-1890) ng ml(-1) and t1/2 was 3.9 (1.1-6.7) h. The renal clearance of laudanosine was 0.9 (0.1-2.5) ml min(-1) kg(-1) and increased with urine flow, but there was no significant relationship with serum creatinine. EEG spikes were confirmed in one child only; the corresponding laudanosine Cmax was 720 ng ml(-1). Monoquaternary alcohol Cmax was 986 (330-1770) ng ml(-1) and t1/2 42.9 (30-57.7) min. Mean recovery time on stopping the atracurium infusion to a TOF ratio >0.75 was 23.6 (12-27) min. Atracurium is an effective and safe neuromuscular blocking agent in this population. Laudanosine concentrations are not excessive if graft function is satisfactory.

Is the gut responsible for multiple organ failure?

Multiple organ failure is the consequence of many pathological processes, an acute reduction in oxygen supply being one of the most important. The splanchnic region is particularly susceptible to hypoxic injury, and the ischaemic gut mucosa may act as a neutrophil activating site. This is followed by leukocyte adhesion to endothelium and migration into the tissues where cytotoxic chemicals are released, producing tissue injury. This process is aggravated by multiple and sequential physiological insults, some of which may not be evident using basic clinical monitoring. The factors which precipitate cell injury and organ failures may be amenable to relatively simple preventative interventions, but once damage has occurred the process becomes increasingly complex and self-sustaining. Natural defence systems may become pathologically hyperactive, or suppressed, at different stages in critical illness, making it difficult to target therapies directed at the immunoinflammatory cascade with any degree of accuracy or safety, explaining in part the failure of immunotherapy for sepsis. There are significant genetic and constitutional components to susceptibility to critical illness, the most important of which affect cardiac reserve and the ability to maximise tissue oxygen supply. Whether the gut is the most important target organ for oxygen delivery in stress is still the subject of continued research.

Basic life support training for health care students.

This paper describes a novel method for delivering basic life support training to undergraduate healthcare students. A comprehensive 8 h programme is organised and delivered by undergraduate students to their peers. These students have undergone training as basic life support instructors validated by the Royal Life Saving Society UK. The course is delivered to multiprofessional groups of medical, dental, physiotherapy, biomaterial and nursing undergraduates. It has been well received by students and academic staff and provides a solution to reduce the workload of over burdened clinical staff while at the same time enhancing quality. It forms part of an overall strategy for improving resuscitation training for undergraduates from all disciplines.

Epidemiology of intensive care medicine: supply versus demand.

Developments in hospital medicine combined with social and demographic changes are likely to increase the need for intensive care services at a time when cost containment and cost-efficacy are the main items on the political agenda. This will exaggerate the supply-demand outcome mismatch unless the problem is approached in a constructive manner by clinicians, managers and politicians. More resources will be required for intensive care, but these must be better targeted and more efficiently employed. Opportunities for prevention should be explored, with intensive care being given a pro-active rather than a re-active role. Intensive care clinicians should understand that this expanded role cannot be achieved if they are willing only to accept responsibility for patient care after the patient has been admitted to the ICU. Clinicians and managers should develop methods for linking the various disciplines which contribute to emergency care, to form an acute care framework within the hospital. Research into the factors which determine risk of critical illness should be combined with enhanced medical and nursing training in intensive care, accompanied by an expansion in resources for intermediate and high dependency care in countries like the UK where there is clear evidence of rationing.

Intensive care training and specialty status in Europe: international comparisons. Task Force on Educational issues of the European Society of Intensive Care Medicine.

OBJECTIVE: To describe current arrangements for postgraduate training and speciality status for intensive care medicine in Europe, and to compare these with three other geographical regions: the Middle East, North America, and Australia and New Zealand. METHODS: An iterative survey, by questionnaire and direct discussion, of council members of the European Society of Intensive Care Medicine, national specialist societies with involvement in intensive care, and national experts, representing four geographical regions and 47 countries. RESULTS: For the purposes of analysis, countries with common training structures have been grouped together; the denominator therefore includes both countries and regions. Formal training programmes in intensive care medicine (ICM) are available in 18 (85%) of the 21 countries or regions surveyed. Twelve (57%) offer multidisciplinary access to intensive care training with a common core curriculum. In six (28%) training in ICM is available solely through anaesthesia. The duration of intensive care training required for recognition as a specialist in the 18 countries or regions with a formal programme ranges from 18 to 30 months, with a median of 24 months. All countries assess competence in intensive care, but methods for doing so vary widely. Eighteen countries or regions offer specialist registration (accreditation) in ICM; in 12 this is provided as dual accreditation in a base speciality and in ICM. CONCLUSIONS: There is substantial support for multidisciplinary training in ICM, as demonstrated by collaborative interspeciality developments in many countries. We propose that these national developments should be strengthened within Europe by the recognition of 'supra-speciality' status for ICM by the European Commission, and by the establishment of a multidisciplinary Board for training in ICM, with international agreement on core competencies and duration of training programmes, and a common approach to the assessment of competence through formal examination.

