A bedside communication tool did not improve the alignment of a multidisciplinary team's goals for intensive care unit patients.

PURPOSE: Establishing well-understood daily patient care goals should improve healthcare team (HCT) communication, reduce errors, and improve patient outcomes. The purpose of this study was to test the hypothesis that implementation of a daily goals "Door Communication Card" (DCC) would improve goal alignment between members of the HCT. METHODS: As part of a process improvement project, HCT members listed their top care goals for a patient on a given day. After initial data collection, DCCs were placed on patients' doors. Anyone was allowed to write on the card, but the "official" daily goals were recorded during multidisciplinary rounds. One month after introduction of the DCC, HCT members were re-queried about their patients' care goals. Three reviewers independently compared goals and assessed their alignment before and after implementation of the DCC. We collected goals over a 4-month period and selected 5 random days before and after intervention for assessment. RESULTS: The goal alignment among HCT members was low before and did not improve after intervention (Attending-to-Nurse 55% vs 38%, P = .02; Attending-to-Resident 60% vs 54%, P = .43; Attending-to-Primary 35% vs 28%, P = .45; Nurse-to-Attending 52% vs 36%, P = .03; Nurse-to-Resident 55% vs 38%, P = .04; Nurse-to-Primary 37% vs 27%, P = .36; Resident-to-Attending 59% vs 54%, P = .4; Resident-to-Nurse 56% vs 40%, P = .05; Resident-to-Primary 36% vs 24%, P = .16; Primary-to-Attending 34% vs 42%, P = .44; Primary-to-Nurse 42% vs 35%, P = .6; Primary-to-Resident 32% vs 34%, P = .8). CONCLUSIONS: Alignment of daily patient care goals among HCT members is low overall and did not improve after implementing a DCC available to all team members. Further study to elucidate the mechanism by which daily goals forms improve patient care is required.

Loss of protein, immunoglobulins, and electrolytes in exudates from negative pressure wound therapy.

BACKGROUND: A relatively new technology in wound care, negative pressure wound therapy (NPWT), has become widely used for the management of open abdomens and soft tissue wounds and provides a means to collect wound exudate to quantify protein loss. METHODS: A prospective observational study was conducted in surgical, trauma, or burn patients (8 patients with open abdomens and 9 patients with acute soft tissue wounds on NPWT). NPWT exudate was collected and assayed to characterize loss of protein, electrolyte, and immunoglobulins over multiple days of NPWT. RESULTS: Total protein was present in open abdomen NPWT exudate, 2.9 ± 0.9 g/dL. In the soft tissue wound exudate, a similar mean concentration was found, 2.59 ± 0.6 g/dL (P = .34). Exudate concentrations of albumin, urea nitrogen, immunoglobulins, and electrolytes between wound types were also not significantly different. There were significant (P = .03) differences in the median volume of exudate, 1031 mL/d for open abdomens in contrast to 245 mL/d soft tissue wounds. Therefore, 24-hour losses of proteins and electrolytes were greater in patients with open abdomens than soft tissue wounds. Mean total protein loss was 25 ± 17 g/d for open abdomens and 8 ± 5 g/d for soft tissue wounds. CONCLUSION: There are significant losses of proteins in wound exudate. As there is no significant difference in the concentration of total protein between wound type, the rate of loss may be calculated as 2.9 g/dL times the volume of wound exudate. The rate of protein loss from wounds is similar to the presently assumed insensible loss rate of 12-25 g/d.

Novel use of a portable ventilation device with low-flow tracheal insufflation of oxygen in a Swine model.

INTRODUCTION: Mechanical ventilation of intubated patients is standard to meet oxygenation and ventilation goals. This can require significant energy and oxygen resources. In military operations and mass casualty disasters, oxygen conserving strategies may be important. Low flow tracheal insufflation of oxygen (TRIO) is a technique that provides adequate oxygenation while conserving oxygen during apnea. This technique, however, is limited by increases in carbon dioxide (CO2) when used for extended periods. The addition of passive pressure release ventilation could potentially improve CO2 elimination and the acceptance of this technique. The purpose of this study was to determine whether TRIO combined with the novel configuration of a portable ventilator used to provide passive pressure release ventilation improves CO2 levels during apneic oxygenation. METHODS: Animals (n = 7) were anesthetized, paralyzed, and intubated. Oxygen (O2) was insufflated through the capillary lumen of the Boussignac endotracheal tube at 2 L/min. The low flow O2 was the only source of power and gas for ventilation. A modified Oxylator EMX transport ventilator connected to the endotracheal tube was configured to release when pressure in the subjects lungs reached 30 cm H2O. No electrical or pneumatic sources were required. Hemodynamic measurements and arterial blood gases were taken at various intervals for 2 hours. RESULTS: All pigs remained adequately oxygenated with Pao2 >390 mm Hg in all subjects at every blood gas measurement and survived the 2-hour experiment. Baseline Paco2 (43 +/- 4 mm Hg) increased and pH (7.48 +/- 0.03) decreased to 72 +/- 5 mm Hg and 7.29 +/- 0.02 at 1 hour and 83 +/- 8, 7.24 +/- 0.03 at 2 hours. This is significantly less than would be expected during apnea over this time period. Hemodynamic measurements remained stable. CONCLUSION: The combination of low flow TRIO with a modified Oxylator in this novel configuration provides acceptable Pao2, Paco2, and hemodynamic parameters for 2 hours in apneic swine. This could be a valuable technique in situations where oxygen and power are limited.