Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study.

BACKGROUND: Clinical frailty among older adults admitted to intensive care has been proposed as an important determinant of patient outcomes. Among this group of patients, an acute episode of delirium is also common, but its relationship to frailty and increased risk of mortality has not been extensively explored. Therefore, the aim of this study was to explore the relationship between clinical frailty, delirium and hospital mortality of older adults admitted to intensive care. METHODS: This study is part of a Delirium in Intensive Care (Deli) Study. During the initial 6-month baseline period, clinical frailty status on admission to intensive care, among adults aged 50 years or more; acute episodes of delirium; and the outcomes of intensive care and hospital stay were explored. RESULTS: During the 6-month baseline period, 997 patients, aged 50 years or more, were included in this study. The average age was 71 years (IQR, 63-79); 55% were male (n = 537). Among these patients, 39.2% (95% CI 36.1-42.3%, n = 396) had a Clinical Frailty Score (CFS) of 5 or more, and 13.0% (n = 127) had at least one acute episode of delirium. Frail patients were at greater risk of an episode of delirium (17% versus 10%, adjusted rate ratio (adjRR) = 1.71, 95% confidence interval (CI) 1.20-2.43, p = 0.003), had a longer hospital stay (2.6 days, 95% CI 1-7 days, p = 0.009) and had a higher risk of hospital mortality (19% versus 7%, adjRR = 2.54, 95% CI 1.72-3.75, p < 0.001), when compared to non-frail patients. Patients who were frail and experienced an acute episode of delirium in the intensive care had a 35% rate of hospital mortality versus 10% among non-frail patients who also experienced delirium in the ICU. CONCLUSION: Frailty and delirium significantly increase the risk of hospital mortality. Therefore, it is important to identify patients who are frail and institute measures to reduce the risk of adverse events in the ICU such as delirium and, importantly, to discuss these issues in an open and empathetic way with the patient and their families.

The concept of frailty in intensive care.

Our population is ageing, and this is also reflected in the ageing of the hospital and intensive care population. Along with ageing, there is also an increase in age-related chronic health conditions or comorbidities, which in turn affects the patient's functional state. There is an increasing need to describe a patient's clinical condition in terms of their functional capacity, such as frailty. Frailty is an age-related syndrome which reduces physiological and cognitive reserves. As a result, frailty increases people's vulnerability to insults such as infection and trauma. The concept of frailty also indicates prognosis and levels of health from a patient's perspective rather than simply from the acute reason for admission to the intensive care unit. Understanding the concept of frailty may facilitate our awareness of long-term outcomes after intensive care and being a trigger for considering its prognostic implications and the need to honestly and empathetically begin discussions with patients and their carers and how the patient's own goals of care could be established around this information.

Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis.

BACKGROUND: Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths (Kaye and Marchaim, J Am Geriatr Soc 62(2):306-11, 2014; Roberts and Scott, Med Care 48(11):1026-35, 2010; Warren and Quadir, Crit Care Med 34(8):2084-9, 2006; Zimlichman and Henderson, JAMA Intern Med 173(22):2039-46, 2013). Importantly, infections acquired during a hospital stay have been shown to be preventable (Loveday and Wilson, J Hosp Infect 86:S1-70, 2014). In particular, due to more invasive procedures, mechanical ventilation, and critical illness, patients cared for in the intensive care unit (ICU) are at greater risk of HAI and associated poor outcomes. This meta-analysis aims to summarise the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce infection. METHODS: A systematic literature search was undertaken to identify trials assessing the effectiveness of CHG bathing to reduce risk of infection, among adult intensive care patients. Infections included were: bloodstream infections; central line-associated bloodstream infections (CLABSI); catheter-associated urinary tract infections; ventilator-associated pneumonia; methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant Enterococcus; and Clostridium difficile. Summary estimates were calculated as incidence rate ratios (IRRs) and 95% confidence/credible intervals. Variation in study designs was addressed using hierarchical Bayesian random-effects models. RESULTS: Seventeen trials were included in our final analysis: seven of the studies were cluster-randomised crossover trials, and the remaining studies were before-and-after trials. CHG bathing was estimated to reduce the risk of CLABSI by 56% (Bayesian random effects IRR = 0.44 (95% credible interval (CrI), 0.26, 0.75)), and MRSA colonisation and bacteraemia in the ICU by 41% and 36%, respectively (IRR = 0.59 (95% CrI, 0.36, 0.94); and IRR = 0.64 (95% CrI, 0.43, 0.91)). The numbers needed to treat for these specific ICU infections ranged from 360 (CLABSI) to 2780 (MRSA bacteraemia). CONCLUSION: This meta-analysis of the effectiveness of CHG bathing to reduce infections among adults in the ICU has found evidence for the benefit of daily bathing with CHG to reduce CLABSI and MRSA infections. However, the effectiveness may be dependent on the underlying baseline risk of these events among the given ICU population. Therefore, CHG bathing appears to be of the most clinical benefit when infection rates are high for a given ICU population.

Patient safety and rapid response systems.

Attention was drawn to the safety of patients in acute care hospitals in the early 1990s when studies found large numbers of potentially preventable deaths. Errors were initially ascribed to individual doctors and nurses, but later it was recognised that errors were mainly related to failure of systems rather than individuals. Mortality is not necessarily a good measure of hospital safety. It depends more on the nature of the patient's underlying clinical state and the type of intervention than on the safety of the hospital, and its prevention (as a measure of patient safety) contributes to the failure of hospitals to recognise and appropriately manage patients who are naturally at the end of life. It is difficult to find agreement on the best ways to measure patient safety in hospitals and, as a result of the enormous resources devoted to improving and studying safety, it is difficult to show that patient safety has improved. However, the concept of safety is beginning to include post-hospital outcomes, such as quality of life. A rapid response system is an organisation-wide patient safety system which recognises the deterioration of a patient's condition and provides urgent and appropriate care. Evaluating the impact of a rapid response system can provide information on hospital safety, including potentially preventable deaths and cardiac arrests.

