Antecedents to hospital deaths.

BACKGROUND: Recent studies have suggested there are a large number of potentially preventable deaths in Australian hospitals. AIM: This study aimed to document antecedent factors in hospital deaths in an attempt to identify potentially preventative factors. METHODS: The study was conducted at three separate acute hospitals. Demographics of all deaths were recorded over a 6-month period as well as antecedent factors present within 0-8 and 8-48 h of all deaths including vital sign abnormalities, cardiorespiratory arrests and admission to intensive care. Separate analysis was performed on 'not for resuscitation' deaths. RESULTS: There were a total of 778 deaths, of which 549 (71%) were 'not for resuscitation'. There were 171 (22%) deaths preceded by arrest and 160 (21%) preceded by admission to intensive care. Of the remaining deaths, 30% had severely abnormal physiological abnormalities documented. This incidence was 50% in the non-do not resuscitate (DNR) subgroup. Concern about the patient's condition was expressed in the patient's notes by attending nursing staff and junior medical staff in approximately one-third of non-DNR deaths. Hypotension (30%) and tachypnoea (17%) were the most common antecedents in the non-DNR deaths. CONCLUSION: There is a high incidence of serious vital sign abnormalities in the period before potentially preventable hospital deaths. These antecedents may identify patients who would benefit from earlier intervention.

Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team.

OBJECTIVES: To evaluate the effectiveness of a medical emergency team (MET) in reducing the rates of selected adverse events. DESIGN: Cohort comparison study after casemix adjustment. PATIENTS AND SETTING: All adult (> or = 14 years) patients admitted to three Australian public hospitals from 8 July to 31 December 1996. INTERVENTION STUDIED: At Hospital 1, a medical emergency team (MET) could be called for abnormal physiological parameters or staff concern. Hospitals 2 and 3 had conventional cardiac arrest teams. MAIN OUTCOME MEASURES: Casemix-adjusted rates of cardiac arrest, unanticipated admission to intensive care unit (ICU), death, and the subgroup of deaths where there was no pre-existing "do not resuscitate" (DNR) order documented. RESULTS: There were 1510 adverse events identified among 50 942 admissions. The rate of unanticipated ICU admissions was less at the intervention hospital in total (casemix-adjusted odds ratios: Hospital 1, 1.00; Hospital 2, 1.59 [95% CI, 1.24-2.04]; Hospital 3, 1.73 [95% CI, 1.37-2.16]). There was no significant difference in the rates of cardiac arrest or total deaths between the three hospitals. However, one of the hospitals with a conventional cardiac arrest team had a higher death rate among patients without a DNR order. CONCLUSIONS: The MET hospital had fewer unanticipated ICU/HDU admissions, with no increase in in-hospital arrest rate or total death rate. The non-DNR deaths were lower compared with one of the other hospitals; however, we did not adjust for DNR practices. We suggest that the MET concept is worthy of further study.

Nurses' responses to acute severe illness.

The medical emergency team (MET) at Liverpool Hospital superseded the cardiac arrest team in 1990 and can be summoned by any staff member who identifies a patient at risk according to preset criteria; for example, severe hypotension. Weekly reviews of MET calls have identified clinical antecedents present prior to the patient's condition deteriorating to a critical level. This study assessed the responses of nurses in the presence of these warning signs. Medical records of 178 patients who required MET assistance during 1994 were retrospectively reviewed. A data collection form designed for the study sought demographic information, time and location off the MET call and documented patient complaints for the 24 hours preceding the MET call. Also collected was information on who was contacted as a result of the critical observation. Analysis included frequencies, percentages, means and standard deviations, including location, type and timing of the MET call. MET calls occurred in the general wards (50 per cent), emergency department (42.3 per cent) and other areas (7.7 per cent). The four main categories of emergency comprised cardiac arrest (25.6 per cent), airway/breathing problems (22 per cent), decreased level of consciousness (20.8 per cent) and 'other', including prolonged chest pain, fitting and hypotension (31.6 per cent). The predominant response to a clinical antecedent was to call the MET (68.4 per cent). Other responses resulted in delays of 1 hour (18 per cent) and up to 3 hours (8 per cent) on some wards before treatment specific to the clinical antecedent commenced. A need to educate health professionals regarding the warning signs of acute severe illness and when to summon assistance has been identified.

