Association of Symptoms and Mode of Transportation to Emergency Department in Patients With Acute Coronary Syndrome.

BACKGROUND: Patients with acute coronary syndrome (ACS) with symptoms matching their expectations of a heart attack are more likely to use emergency medical services (EMS) than not. OBJECTIVE: To determine whether presenting symptom clusters are associated with EMS use in ACS patients and if EMS use or symptom clusters are associated with prehospital delay. METHODS: This secondary analysis used data from the PROMOTION trial, a randomized clinical trial that enrolled 3522 subjects with a history of or at risk for ACS from 5 sites in the United States, Australia, and New Zealand. Subjects were randomized to usual care or an educational intervention to reduce prehospital delay. During the 2-year follow-up, subjects admitted for ACS were asked about symptoms, time of symptom onset, and mode of transportation to the hospital. Symptoms were grouped into classic ACS, pain symptoms, and stress symptoms clusters. RESULTS: Of 3522 subjects enrolled, 331 sought care for ACS during follow-up; 278 had transportation mode documented; 121 (44%) arrived via EMS. Classic ACS plus pain symptoms (adjusted odds ratio [AOR], 2.66; P = .011), classic ACS plus stress symptoms (AOR, 2.61; P = .007), and classic ACS plus both pain and stress symptoms (AOR, 3.90; P = .012) were associated with higher odds of EMS use versus classic ACS symptoms alone. Emergency medical services use resulted in a 68.5-minute shorter median delay (P = .002) versus non-EMS use. Symptom clusters were not predictive of delay time in the adjusted model (P = .952). DISCUSSION: Although chest symptoms were the most prevalent symptoms for most (85%), the combination of classic ACS symptoms with other symptom clusters was associated with higher EMS use. Further research is needed to determine whether a combination of symptom clusters helps patients correctly interpret ACS symptoms to better understand how symptom clusters influence EMS use.

A Systematic Review of Risk Factors for Sleep Disruption in Critically Ill Adults.

OBJECTIVES: Numerous risk factors for sleep disruption in critically ill adults have been described. We performed a systematic review of all risk factors associated with sleep disruption in the ICU setting. DATA SOURCES: PubMed, EMBASE, CINAHL, Web of Science, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. STUDY SELECTION: English-language studies of any design published between 1990 and April 2018 that evaluated sleep in greater than or equal to 10 critically ill adults (> 18 yr old) and investigated greater than or equal to 1 potential risk factor for sleep disruption during ICU stay. We assessed study quality using Newcastle-Ottawa Scale or Cochrane Risk of Bias tool. DATA EXTRACTION: We abstracted all data independently and in duplicate. Potential ICU sleep disruption risk factors were categorized into three categories based on how data were reported: 1) patient-reported reasons for sleep disruption, 2) patient-reported ratings of potential factors affecting sleep quality, and 3) studies reporting a statistical or temporal association between potential risk factors and disrupted sleep. DATA SYNTHESIS: Of 5,148 citations, we included 62 studies. Pain, discomfort, anxiety/fear, noise, light, and ICU care-related activities are the most common and widely studied patient-reported factors causing sleep disruption. Patients rated noise and light as the most sleep-disruptive factors. Higher number of comorbidities, poor home sleep quality, home sleep aid use, and delirium were factors associated with sleep disruption identified in available studies. CONCLUSIONS: This systematic review summarizes all premorbid, illness-related, and ICU-related factors associated with sleep disruption in the ICU. These findings will inform sleep promotion efforts in the ICU and guide further research in this field.

The effect of metoprolol and aspirin on cardiovascular risk in bereavement: A randomized controlled trial.

BACKGROUND: Bereavement is associated with an increased risk of cardiovascular disease; however, no reports exist of interventions to reduce risk. In a randomized, double-blind, placebo-controlled trial of 85 recently bereaved participants, we determined whether ß-blocker (metoprolol 25 mg) and aspirin (100 mg) reduce cardiovascular risk markers and anxiety, without adversely affecting bereavement intensity. METHODS: Participants were spouses (n = 73) or parents (n = 12) of deceased from 5 hospitals in Sydney, Australia, 55 females, 30 males, aged 66.1 ±â€¯9.4 years. After assessment within 2 weeks of bereavement, subjects were randomized to 6 weeks of daily treatment or placebo, and the effect evaluated using ANCOVA, adjusted for baseline values (primary analysis). RESULTS: Participants on metoprolol and aspirin had lower levels of home systolic pressure (P = .03), 24-hour average heart rate (P < .001) and anxiety (P = .01) platelet response to arachidonic acid (P < .001) and depression symptoms (P = .046) than placebo with no difference in standard deviation of NN intervals index (SDNNi), von Willebrand Factor antigen, platelet-granulocyte aggregates or bereavement intensity. No significant adverse safety impact was observed. CONCLUSIONS: In early bereavement, low dose metoprolol and aspirin for 6 weeks reduces physiological and psychological surrogate measures of cardiovascular risk. Although further research is needed, results suggest a potential preventive benefit of this approach during heightened cardiovascular risk associated with early bereavement.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

