Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study.

OBJECTIVE: To determine the percentage of drug remaining in discarded antibiotic vials after use. DESIGN: Blinded prospective observational trial. SETTING: 26-bed Australian metropolitan tertiary referral intensive care unit. MAIN OUTCOME MEASURES: Percentage of labelled dose remaining in the vial after discard. METHOD: Discarded antibiotic vials collected over a 7-day period in an adult intensive care unit were analysed. Each collected vial had any drug remnant washed out and made up to a known volume. A 1 ml aliquot of each vials washings was analysed using high performance liquid chromatography. From this concentration, the percentage of the drug remaining in the vial after discard was calculated. Additionally, each vial was weighed before and after washing to determine the weight of the remnant in each vial. RESULTS: A total of 311 vials comprising of 11 different drugs and 14 individual vial types were collected. The median residual drug error across all vials was 3.7 %. The drug with the highest median was piperacillin at 6.1 % (IQR 4.3) and the lowest was amoxicillin 0.2 % (IQR 0.1). The single highest value for a given vial was vancomycin (500 mg) with 33.2 % and the lowest for a given vial was 0.1 % amoxicillin (1 g). These two drugs also exhibited the greatest range between the maximum and minimum value for any drug being 32 % and 0.9 % respectively. CONCLUSIONS: Our study shows that up to a third of the intended dose may fail to reach the patient, highlighting a significant factor in the administration of antibiotics to the critically ill population. IMPLICATIONS FOR CLINICAL PRACTICE: Residual drug often remains in antibiotic vials meaning that drug is not reaching the patient. There is considerable variation in the method by which medications are reconstituted in clinical settings. Two person checks should be completed after reconstitution in order to ensure that the medication is fully reconstituted and extracted from the vial.

Staff perceptions of family access and visitation policies in Australian and New Zealand intensive care units: The WELCOME-ICU survey.

BACKGROUND: Family-centred critical care recognises the impact of a loved one's critical illness on his relatives. Open visiting is a strategy to improve family satisfaction and psychological outcomes by permitting unrestricted or less restricted access to visit their family member in the intensive care unit (ICU). However, increased family presence may result in increased workload and a risk of burnout for ICU staff. OBJECTIVES: The objective of this study was to evaluate ICU staff perceptions regarding visiting hours and family access in Australian and New Zealand ICUs. Secondary outcomes included an evaluation of current visiting policies, witnessed events in ICUs, and barriers to implementing open visiting policies. DESIGN: A web-based survey open to all healthcare workers in Australia and New Zealand ICUs was distributed through local, state-based, and national critical care networks. Open visiting was defined as ICUs open for visiting >14 h per day. MAIN RESULTS: We received 1255 valid responses. Most respondents were nurses (n = 930, 74.1%) with a median critical care experience of 10 y. Most worked in open visiting ICUs (n = 749, 59.7%). Reported visiting hours varied greatly with a median of 20 h per day (interquartile range: 10-24 h). Open visiting was perceived as beneficial for the relatives, but less so for patients and staff (relatives: n = 845, 67.3%, patients: n = 561, 44.7%, staff: n = 257, 20.5%, p < 0.0001). Respondents from closed visiting units and nurses identified more risks from open visiting than other professional groups. Generally, staff preferred not to change from their current practice. CONCLUSION: We report that staff perceived open visiting as beneficial for relatives, but also identified risks to themselves, including increased workload, a risk of burnout, and a risk of occupational violence. Reluctance to change highlights the importance of addressing staff perceptions when implementing an open visiting policy.

Incidence and Prevalence of Pressure Injuries in Adult Intensive Care Patients: A Systematic Review and Meta-Analysis.

OBJECTIVES: To systematically assess the incidence and prevalence of pressure injuries in adult ICU patients and the most frequently occurring pressure injury sites. DATA SOURCES: MEDLINE, Embase, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature. STUDY SELECTION: Observational studies reporting incidence rates, cumulative incidence, and prevalence of pressure injuries. DATA EXTRACTION: Two reviewers independently screened studies, extracted data, and assessed the risk of bias. Meta-analyses of pooled weighted estimates were calculated using random effect models with 95% CIs reported due to high heterogeneity. Sensitivity analyses included studies that used skin inspection to identify a pressure injury, studies at low risk of bias, studies that excluded stage 1 and each stage of pressure injury. DATA SYNTHESIS: Twenty-two studies, 10 reporting cumulative incidence of pressure injury irrespective of stage, one reporting incidence rate (198/1,000 hospital-days), and 12 reporting prevalence were included. The 95% CI of cumulative incidence and prevalence were 10.0-25.9% and 16.9-23.8%. In studies that used skin inspection to identify pressure injuries, the 95% CI of cumulative incidence was 9.4-27.5%; all prevalence studies used skin inspection therefore the results were unchanged. In studies assessed as low risk of bias, the 95% CI of cumulative incidence and prevalence were 6.6-36.8% and 12.2-24.5%. Excluding stage 1, the 95% CI of cumulative incidence and prevalence were 0.0-23.8% and 12.4-15.5%. Five studies totalling 406 patients reported usable data on location; 95% CI of frequencies of PIs were as follows: sacrum 26.9-48.0%, buttocks 4.1-46.4%, heel 18.5-38.9%, hips 10.9-15.7%, ears 4.3-19.7%, and shoulders 0.0-40.2%. CONCLUSIONS: Although well-designed studies are needed to ensure the scope of the problem of pressure injuries is better understood, it is clear prevention strategies are also required.