Quality of life outcomes after intensive care. Comparison with a community group.

OBJECTIVE: Compare the health related quality of life of intensive care patients with a community sample. DESIGN: Self-completed questionnaire posted to a consecutive sample of 238 patients 16 months after discharge from an intensive care unit (ICU) and to a random community sample (n = 242). SETTING: The Liverpool Hospital is the main referral and teaching hospital in a community of 620,000 people. It has a ten-bed general ICU. PATIENTS AND PARTICIPANTS: All patients admitted to the ICU over 8 months with a length of stay > or = 24 h and a sample drawn from the community telephone directory. MEASUREMENTS AND MAIN RESULTS: The self completed questionnaire contained physical and psychosocial health and quality of life (QOL) scales. Analysis of variance indicated that ICU patients were more physically ill and anxiously depressed than the community sample. Sixty-three per cent of patients had not attained full health, were functionally impaired and had a poorer QOL than those patients who had returned to full health and the community. Psychosocial health (apart from anxious depression) was related to the level of perceived physical health rather than to whether or not they had been admitted to the ICU. Those subjects not in full health had poorer interpersonal relationships, less positive attitudes about life, more anxious depression and more suicidal depression. CONCLUSIONS: ICU patients following discharge have worse perceived health and more anxiety than others in the community. Sixty-three per cent of patients had a poorer QOL and functional health than those who returned to full health and those in the community.

How consistently do RNs perform the procedure of collecting specimens for measurement of gastric pHi and CO2?

Gastric Tonometry is an important tool being used more frequently in the Intensive Care Unit (ICU). Tonometry is used to collect normal saline which has equilibrated with the stomach contents and is used in combination with a sample of arterial blood to calculate intragastric PaCO2 and intramucosal pH (pHi). These values are indicative of gastric perfusion. Correct performance of each of the 5 procedural steps to instill and then collect the normal saline is paramount for accuracy of the CO2 and pHi results. The aim of this study was to examine how consistently nurses perform the procedure. Study participants comprised two groups of 15 registered nurses (RNs) chosen at random from the nurses employed in the ICU at Liverpool Hospital (NSW, Australia). The first group of RNs were asked to answer a questionnaire before and after performing the tonometry procedure under simulated conditions. The second group were asked to perform the tonometry procedure only. Each participant was observed by one of the researchers whilst performing all of the procedural steps. Regardless of critical care experience of participants or the number of years since registration a s a nurse, error rates in performing the specimen collection/procedure were as high as 34%. This study is designed to examine the previously unaddressed area of how accurately nursing staff follow systematic instructions to collect the mucosal sample.

The Medical Emergency Team.

The concept of a Medical Emergency Team was developed in order to rapidly identify and manage seriously ill patients at risk of cardiopulmonary arrest and other high-risk conditions. The aim of this study was to describe the utilization and outcome of Medical Emergency Team interventions over a one-year period at a teaching hospital in South Western Sydney. Data was collected prospectively using a standardized form. Cardiopulmonary resuscitation occurred in 148/522 (28%) calls. Alerting the team using the specific condition criteria occurred in 253/522 (48%) calls and on physiological/pathological abnormality criteria in 121/522 (23%) calls. Survival rate to hospital discharge following cardiopulmonary arrest was low (29%), compared with other medical emergencies (76%).

A CQI approach to the investigation of noise levels within the intensive care unit environment.