OBJECTIVE: To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN: Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS: Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS: The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS: We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Sleep Quality During and After Cardiothoracic Intensive Care and Psychological Health During Recovery.

BACKGROUND: Intensive care patients experience poor sleep quality. Psychological distress and diminished health-related quality of life (HRQOL) are also common among former intensive care unit (ICU) patients. Coronary artery bypass graft (CABG) surgery is a frequent reason adults require treatment in ICU. The effect of on- versus off-pump surgery on sleep and recovery has not been reported. OBJECTIVE: The aim of this study was to assess sleep quality of CABG patients during and after ICU, psychological well-being, HRQOL during recovery, and whether on- versus off-pump surgery affects sleep and recovery. METHODS: Data were collected in the ICU and hospital ward, and 2 and 6 months after hospital discharge using validated self-report questionnaires. RESULTS: The sample (n = 101) had a mean age of 66.6 ± 11.1 years, was 79% male, and had a median ICU stay of 2 (2-4) days and a mean body mass index of 27.3 ± 4.3; 75% underwent on-pump surgery. Poor sleep was reported by 62% of the patients at 6 months and by 12% of the patients at all time points. Off-pump CABG patients had fewer posttraumatic stress symptoms (P = .02) and better physical HRQOL (P = .01). In multivariate analysis, prehospital insomnia (P = .004), and physical (P < .0005) and mental (P < .0005) HRQOL were independently associated with sleep quality at 6 months. There was no association between on- versus off-pump CABG and sleep quality at 6 months. CONCLUSIONS: Sleep quality of postoperative CABG patients was poor in the ICU and hospital ward and up to 6 months after discharge from the hospital. Poor sleep quality at 6 months was associated with prehospital insomnia, and physical and mental HRQOL at 6 months, but not with on- versus off-pump surgery.

Repeated sleep-quality assessment and use of sleep-promoting interventions in ICU.

To describe sleep quality using repeated subjective assessment and the ongoing use of sleep-promoting interventions in intensive care. It is well known that the critically ill experience sleep disruption while receiving treatment in the intensive care unit. Both the measurement and promotion of sleep is challenging in the complex environment of intensive care unit. Repeated subjective assessment of patients' sleep in the intensive care unit and use of sleep-promoting interventions has not been widely reported. An observational study was conducted in a 58-bed adult intensive care unit. Sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) each morning. intensive care unit audit sleep-promoting intervention data were compared to data obtained prior to the implementation of a sleep guideline. Patients answered open-ended questions about the facilitators and deterrents of their sleep in intensive care unit. The sample (n = 50) was predominately male (76%) with a mean age: 62.6±16.9 years. Sleep quality was assessed on 2 days or more for 21 patients. The majority of patients (98%) received sleep-promoting interventions. Sleep quality had not improved significantly since the guideline was first implemented. The mean Richards-Campbell Sleep Questionnaire score was 47.9±24.1 mm. The main sleep deterrents were discomfort and noise. Frequently cited facilitators were nothing (i.e. nothing helped) and analgesia. The Richards-Campbell Sleep Questionnaire was used on repeated occasions, and sleep-promoting interventions were used extensively. There was no evidence of improvement in sleep quality since the implementation of a sleep guideline. The use of the Richards-Campbell Sleep Questionnaire for the subjective self-assessment of sleep quality in intensive care unit patients and the implementation of simple-promoting interventions by intensive care unit clinicians is both feasible and may be the most practical way to assess sleep in the intensive care unit context.

User compliance with documenting on a track and trigger-based observation and response chart: a two-phase multi-site audit study.