Rapid response systems.

Rapid response systems (RRSs) are one of the first organisation-wide, patient-focused systems to be developed to prevent potentially avoidable deaths and serious adverse events such as cardiac arrests. RRSs identify seriously ill and at-risk patients and those whose condition is deteriorating, using abnormal vital signs and observations that trigger an urgent response by staff who are able to deal with any medical emergency. RRS teams also respond to staff concern--any bedside nurse or doctor who is concerned about his or her patient can seek assistance. RRSs require the support of the whole hospital. This includes resources, educational programs and agreed ways of evaluating RRS effectiveness. RRSs may reduce deaths by up to one-third and cardiac arrests by up to 50%.

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion.

OBJECTIVES: To understand the changes in the population incidence of inhospital cardiopulmonary arrest (IHCA) and mortality associated with the introduction of rapid response systems (RRSs). DESIGN, SETTING AND PARTICIPANTS: Population-based study of 9 221 138 hospital admissions in 82 public acute hospitals in New South Wales, using data linked to a death registry, from 1 Jan 2002 to 31 Dec 2009. MAIN OUTCOME MEASURES: Changes in IHCA, IHCA-related mortality, hospital mortality and proportion of IHCA patients surviving to hospital discharge. RESULTS: RRS uptake increased from 32% in 2002 to 74% in 2009. This increase was associated with a 52% decrease in IHCA rate, a 55% decrease in IHCA-related mortality rate, a 23% decrease in hospital mortality rate and a 15% increase in survival to discharge after an IHCA (all P < 0.01). The adjusted absolute reductions in IHCA-related mortality and hospital mortality were 1.49 (95% CI, 1.30-1.68) and 4.05 (95% CI, 3.17-4.76) patients per 1000 admissions, respectively. The decrease in IHCA incidence rate accounted for 95% of the reduction in IHCA-related mortality. In contrast, the increase in IHCA survival accounted for only 5% of the reduction in IHCA-related mortality. CONCLUSIONS: During nearly a decade, as RRSs were progressively introduced, there was a coincidental reduction in IHCA, IHCA-related deaths and hospital mortality and an increased survival to hospital discharge after an IHCA. Reduced IHCA incidence, rather than improved postcardiac arrest survival, was the main contributor to the reduction in IHCA mortality.

Access block and ED overcrowding.

Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20-30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998-1999) to 2.4 beds per 1000 (2002-2007) in 2002, and has remained steady at between 2.5-2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998-1999 rates, the number of available beds in 2006-2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.

A review of the nursing role in central venous cannulation: implications for practice policy and research.

AIMS AND OBJECTIVES: The aim of this article is to review published studies about central vein cannulation to identify implications for policy, practice and research in an advanced practice nursing role. DESIGN: Modified integrative literature review. METHODS: Searches of the electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL); Medline, Embase, and the World Wide Web were undertaken using MeSH key words. Hand searching for relevant articles was also undertaken. All studies relating to the nurses role inserting central venous cannulae in adult populations met the search criteria and were reviewed by three authors using a critical appraisal tool. RESULTS: Ten studies met the inclusion criteria for the review, all reported data were from the UK. There were disparate models of service delivery and study populations and the studies were predominantly non experimental in design. The results of this review need to be considered within the methodological caveats associated with this approach. The studies identified did not demonstrate differences in rates of adverse events between a specialist nurse and a medical officer. CONCLUSIONS: There were only a small number of studies found in the literature review and the limited availability of clinical outcome data precluded formal analysis from being generated. RELEVANCE TO CLINICAL PRACTICE: Central vein cannulation is potentially an emerging practice area with important considerations for policy practice and research. Training specialist nurses to provide such a service may facilitate standardising of practice and improving surveillance of lines, and possibly improve the training and accreditation process for CVC insertions for junior medical officers. For this to occur, there is a need to undertake well-conducted clinical studies to clearly document the value and efficacy of this advanced practice nursing role.

Medical emergency team calls: the need to communicate a resuscitation plan.

As illustrated in the case report of a 79-year-old woman, actions can be taken to ensure that the rapid response system is not used as the surrogate "do not actively resuscitate" team.

The medical emergency team as a safety net.

In the case of an 11-year-old boy with stable physiological parameters, the deterioration in condition was so sudden that only a rapid response system could ensure any chance of survival.

Access block in NSW hospitals, 1999-2001: does the definition matter?

OBJECTIVES: To estimate the magnitude of access block and its trend over time in New South Wales hospitals, using different definitions of access block, and to explore its association with clinical and non-clinical factors. DESIGN AND SETTING: An epidemiological study using the Emergency Department Information System datasets (1 January 1999 to 31 December 2001) from a sample of 55 NSW hospitals. MAIN OUTCOME MEASURES: Prevalence of access block measured by four different definitions; strength of association between access block, type of hospital, year of presentation, mode and time of arrival, triage category (an indicator of urgency), age and sex. RESULTS: Rates of access block (for all four definitions) increased between 1999 and 2001 by 1%-2% per year. There were increases across all regions of NSW, but urban regions in particular. Patients presenting to Principal Referral hospitals and those who arrived at night were more likely to experience access block. After adjusting for triage category and year of presentation, the mode of arrival, time of arrival, type of hospital, age and sex were significantly associated with access block. CONCLUSIONS: Access block continues to increase across NSW, whatever the definition used. We recommend that hospitals in NSW and Australia move to the use of one standard definition of access block, as our study suggests there is no significant additional information emerging from the use of multiple definitions.