In February 1991, the Intensive Care Unit (ICU) at Liverpool Hospital was extended and relocated to a larger area. It soon became apparent that noise levels within the newly renovated unit were particularly worrying to patients, staff and relatives. A Continuous Quality Improvement (CQI) group was formed to investigate, and develop measures to reduce these noise levels. Through the implementation of various CQI tools a study plan was developed to investigate the noise problem. The study plan included: a patient, relative and staff questionnaire; a literature search; identification of levels of noise using a sound level meter; contracting a noise consultant to visit and review the ICU environment. The results of the CQI investigations revealed that there was an inappropriately high level of noise in the ICU. Several key contributing factors were also identified. These findings provided the basis for several positive measures to be undertaken including: the installation of sound absorbing ceilings; removal of rubbish bin lids; revision of the telephone ringing system; revision of the mobile x-ray machine; prioritisation of audible machine alarms; education of staff in noise level awareness; The application of the Continuous Quality Improvement (CQI) process to the noise problem facilitated the exploration of the source of noise, the effects on staff and patients, and ways to reduce noise levels in the intensive care environment.

The basic knowledge assessment tool: is it useful?

Registered Nurses (RN's) caring for the critically ill, require a wide range of specialised skills and knowledge. Assessing knowledge of RN's within Intensive Care Units (ICU's) is imperative if we are to ensure that patients are afforded quality care. The aim of this study was to evaluate existing knowledge of the RN's working in the ICU of a major teaching hospital using the Basic Knowledge Assessment Tool (BKAT). Overall mean test scores of 78% were encouraging. Knowledge gaps were evident in gastrointestinal and endocrine disorders. Significantly higher scores were obtained by RN's trained in the hospital based system (p = 0.02) and those possessing ICU qualifications (p = 0.01). There were no differences in scores according to age and length of ICU experience. Registered nurses scored badly in a number of questions, which highlighted some problems in the terminology used in the BKAT.

Problems following discharge after intensive care.

Intensive care units (ICUs) are now present in most acute care hospitals. While long-term studies on patients admitted to these units have been performed to identify mortality, functional outcome and quality of life, there is little information on the recovery period in the weeks immediately following discharge. The aim of this study was to identify and describe the sequelae found in patients at 3 months after leaving the ICU. The study was conducted over a 6-month period during 1991, in a university teaching hospital in Sydney, Australia. 54 patients with a length stay (LOS) of greater than 48 hours in the ICU were included. Each patient was interviewed in an outpatient clinic attached to the ICU. Information collected included pre-admission details, reason for admission, treatments provided and complications encountered. General health state, social and employment details, functional status, referral patterns since discharge and recollection of ICU stay were studied. The major findings indicated that many of the patients interviewed were returning towards near normal general health, but were suffering mild to moderate physical and psychosocial sequelae. In the majority of cases the problems were not incapacitating. The predominant complaints were minor to severe pain, sleeping difficulties, tiredness and breathlessness. Financial problems were reported by a small number of patients. Depression, irritability or a feeling of loneliness were present in over one-third of the group. More than half the patients required referral for further assessment. 34% of patients had no recollection of their ICU stay. 16 patients (29.6%) reported unpleasant memories including nightmares and hallucinations.(ABSTRACT TRUNCATED AT 250 WORDS)

Fluid balance charts: do they measure up?

Many current nursing activities are performed without regular reviews of their usefulness. The recording of fluid gains and losses on a fluid balance chart is one such activity. This article explores the practice of fluid monitoring on the wards of a university teaching hospital.

Do nurses know when to summon emergency assistance?