Candida albicans colonisation, continence status and incontinence-associated dermatitis in the acute care setting: a pilot study.

Candida albicans is the most prevalent human fungal commensal organism and is reported to be the most frequent aetiological organism responsible for infection associated with incontinence-associated dermatitis. However, it remains unclear whether incontinence predisposes a patient to increased Candida colonisation or whether incontinence acts as a trigger for Candida infection in those already colonised. The purpose of this observational cross-sectional study was to estimate colonisation rates of C. albicans in continent, compared to incontinent patients, and patients with incontinence-associated dermatitis. Data were collected on 81 inpatients of a major Australian hospital and included a pelvic skin inspection and microbiological specimens to detect C. Albicans at hospital admission. The mean age of the sample was 76 years (SD = 12.22) with 53% being male. Incontinent participants (n = 53) had a non-significant trend towards greater Candida colonisation rates at the perianal site (43% versus 28%) χ2 (1, N = 81) = 4·453, p = ·638 and the inguinal site (24% versus 14%) χ2 (1, N = 81) = 6·868, p = ·258 compared to continent patients (n = 28). The incontinent subgroup with incontinence-associated dermatitis (n = 22) showed no difference in colonisation rates compared to those without incontinence-associated dermatitis. Understanding the epidemiology of colonisation may have implications for the prevention of Candida infection in these patients.

Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting.

The purpose of this cross-sectional study was to identify the prevalence of incontinence and incontinence-associated dermatitis (IAD) in Australian acute care patients and to describe the products worn to manage incontinence, and those provided at the bedside for perineal skin care. Data on 376 inpatients were collected over 2 days at a major Australian teaching hospital. The mean age of the sample group was 62 years and 52% of the patients were male. The prevalence rate of incontinence was 24% (91/376). Urinary incontinence was significantly more prevalent in females (10%) than males (6%) (χ(2) = 4·458, df = 1, P = 0·035). IAD occurred in 10% (38/376) of the sample group, with 42% (38/91) of incontinent patients having IAD. Semi-formed and liquid stool were associated with IAD (χ(2) = 5·520, df = 1, P = 0·027). Clinical indication of fungal infection was present in 32% (12/38) of patients with IAD. Absorbent disposable briefs were the most common incontinence aids used (80%, 70/91), with soap/water and disposable washcloths being the clean-up products most commonly available (60%, 55/91) at the bedside. Further data are needed to validate this high prevalence. Studies that address prevention of IAD and the effectiveness of management strategies are also needed.

The Skin Safety Model: Reconceptualizing Skin Vulnerability in Older Patients.

PURPOSE: To develop a unique skin safety model (SSM) that offers a new and unified perspective on the diverse yet interconnected antecedents that contribute to a spectrum of potential iatrogenic skin injuries in older hospitalized adults. ORGANIZING CONSTRUCT: Discussion paper. METHODS: A literature search of electronic databases was conducted for published articles written in English addressing skin integrity and iatrogenic skin injury in elderly hospital patients between 1960 and 2014. FINDINGS: There is a multiplicity of literature outlining the etiology, prevention, and management of specific iatrogenic skin injuries. Complex and interrelated factors contribute to iatrogenic skin injury in the older adult, including multiple comorbidities, factors influencing healthcare delivery, and acute situational stressors. A range of injuries can result when these factors are complicated by skin irritants, pressure, shear, or friction; however, despite skin injuries sharing multiple antecedents, no unified overarching skin safety conceptual model has been published. CONCLUSIONS: The SSM presented in this article offers a new, unified framework that encompasses the spectrum of antecedents to skin vulnerability as well as the spectrum of iatrogenic skin injuries that may be sustained by older acute care patients. Current skin integrity frameworks address prevention and management of specific skin injuries. In contrast, the SSM recognizes the complex interplay of patient and system factors that may result in a range of iatrogenic skin injuries. Skin safety is reconceptualized into a single model that has the potential for application at the individual patient level, as well as healthcare systems and governance levels. CLINICAL RELEVANCE: Skin safety is concerned with keeping skin safe from any iatrogenic skin injury, and remains an ongoing challenge for healthcare providers. A conceptual framework that encompasses all of the factors that may contribute to a range of iatrogenic skin injuries is essential, and guides the clinician in maintaining skin integrity in the vulnerable older patient.