AIMS: To examine user compliance and completeness of documentation with a newly designed observation and response chart and whether a rapid response system call was triggered when clinically indicated. BACKGROUND: Timely recognition and responses to patient deterioration in hospital general wards remain a challenge for healthcare systems globally. Evaluating practice initiatives to improve recognition and response are required. DESIGN: Two-phase audit. METHODS: Following introduction of the charts in ten health service sites in Australia, an audit of chart completion was conducted during a short trial for initial usability (Phase 1; 2011). After chart adoption as routine use in practice, retrospective and prospective chart audits were conducted (Phase 2; 2012). FINDINGS: Overall, 818 and 1,058 charts were audited during the two phases respectively. Compliance was mixed but improved with the new chart (4%-14%). Contrary to chart guidelines, numbers rather than dots were written in the graphing section in 60% of cases. Rates of recognition of abnormal vital signs improved slightly with new charts in use, particularly for higher levels of surveillance and clinical review. Based on local calling criteria, an emergency call was initiated in 33% of cases during the retrospective audit and in 41% of cases with the new chart. CONCLUSIONS: User compliance was less than optimal, limiting full function of the chart sections and compliance with local calling criteria. Overcoming apparent behavioural and work culture barriers may improve chart completion, aiding identification of abnormal vital signs and triggering a rapid response system activation when clinical deterioration is detected.

Sleep assessment by patients and nurses in the intensive care: An exploratory descriptive study.

BACKGROUND: Sleep disruption is common in intensive care unit (ICU) patients, with reports indicating reduced quality and quantity of sleep in many patients. There is growing evidence that sleep in this setting may be improved. AIM: To describe ICU patients' self-report assessment of sleep, examine the relationship between patients' self-reported sleep and their reported sleep by the bedside nurse, and describe the strategies suggested by patients to promote sleep. METHODS: An exploratory descriptive study was undertaken with communicative adult patients consecutively recruited in 2014-2015. Patients reported sleep using the Richards-Campbell Sleep Questionnaire (score range 0-100mm; higher score indicates better sleep quality), with nursing assessment of sleep documented across a five level ordinal variable. Patients were asked daily to describe strategies that helped or hindered their sleep. Ethical approval for the study was gained. Descriptive statistical analysis was performed [median (interquartile range)]; relationships were tested using Spearman's rank correlation and differences assessed using the Kruskal-Wallis test; p<0.05 was considered significant. RESULTS: Participants (n=151) were recruited [age: 60 (46-71) years; ICU length of stay 4 (2-9) days] with 356 self-reports of sleep. Median perceived sleep quality was 46 (26-65) mm. A moderate relationship existed between patients' self-assessment and nurses' assessment of sleep (Spearman's rank correlation coefficient 0.39-0.50; p<0.001). Strategies identified by patients to improve sleep included adequate pain relief and sedative medication, a peaceful and comfortable environment and physical interventions, e.g. clustering care, ear plugs. CONCLUSION: Patients reported on their sleep a median of 2 (1-3) days during their ICU stay, suggesting that routine use of self-report was feasible. These reports revealed low sleep quality. Patients reported multiple facilitators and barriers for sleep, with environmental and patient comfort factors being most common. Interventions that target these factors to improve patient sleep should be implemented.

Congruence of the Medical Record and Subject Interview on Time of Symptom Onset in Patients Diagnosed With Acute Coronary Syndrome.

BACKGROUND: Past research has shown discrepancies between the time of symptom onset for patients with acute coronary syndrome (ACS) as documented in the medical record (MR) and patients' recall of the time assessed through subject interviews done later by researchers. PURPOSE: The aim of this study is to determine if there were differences between the time of symptom onset documented in the MR and subject interview taking into consideration sex, age group, and recall period for patients admitted to the emergency department for symptoms suggestive of ACS. METHODS: A secondary analysis was conducted on data from the PROMOTION (Patient Response to Myocardial Infarction Following a Teaching Intervention Offered by Nurses) trial, a multicenter randomized clinical trial to reduce patient prehospital delay to treatment in ACS. RESULTS: Of the 3522 subjects with CAD enrolled into the trial, 3087 subjects completed 2-year follow-up. Of these, 331 subjects sought treatment in the emergency department for ACS symptoms and 276 patients (83%) had complete information on the time of symptom onset from both sources. Of the 276 patients, 25 (9%) had differing times more than 48 hours and were thus excluded. The median difference between the 2 sources was 45.0 minutes. When both times were examined, there were no significant differences in time by sex (P = .720) or by age group (P = .188). The median number of days between the interview and the date of symptom onset was 29.5 days. There was a significant correlation between differences in the time of symptom onset and the length of recall period (rs = 0.148, P = .023). In multivariable modeling, a longer recall period was associated with greater median differences in the symptom onset time (b = 13.2, P = .023). CONCLUSION: These results suggest that the time of symptom onset obtained at the time of the index event and documented in the MR is not interchangeable with data obtained later by research staff, especially if the interview is not conducted near the time of the index event.

