Australian Critical Care

2011-11-01

Editorial Board

2011-11-01

Human factors and patient safety: Changing roles in critical care

Mandy Odell — 2011-03-14

Summary: The high numbers of patients suffering from adverse incidents has resulted in wide spread commitment to improving patient safety. While a lack of technical skill can play a part, there is growing evidence that poor non-technical skills can be a major cause of error in healthcare. Non-technical skills, or human factors, play an important role in improving team function and improving these skills can drive improvements in patient safety and outcome. This editorial challenges traditional role stereo-types, and argues that fundamental changes in the behaviour of professionals need to be made, and sustained, in order that the whole team can make a valuable contribution to the patient safety agenda.

Maternal severity of illness across levels of care: A prospective, cross-sectional study

Wendy E. Pollock, Nerina S. Harley, Sioban M. Nelson — 2011-05-04

Summary: Background: The severity of illness of women experiencing severe maternal morbidity has not been quantified outside of the intensive care setting yet is likely to have a bearing on clinical needs.Aim: To examine severity of illness in women with severe maternal morbidity.Methods: A prospective observational study of critically ill pregnant and postpartum women was undertaken in intensive care units (ICU), high dependency units (HDU) and delivery suites (DS) of seven tertiary-level hospitals in Melbourne, during 2002–2004. Severity of illness was scored using the Acute Physiology and Chronic Health Evaluation version II (APACHE II) and Therapeutic Intervention Scoring System 28 items (TISS 28).Results: 137 women participated in the study: ICU (n=33), HDU (n=46) and DS (n=58). The mean APACHE II score was 8.6 (95% CI 7.7–9.5) and mean TISS 28 score was 22.5 (95% CI 21.2–23.9). Women in ICU were sicker according to both APACHE II (mean 12.6, 95% CI 8.3–16.9) and TISS 28 (mean 31.5, 95% CI 28.2–35.5) compared to women not admitted to ICU (p<.005). There was no difference in the mean APACHE II scores of women in HDU (7.7, 95% CI 5.5–9.9) and DS (7.0, 95% CI 5.2–8.8; p=.20). Women born outside of Australia were more likely to be admitted to ICU (OR 3.27, 95% CI 1.19–8.97). Known risk factors like multiple pregnancy, age ≥35 years and nulliparity were not associated with ICU admission.Conclusions: There was no difference in the severity of illness in women cared for in HDU and DS. It was not possible to predict which women would require ICU admission. Measurement of severity of illness adds a valuable dimension to the study of severe maternal morbidity.

The severe sepsis bundles as processes of care: A meta-analysis

Diane J. Chamberlain, Eileen M. Willis, Andrew B. Bersten — 2011-02-17

Summary: Objective: The use of the sepsis bundles in patients with severe sepsis and septic shock has been controversial in the last decade. Clinical studies have reported beneficial, as well as negative results. We conducted a meta-analysis to assess the clinical evidence and to evaluate survival effects.Data source: Database searches (2004–current) of Medline, CINAHL, Pubmed, Cochrane, Scopus and Google scholar databases which covered full publications, abstracts from conferences and digital thesis were performed using the search terms sepsis, septic shock and/or bundles, processes of care, guidelines, early goal directed therapy, resuscitation.Results: From 253 identified studies, 21 sepsis bundle original studies were selected and included 23,438 patients. The Resuscitation 6 hour Bundle pooled analysis (1819 patients) achieved the greatest survival benefit (odds ratio (OR) 2.124, 95% CI 1.701–2.651, p<0.000) with the Management 24 hour Bundle pooled analysis the lowest survival benefit (16,521 patients) (OR 1.646, 95% CI 1.036–2.614, p<0.035). Both bundles together (Complete Bundle) achieved a combined survival benefit (OR 1.744, 95% CI 1.421–2.141, p<0.000). ScvO2 and blood glucose components were analysed individually to assess their contribution to survival.Conclusion: The Resuscitation 6 hour bundle in the context of the patient population at hand is unlikely to do harm and is yet to be established in primary research in Australia. The Management 24 hour Bundle could not establish a strong enough survival benefit above current routine practice. The sepsis guidelines and bundles have demanded more credible process measurements and debate to induce positive changes in the intervention and treatment care of patients with severe sepsis.

Creating an environment to implement and sustain evidence based practice: A developmental process

2011-02-08

Summary: Background: Elements of evidence based practice (EBP) are well described in the literature and achievement of EBP is frequently being cited as an organisational goal. Despite this, the practical processes and resources for achieving EBP are often not readily apparent, available or successful.Purpose: To describe a multi-dimensional EBP program designed to incorporate evidence into practice to lead to sustainable improvement in patient care and ultimately patient outcome.Implementation strategies: A multi-dimensional EBP program incorporating EBP champions and mentors, provision of resources, creation of a culture to foster EBP and use of practical EBP strategies was implemented in a 22-bed intensive care unit (ICU) in a public, tertiary hospital in Brisbane, Australia. The practical EBP strategies included workgroups, journal club and nursing rounds.Achievements: The multi-dimensional EBP program has been successfully implemented over the past three years. EBP champions and mentors are now active and two EBP workgroups have investigated specific aspects of practice, with one of these resulting in development of an associated research project. Journal club is a routine component of the education days that all ICU nurses attend. Nursing rounds is now conducted twice a week, with between one and seven short-term issues identified for each patient reviewed in the first 12 months.Conclusions: A multi-dimensional program of practice change has been implemented in one setting and is providing a forum for discussion of practice-related issues and improvements. Adaptation of these strategies to multiple different health care settings is possible, with the potential for sustained practice change and improvement.