A prospective window into medical device-related pressure ulcers in intensive care.

The aim of this study was to determine the prevalence, severity, location, aetiology, treatment and healing of medical device-related pressure ulcers (PUs) in intensive care patients for up to 7 days. A prospective repeated measures study design was used. Patients in six intensive care units of two major medical centres, one each in Australia and the USA, were screened 1 day per month for 6 months. Those with device-related ulcers were followed daily for up to 7 days. The outcome measures were device-related ulcer prevalence, pain, infection, treatment and healing. Fifteen of 483 patients had device-related ulcers and 9 of 15 with 11 ulcers were followed beyond screening. Their mean age was 60·5 years, and most were men, overweight and at increased risk of PU. Endotracheal (ET) and nasogastric (NG) tubes were the cause of most device-related ulcers. Repositioning was the most frequent treatment. Four of 11 ulcers healed within the 7-day observation period. In conclusion, device-related ulcer prevalence was 3·1%, similar to that reported in the limited literature available, indicating an ongoing problem. Systematic assessment and repositioning of devices are the mainstays of care. We recommend continued prevalence determination and that nurses remain vigilant to prevent device-related ulcers, especially in patients with NG and ET tubes.

The provision of patient personal hygiene in the intensive care unit: a descriptive exploratory study of bed-bathing practice.

BACKGROUND/OBJECTIVES: The provision of the patient bed-bath is a fundamental nursing care activity yet few quantitative data and no qualitative data are available on registered nurses' (RNs) clinical practice in this domain in the intensive care unit (ICU). The aim of this study was to describe ICU RNs current practice with respect to the timing, frequency and duration of the patient bed-bath and the cleansing and emollient agents used. METHODS: The study utilised a two-phase sequential explanatory mixed method design. Phase one used a questionnaire to survey RNs and phase two employed semi-structured focus group (FG) interviews with RNs. Data was collected over 28 days across four Australian metropolitan ICUs. Ethical approval was granted from the relevant hospital and university human research ethics committees. RNs were asked to complete a questionnaire following each episode of care (i.e. bed-bath) and then to attend one of three FG interviews: RNs with less than 2 years ICU experience; RNs with 2-5 years ICU experience; and RNs with greater than 5 years ICU experience. RESULTS: During the 28-day study period the four ICUs had 77.25 beds open. In phase one a total of 539 questionnaires were returned, representing 30.5% of episodes of patient bed-baths (based on 1767 bed occupancy and one bed-bath per patient per day). In 349 bed-bath episodes 54.7% patients were mechanically ventilated. The bed-bath was given between 02.00 and 06.00h in 161 episodes (30%), took 15-30min to complete (n=195, 36.2%) and was completed within the last 8h in 304 episodes (56.8%). Cleansing agents used were predominantly pH balanced soap or liquid soap and water (n=379, 71%) in comparison to chlorhexidine impregnated sponges/cloths (n=86, 16.1%) or other agents such as pre-packaged washcloths (n=65, 12.2%). In 347 episodes (64.4%) emollients were not applied after the bed-bath. In phase two 12 FGs were conducted (three FGs at each ICU) with a total of 42 RN participants. Thematic analysis of FG transcripts across the three levels of RN ICU experience highlighted a transition of patient hygiene practice philosophy from shades of grey - falling in line for inexperienced clinicians to experienced clinicians concrete beliefs about patient bed-bath needs. CONCLUSIONS: This study identified variation in process and products used in patient hygiene practices in four ICUs. Further study to improve patient outcomes is required to determine the appropriate timing of patient hygiene activities and cleansing agents used to improve skin integrity.

A prospective pilot study evaluating the 'cardiac decompensation score' in the setting of intraaortic balloon counterpulsation.