Posttraumatic stress symptoms in intensive care patients: An exploration of associated factors.

PURPOSE/OBJECTIVE: To explore demographic, clinical, and psychological factors in intensive care unit (ICU), including self-reported sleep quality and experiences that were associated with posttraumatic stress (PTS) symptoms 6 months after discharge from hospital. RESEARCH METHOD/DESIGN: A prospective survey was conducted (N = 222). On the day of transfer to the hospital ward, ICU patients reported pain and state-anxiety levels, as well as ICU and prehospital sleep quality. Two months after hospital discharge, they reported sleep quality at home and experiences in ICU. Six months after hospital discharge, sleep quality, PTS symptoms (measured with the Posttraumatic Stress Disorder Checklist-Specific; PCL-S; VA National Center for PTSD, 2014) and psychological well-being (using Depression, Anxiety and Stress Scales-21; DASS-21; Ware, Kosinski, & Keller, 1994) were reported. Descriptive data analyses were performed and factors associated with PTS symptoms were explored with multiple linear regression. RESULTS: The sample was predominately male (65%), with a mean age 57 years. At baseline, pain intensity was low (M ± SD; 2.25 ± 1.14) and state-anxiety levels were moderate (2.50 ± 2.90). At 6 months, 30% of the sample demonstrated depression, and 13.5% (mean PCL-S score: 26.54 ± 10.52) reported symptoms reflective of PTS. The regression model explained 68.2% of the variance in the PCL-S score. Higher PTS scores were independently associated with frightening experiences in ICU, higher stress and depression scores, pain intensity at baseline, and sleep quality at 6 months. CONCLUSION/IMPLICATIONS: Continuing symptoms of PTS were evident in 14% of the cohort. Screening for prevention and treatment of delirium while a patient is in ICU is essential, and psychological screening and follow-up during recovery would therefore also be beneficial for many patients. (PsycINFO Database Record

User acceptance of observation and response charts with a track and trigger system: a multisite staff survey.

AIMS AND OBJECTIVES: To examine user acceptance with a new format of charts for recording observations and as a prompt for responding to episodes of clinical deterioration in adult medical-surgical patients. BACKGROUND: Improving recognition and response to clinical deterioration remains a challenge for acute healthcare institutions globally. Five chart templates were developed in Australia, combining human factors design principles with a track and trigger system for escalation of care. Two chart templates were previously tested in simulations, but none had been evaluated in clinical practice. DESIGN: Prospective multisite survey of user acceptance of the charts in practice. METHODS: New observation and response charts were trialled in parallel with existing charts for 24 hours across 36 adult acute medical-surgical wards, covering 108 shifts, in five Australian states. Surveys were completed by 477 staff respondents, with open-ended comments and narrative from short informal feedback groups providing elaboration and context of user experiences. RESULTS: Respondents were broadly supportive of the chart format and content for monitoring patients, and as a prompt for escalating care. Some concerns were noted for chart size and style, use of ranges to graph vital signs and with specific human factors design features. Information and training issues were identified to improve usability and adherence to chart guidelines and to support improved detection and response for patients with clinical deterioration. CONCLUSIONS: This initial evaluation demonstrated that the charts were perceived as appropriate for documenting observations and as a prompt to detect clinical deterioration. Further evaluation after some minor modifications to the chart is recommended. RELEVANCE TO CLINICAL PRACTICE: Explicit training on the principles and rationale of human factors chart design, use of embedded change management strategies and addressing practical issues will improve authentic engagement, staff acceptance and adoption by all clinical users when implementing a similar observation and response chart into practice.

Health-Related Quality of Life and Associated Factors in Intensive Care Unit Survivors 6 Months After Discharge.