Chest x-ray quiz (Question)

2011-11-01

Cochrane Corner

2011-11-01

Intensive Care Research Coordinators in Australia and New Zealand: A cross-sectional survey of demographics, responsibilities, job satisfaction and importance

Brigit Roberts, Glenn M. Eastwood, Heike Raunow, Belinda Howe, Claire M. Rickard — 2011-03-21

Summary: Introduction: The achievement of successful clinical research projects depends on multiple team members including Research Coordinators (RCs), who are the link between the researcher and the trial participants. The RCs main responsibility is to ensure that all research is conducted according to the appropriate protocols, regulations and guidelines.Aim: Description of demographics, the role and associated responsibilities and assessment of items of importance to, and satisfaction with, various job related items.Method: An observational web-based cross-sectional study of RCs working in Intensive Care Units (ICU) across Australia and New Zealand.Results: Fifty-six participants completed the survey. Forty percent had more than 6 years experience in ICU research and one-third held a Masters Degree. Most respondents performed research related tasks including ethics submission, patient screening, education and data collection. Autonomy and work hours were the most satisfying job characteristics reported and aspects relating to autonomy were most important for the RCs. Inadequate remuneration was of great concern to the participants.Conclusion: Research Coordinators in Australia and New Zealand have many and varied roles with a significant workload. Unfortunately, the RCs do not feel their employers are adequately remunerating the demand on their time and efforts. The results indicate that RCs enjoy high levels of satisfaction with general conditions and facets of their work and its environment and they remain passionate about their role in the ICU setting.

Low-flow oxygen therapy in intensive care: An observational study

Glenn M. Eastwood, Bev O’Connell, Julie Considine — 2011-05-16

Summary: Background: There is scant published evidence that explains how ICU nurses’ manage low-flow oxygen therapy; and, hence little is known about how low-flow oxygen therapy is delivered on a daily basis.Aim: The aims of this study were first to observe how ICU nurses’ manage low-flow oxygen therapy and then to compare observed nursing practice on the management of oxygen therapy with patients’ documented measures of oxygen saturation (SpO2) and respiratory rate (RR).Method: From May to July 2009, eight 2h observation periods were conducted in one ICU of a metropolitan hospital in Melbourne, Victoria. Data were collected at using a structured observation tool, field notes and chart review. Quantitative data were analysed using descriptive and frequency statistics, and textual data were reviewed using a content analysis procedure.Results: Over the 16h of observed nursing practice, there were 96 points of measurement involving 16 patients and 16 ICU nurses. The management of low-flow oxygen therapy varied between nurses and data revealed that nurses did not always promote effective oxygenation. Documented SpO2 was 98.0% (SD 2.8%) and observed SpO2 was 96.3% (SD 1.8%). Documented RR was 19.6breaths/min (SD 3.5) and observed RR was 21.0breaths/min (SD 16.8). Episodes of hypoxaemia and tachypnoea occurred while patients were receiving oxygen and nurses did not always respond appropriately.Conclusion: ICU nurses’ management of low-flow oxygen therapy was suboptimal and documentation of oxygenation and respiratory rate was inaccurate. Further exploration of how ICU nurses manage low-flow oxygen therapy is a necessary prelude to the conduct of interventional studies and the development of better guidance to support low-flow oxygen therapy in the ICU.

Implantable cardiac defibrillators and end-of-life care—Time for reflection, deliberation and debate?

Maria Sheehan, Phillip J. Newton, Paul Stobie, Patricia Mary Davidson — 2011-06-16

Summary: Heart failure (HF) is a common condition associated with high rates of morbidity and mortality. Implantable cardiac defibrillators (ICDs) are an important management strategy in HF management and decrease mortality for both primary and secondary prevention. An emerging body of literature identifies the challenges of managing ICDs at the end of life. This report discusses a critical incident experienced by a HF team in a referral centre and outlines the issues to be considered in advancing discussion and debate of managing ICDs at the end of life. Engaging in debate, discussion and consensus guidelines is likely to be crucial in minimising distress and burden for clinicians, patients and their families alike.

Chest x-ray quiz (Answer & Discussion)

2011-11-01

Australian Critical Care

Contents

Editorial Board

Human factors and patient safety: Changing roles in critical care

Maternal severity of illness across levels of care: A prospective, cross-sectional study

The severe sepsis bundles as processes of care: A meta-analysis

Creating an environment to implement and sustain evidence based practice: A developmental process

Chest x-ray quiz (Question)

Cochrane Corner

Intensive Care Research Coordinators in Australia and New Zealand: A cross-sectional survey of demographics, responsibilities, job satisfaction and importance

Low-flow oxygen therapy in intensive care: An observational study

Implantable cardiac defibrillators and end-of-life care—Time for reflection, deliberation and debate?

Chest x-ray quiz (Answer & Discussion)