The study objective was to determine whether the 'cardiac decompensation score' could identify cardiac decompensation in a patient with existing cardiac compromise managed with intraaortic balloon counterpulsation (IABP). A one-group, posttest-only design was utilised to collect observations in 2003 from IABP recipients treated in the intensive care unit of a 450 bed Australian, government funded, public, cardiothoracic, tertiary referral hospital. Twenty-three consecutive IABP recipients were enrolled, four of whom died in ICU (17.4%). All non-survivors exhibited primarily rising scores over the observation period (p<0.001) and had final scores of 25 or higher. In contrast, the maximum score obtained by a survivor at any time was 15. Regardless of survival, scores for the 23 participants were generally decreasing immediately following therapy escalation (p=0.016). Further reflecting these changes in patient support, there was also a trend for scores to move from rising to falling at such treatment escalations (p=0.024). This pilot study indicates the 'cardiac decompensation score' to accurately represent changes in heart function specific to an individual patient. Use of the score in conjunction with IABP may lead to earlier identification of changes occurring in a patient's cardiac function and thus facilitate improved IABP outcomes.

Part 1. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: contributing factors.

Chemical and physical restraints are frequently used in the intensive care unit (ICU) to control agitated patients and to prevent self-harm and unplanned extubations. Published work relating to the numerous issues of the care and treatment strategies for these patients remains conflicting and unclear. Literature regarding sedation and chemical restraint reveals a trend towards management with lighter sedation, use of sedation assessment tools and sedation protocols. It remains unclear which treatment is best for agitated and delirious patients, and the evidence on the effect of sedation is conflicting. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. The purpose of this paper is to provide a summary of the existing literature on the use of physical and chemical restraints in the ICU setting. In Part 1 of this two-part paper, the evidence on chemical and physical restraints is explored with specific focus on definition of terms, unplanned extubation, agitation, delirium and the impact of nurse-patient ratios in the ICU on these issues. Part 2 of the paper examines the evidence related to chemical and physical restraints from the perspective of the mechanically ventilated patient.

Part 2. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: a patient perspective.

An important goal of the care for the mechanically ventilated patient is to minimize patient discomfort and anxiety. This is partly achieved by frequent use of chemical and physical restraints. The majority of patients in intensive care will receive some form of sedation. The goal and use of sedation has changed considerably over the past few decades with literature evidencing trends toward overall lighter sedation levels and daily interruption of sedation. Conversely, the use of physical restraint for the ventilated patient in ICU differs considerably between nations and continents. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. Recent literature suggests minimal use of physical restraint in the ICU, and that reduction programmes have been initiated. However, very few papers illuminate the patient's experience of physical and chemical restraints as a treatment strategy. In Part 1 of this two-part review, the evidence on chemical and physical restraints was explored with specific focus on definitions of terms, unplanned extubation, agitation, delirium as well as the impact of nurse-patient ratios in the ICU on these issues. This paper, Part 2, examines the evidence related to chemical and physical restraints from the mechanically ventilated patient's perspective.

Nursing care of the mechanically ventilated patient: what does the evidence say? Part two.

The care of the mechanically ventilated patient is a fundamental component of a nurse's clinical practice in the intensive care unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly, yet is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient was explored with specific focus on patient safety: particularly patient and equipment assessment. This article, part two, examines the evidence related to the mechanically ventilated patient's comfort: patient position, hygiene, management of stressors (such as communication, sleep disturbance and isolation), pain management and sedation.

Nursing care of the mechanically ventilated patient: what does the evidence say? Part one.

The care of the mechanically ventilated patient is at the core of a nurse's clinical practice in the Intensive Care Unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly. Literature focuses on patient assessment and management strategies for patient stressors, pain and sedation. Yet this literature is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient is explored with specific focus on patient safety: particularly patient and equipment assessment. Part two of the paper examines the evidence related to the mechanically ventilated patient's comfort, the patient/family unit, patient position, hygiene, management of stressors, pain management and sedation.

The experience of agency nurses working in a London teaching hospital.

This Husserlian phenomenological study explored the lived experience of eight full-time agency nurses working in the environment of intensive care in London, United Kingdom. In-depth interviews were used to ascertain the participants' experiences of full-time agency nursing in intensive care. Colaizzi's [Colaizzi P. Psychological research as the phenomenologist views it. In: Vale R, King M, editors. Existential-phenomenological alternatives for psychology. London: Oxford University Press; 1978, p. 48-71] method of data analysis was utilised. Thematic analysis identified three cluster themes: the shared experience of lacking confidence; the shared experience of deskilling; and the shared experience of feelings of isolation. The theme of the shared experience of lacking confidence identified the importance of support and understanding of agency nurses' needs in the ICU. The theme of the shared experience of deskilling illuminated participants concern at not having the opportunity to care for patients of higher acuity. The theme of the shared experience of feelings of isolation highlighted that often participants did not feel they "belonged to a team". Study findings suggest the need to include: the implementation of protocols within the clinical setting; the provision of performance feedback to agency nurses; and the consideration of ongoing structured professional development and education for ICU agency nurses.