BACKGROUND: Intensive care unit survivors often have diminished health-related quality of life. OBJECTIVES: To describe health-related quality of life of former intensive care patients and identify associated factors 6 months after hospital discharge. METHODS: Six months after discharge, 193 patients from an intensive care unit completed the Short Form-36 Health Survey; measures of sleep; Intensive Care Experience Questionnaire; Depression, Anxiety and Stress Scales; and Posttraumatic Stress Disorder Checklist. Norm-based scores were calculated for the Short Form-36. Bivariate associations with Short Form-36 scores were tested by using the Pearson correlation. Multiple linear regression was used to identify independent associations with health-related quality of life. RESULTS: All scores on the Short Form-36 (physical component summary, 41.8; mental component summary, 48.2) were less than population norms. Bivariate associations with health-related quality of life (P < .05) were scores on the Acute Physiology and Chronic Health Evaluation II, hospital length of stay, awareness of surroundings and frightening experiences, depression, anxiety, stress, posttraumatic symptoms, and sleep quality at 2 and 6 months. In linear regression, scores on the Acute Physiology and Chronic Health Evaluation II, hospital length of stay, and sleep quality at 6 months were independently associated with Short Form-36 physical summary scores (P < .001); depression and stress were independently associated with mental summary scores (P < .001). CONCLUSION: Sleep, depression, and stress are potential targets for interventions to improve health-related quality of life and improve recovery.

The nature of death, coping response and intensity of bereavement following death in the critical care environment.

INTRODUCTION: Bereavement, defined as the situation of having recently lost a significant other, is recognised as one of life's greatest stressors and may lead to decrements in health status, psychological morbidity and excess risk of mortality. AIM: The aim of this study was firstly to describe the relationships between the nature of death and bereavement intensity following death in the adult critical care environment and secondly to examine the modifying effects of coping responses on intensity of bereavement reaction. METHOD: Prospective evaluation of the impact of the nature of death and coping responses on bereavement intensity. 78 participants completed a nature of death questionnaire within 2 weeks of bereavement and at 3 and 6 months completed the Core Bereavement Items Questionnaire (CBI-17) and Brief COPE Inventory. RESULTS: At 6 months, univariate variables significantly associated with bereavement intensity were: being unprepared for the death (p<0.001), a drawn out death (p<0.001), a violent death (p=0.007) and if the deceased appeared to suffer more than expected (p=0.03). Multivariate analysis revealed being unprepared for the death appears to account for these relationships. Regarding coping, there were significant increases from 3 to 6 months in both acceptance scales (p=0.01) and planning (p=0.02) on The Brief COPE Inventory. Greater use of emotional support (p=0.02), self-blame (0.003) and denial (p<0.001) were multivariate variables associated with higher bereavement intensity at 6 months. CONCLUSION: The results from this evaluation provide insight into the impact of bereavement after death in the critical care environment and inform potential preventative approaches at the time of death to reduce bereavement intensity.

The complexities of recruiting bereaved family members into a research study in the critical care environment: a discussion paper.

Research on the effects of stressful events on human health and wellbeing has progressed in recent years. One such stress, bereavement, is considered one of life's greatest stresses, requiring significant readjustment. The Cardiovascular Risk in Bereavement study (CARBER) investigated in detail cardiovascular risk factors during the first weeks following the death of a partner or adult child in the critical care environment. The purpose of this paper is to explore the once held perception that the bereaved population should not be involved in research, using an actual illustrative project. The paper specifically focuses on the challenges regarding acceptability and feasibility of recruitment of recently bereaved individuals from the critical care environment. The question of whether bereaved individuals have capacity to consent to involvement in research immediately after loss is considered. The appropriateness of asking newly bereaved individuals to participate in research immediately after the death of their relative is also discussed. The work of the research team demonstrates that early recruitment of bereaved family members into a research project is feasible and acceptable to participants, especially when a multidisciplinary collaborative approach is employed and a personal mode of recruitment used.

Physical recovery in intensive care unit survivors: a cohort analysis.

BACKGROUND: Some survivors of critical illness experience poor physical recovery, but which patients experience the most compromise during recovery is unknown. OBJECTIVE: To identify factors associated with physical recovery by using the 6-minute walk test in adult survivors of critical illness 26 weeks after discharge from the hospital. METHODS: A total of 195 adult survivors of a critical illness were enrolled in a multicenter trial of physical rehabilitation after discharge from the hospital. The 6-minute walk test, the 36-Item Short Form Health Survey, and sleep rated on a 5-point scale were completed at weeks 1 and 26. Clinical and demographic data were obtained from patient records. RESULTS: A total of 145 patients completed the 26-week test. Of these, 94 (65%) increased the distance walked in 6 minutes by at least 75 m from the 1-week value and were therefore considered to have improved on the test. Factors associated with improvement included moderate to severe sleeping problems in week 1, moderate to vigorous exercise in week 26, and higher vitality in week 26. Conversely, respiratory problems and higher social functioning in week 1 were associated with less improvement in the distance walked. CONCLUSION: Multiple factors are associated with physical recovery after critical illness. Interventions to target multidimensional aspects of recovery such as sleep and exercise may result in improved physical function after critical illness.