At Liverpool Hospital in 1989, mortality from cardiopulmonary arrest was 71% in the general wards, and 64% in the Emergency department. In an attempt to identify and treat seriously ill patients before they progressed to cardiac arrest, a medical emergency team (MET) was established. The MET replaced the existing cardiac arrest team and comprised a nurse from the intensive care unit (ICU), a resuscitation registrar (an anaesthetics trainee), a medical registrar and a senior registrar from the ICU. The resuscitation registrar was the team leader. The calling criteria for the MET were based on predetermined physiological variables, abnormal laboratory results, and specific conditions or if nursing or medical staff were concerned by the patient's condition. A study was conducted 2 years following implementation of the MET system, to determine registered nurses' (RNs) opinions, knowledge and use of the system. A questionnaire distributed to 141 nurses rostered on the chosen study date revealed a positive attitude the MET, although there was a low awareness regarding the availability of the MET information booklet. 53% of nurses had called the MET in the last 3 months; all would call the team again in the same circumstances. The correct response in three of four hypothetical situations presented was to call the MET. The number of correct responses varied between scenarios from 17-73%. Hypotension did not appear to alert nurses to summon emergency assistance. Some nurses, despite the presence of severe deterioration and patient distress, called the resident rather than the MET.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of the intensive care nurse--their choice.

An inability to attract and retain sufficient numbers of Registered Nurses (RN's), and Resident Medical Officer shortages in 1990 lead to a concern about who would provide services and whether RN's should "extend" their roles. This survey was developed to allow clinical nurses to identify what their role should be and to quantify the degree of role extension already occurring in the Intensive Care Units (ICU's) of New South Wales' hospitals. Surveys (823) were sent to 33 ICU's across New South Wales. Major Teaching (MTH), Suburban (SH) and Country (CH) hospitals were included in equal numbers. Nurse Unit Managers were contacted and agreed to the distribution of the questionnaire to all RN's working in these units. General demographic information was sought regarding experience in ICU, with the remainder of the questions related to whether nurses should take on extra tasks and what nursing duties could be relinquished. Overall return rate was 51.8% with variations in the type of hospital, MTH (35%), SH (57%), CH (68%). Nurses (72%) want to extend or already do have an extended role. However, they are very definite about what tasks they wish to perform and consistently throughout New South Wales do not wish to perform clerical tasks, some invasive procedures such as endotracheal intubation or arterial cannulation or prescribe medications. The majority of RN's want to relinquish non nursing duties such as cleaning, ordering supplies and clerical tasks. The study demonstrated that, a great many nurses working in ICU would like to and/or perceive the need for some role extension. Clearly nurses must be included in all discussions and decisions affecting their future.

Active management of the dying patient.

OBJECTIVE: To document the process of managing the dying patient in the intensive care unit (ICU) and thus to broaden community debate about an issue that is usually only discussed at a theoretical or philosophical level. SETTING: A six-bed ICU in Liverpool Hospital, a 419-bed teaching institution in the southwestern area of Sydney. PATIENTS: Twenty-seven patients, seen over a nine-month period, who had curative treatment withdrawn or withheld. The mean age of the patients was 68 years and the severity of illness, by the APACHE II scoring system, ranged from 12 to 45. INTERVENTIONS: Twenty-three of the 27 patients were mechanically ventilated and 11 were receiving inotropic support. Medical staff usually initiated discussions and sought staff consensus that the patient should be allowed to die (on 23 of 27 occasions). Most relatives (25 of 27) accepted this decision. Support therapies and routine care were stopped according to policy guidelines. Sedatives and narcotics were used in some patients (18 of 27). Twenty-one patients died in the ICU and six in the general ward areas. CONCLUSION: Introduction of a policy to guide management of dying patients in intensive care has been accepted by staff. Most dying patients are now managed in accordance with these guidelines. Further discussion and debate of this important issue, by health professionals and society as a whole, is required.

Cost awareness study.

A cost awareness study was performed to elicit how aware Intensive Care Unit staff were of the cost of commonly used items. All staff attached to the Unit were given a questionnaire and asked to estimate the price of a list of drugs, fluids, equipment and disposables. Response rate was 100%, with 97% validity. The range, mean and stand deviation of the estimated costs were computed and then compared with the actual price of each item. This paper reviews the results and briefly discusses three questions. What had the study achieved? Should we consider costs? How much does it cost to run our department?