A comparison of cisatracurium (51W89) and atracurium by infusion in critically ill patients.

OBJECTIVE: To evaluate and compare the safety and efficacy of cisatracurium (51W89) and atracurium administered by continuous infusion to critically ill patients requiring neuromuscular blocking agents to facilitate mechanical ventilation. DESIGN: Open, randomized, multicenter study of patients receiving cisatracurium or atracurium infusion to facilitate mechanical ventilation. SETTING: Five university teaching hospital intensive care units in the United Kingdom. PATIENTS: Sixty-one adult patients requiring neuromuscular blocking agents to facilitate mechanical ventilation. INTERVENTIONS: Bolus doses followed by continuous infusions of cisatracurium or atracurium were administered. Onset, maintenance, and recovery of neuromuscular blockade were measured, using transcutaneous ulnar nerve stimulation and an accelerometer. MEASUREMENTS AND MAIN RESULTS: Forty patients received cisatracurium (mean duration 48.1 +/- 4.2 [SEM] hrs), and 21 patients received atracurium (mean duration 46.1 +/- 5.8 hrs). The infusion rate for patients receiving cisatracurium was 3.1 +/- 0.2 microg/kg/min, and for patients receiving atracurium 10.4 +/- 0.9 microg/kg/min. There were no significant differences in mean times to 70% recovery of Train-of-Four ratio (cisatracurium 60 mins, atracurium 57 mins), although there was considerable interpatient variation (20 to 175 mins with cisatracurium vs. 35 to 85 mins with atracurium). One patient who received cisatracurium exhibited intermittent bronchospasm during and after the study period. CONCLUSIONS: Cisatracurium, an isomer of atracurium, appears to be a suitable agent for providing muscle relaxation in critically ill patients.

Intestinal permeability, gastric intramucosal pH, and systemic endotoxemia in patients undergoing cardiopulmonary bypass.

OBJECTIVE: To examine the relationship between gastric intramucosal pH, intestinal permeability, endotoxemia, and oxygen delivery in patients undergoing cardiopulmonary bypass (CPB). DESIGN: Prospective, observational study. SETTING: Tertiary care center. PATIENTS: Fifty patients undergoing elective cardiac surgery and 10 patients awaiting elective cardiac surgery. INTERVENTIONS: Patients received chromium 51-labeled ethylenediaminetetraacetic acid (51Cr-EDTA) as a marker of intestinal permeability; insertion of a nasogastric tonometer to measure intramucosal pH (pHi); insertion of a pulmonary artery catheter to measure systemic oxygen delivery and consumption variables; arterial blood sampling for plasma endotoxin by the Limulus amebocyte lysate assay; and blood and urine sampling for measurement of 51Cr-EDTA. MAIN OUTCOME MEASURES: Systemic oxygen delivery, duration of gastric mucosal acidosis, absorption of 51Cr-EDTA, appearance of systemic endotoxemia, renal dysfunction, and duration of hospital stay. RESULTS: Median (range) 24-hour urinary recovery of 51Cr-EDTA in patients was 10.6% (2.1% to 40.2%) while that in controls was 1.2% (0.7% to 2.0%, P<.001). Intestinal permeability increased during CPB. The median (range) for the lowest pHi after bypass was 6.98 (6.74 to 7.17). The pHi did not decline until CPB was discontinued and the heart took over the load of the circulation. Endotoxin was detectable (>0.2 endotoxin unit per milliliter) in the plasma of 21 patients (42%) during the study, most of whom were endotoxemic by the end of CPB. There was no evident relationship between the degree of gut permeability, endotoxemia, gut ischemia, or systemic oxygen dynamics. CONCLUSIONS: Cardiopulmonary bypass is associated with increases in gut permeability, which precede gut mucosal ischemia. In cardiac surgical patients, a low pHi is not necessarily indicative of an adverse clinical outcome. Endotoxemia as measured by the Limulus amebocyte lysate assay is common. The increased intestinal absorption of 51Cr-EDTA and gastric mucosal acidosis occur as independent phenomena and are not related in severity or time of onset.