Clinical user experiences of observation and response charts: focus group findings of using a new format chart incorporating a track and trigger system.

BACKGROUND: Optimising clinical responses to deteriorating patients is an international indicator of acute healthcare quality. Observation charts incorporating track and trigger systems are an initiative to improve early identification and response to clinical deterioration. A suite of track and trigger 'Observation and Response Charts' were designed in Australia and initially tested in simulated environments. This paper reports initial clinical user experiences and views following implementation of these charts in adult general medical-surgical wards. METHODS: Across eight trial sites, 44 focus groups were conducted with 218 clinical ward staff, mostly nurses, who received training and had used the charts in routine clinical practice for the preceding 2-6 weeks. Transcripts of audio recordings were analysed for emergent themes using an inductive approach. FINDINGS: In this exploration of initial user experiences, key emergent themes were: tensions between vital sign 'ranges versus precision' to support decision making; using a standardised 'generalist chart in a range of specialist practice' areas; issues of 'clinical credibility', 'professional autonomy' and 'influences of doctors' when communicating abnormal signs; and 'permission and autonomy' when escalating care according to the protocol. Across themes, participants presented a range of positive, negative or mixed views. Benefits were identified despite charts not always being used up to their optimal design function. Participants reported tensions between chart objectives and clinical practices, revealing mismatches between design characteristics and human staff experiences. Overall, an initial view of 'increased activity/uncertain benefit' was uncovered. CONCLUSIONS: Findings particularly reinforced the significant influences of organisational work-based cultures, disciplinary boundaries and interdisciplinary communication on implementation of this new practice chart. Optimal use of all chart design characteristics will be possible when these broader cultural issues are addressed.

Clinical utility of an observation and response chart with human factors design characteristics and a track and trigger system: study protocol for a two-phase multisite multiple-methods design.

BACKGROUND: Clinical deterioration of adult patients in acute medical-surgical wards continues to occur, despite a range of systems and processes designed to minimize this risk. In Australia, a standardized template for adult observation charts using human factors design principles and decision-support characteristics was developed to improve the detection of and response to abnormal vital signs. OBJECTIVE: To describe the study protocol for the clinical testing of these observation and response charts (ORCs). METHODS: We propose a two-phase multisite multiple-methods design to test the initial clinical utility of the charts in 10 hospitals of differing types and sizes across state jurisdictions in Australia. Data collection in the first phase includes user surveys, observations and field notes by project officers, handover de-briefs (short interviews with small groups of staff), and an audit of ORC documentation completion compared to the site's existing observation chart. For the second phase, data will be collected using a retrospective audit of observation documentation from the previous hospital observation chart, prospective audit of observation documentation following implementation of the selected ORC, user focus groups, observational field notes, and patient outcome data from routinely collected organizational data sources. RESULTS: Site selection and preparation, project officer training, chart selection and implementation, participant recruitment, and data collection has been completed and the analysis of these results are in progress. CONCLUSIONS: This detailed description of these study methods and data collection approaches will enable a comprehensive assessment of the clinical utility of these newly developed track and trigger charts and will be useful for clinicians and researchers when planning and implementing similar studies. Potential methodological limitations are also noted.

Factors affecting sleep in the critically ill: an observational study.

PURPOSE: The aims of the current study were to describe the extrinsic and intrinsic factors affecting sleep in critically ill patients and to examine potential relationships with sleep quality. MATERIALS AND METHODS: Sleep was recorded using polysomnography (PSG) and self-reports collected in adult patients in intensive care. Sound and illuminance levels were recorded during sleep recording. Objective sleep quality was quantified using total sleep time divided by the number of sleep periods (PSG sleep period time ratio). A regression model was specified using the "PSG sleep period time ratio" as a dependent variable. RESULTS: Sleep was highly fragmented. Patients rated noise and light as the most sleep disruptive. Continuous equivalent sound levels were 56 dB (A). Median daytime illuminance level was 74 lux, and nighttime levels were 1 lux. The regression model explained 25% of the variance in sleep quality (P = .027); the presence of an artificial airway was the only statistically significant predictor in the model (P = .007). CONCLUSIONS: The presence of an artificial airway during sleep monitoring was the only significant predictor in the regression model and may suggest that although potentially uncomfortable, an artificial airway may actually promote sleep. This requires further investigation.