The weekend effect in status epilepticus: a national cohort study.

Higher mortality following admission to hospital at the weekend has been reported for several conditions. It is unclear whether this variation is due to differences in patients or their care. Status epilepticus mandates hospital admission and usually critical care: its study might provide new insights into the nature of any weekend effect. We studied 20,922 adults admitted to UK critical care with status epilepticus from 2010 to 2015. We used multiple logistic regression to evaluate the association between weekend admission and in-hospital mortality, comparing university hospitals with other hospitals. There were 2462 in-hospital deaths (12%). There was no difference in mortality after weekend admission to university hospitals, adjusted odds ratio (95%CI) 0.99 (0.84-1.16), p = 0.89. Mortality was less after weekend admission than after admissions Monday to Friday in hospitals not associated with a university, adjusted odds ratio (95%CI) 0.74 (0.64-0.87), p = 0.0001. There is no evidence that adults admitted to UK critical care at the weekend in status epilepticus are more likely to die than similar patients admitted during the week.

Human factors in the management of the critically ill patient.

Unreliable delivery of best practice care is a major component of medical error. Critically ill patients are particularly susceptible to error and unreliable care. Human factors analysis, widely used in industry, provides insights into how interactions between organizations, tasks, and the individual worker impact on human behaviour and affect systems reliability. We adopt a human factors approach to examine determinants of clinical reliability in the management of critically ill patients. We conducted a narrative review based on a Medline search (1950-March 2010) combining intensive/critical care (units) with medical errors, patient safety, or delivery of healthcare; keyword and Internet search 'human factors' or 'ergonomics'. Critical illness represents a high-risk, complex system spanning speciality and geographical boundaries. Substantial opportunities exist for improving the safety and reliability of care of critically ill patients at the level of the task, the individual healthcare provider, and the organization or system. Task standardization (best practice guidelines) and simplification (bundling or checklists) should be implemented where scientific evidence is strong, or adopted subject to further research ('dynamic standardization'). Technical interventions should be embedded in everyday practice by the adjunctive use of non-technical (behavioural) interventions. These include executive 'adoption' of clinical areas, systematic methods for identifying hazards and reflective learning from error, and a range of techniques for improving teamworking and communication. Human factors analysis provides a useful framework for understanding and rectifying the causes of error and unreliability, particularly in complex systems such as critical care.

Surveillance of bloodstream infections in intensive care units in England, May 2016-April 2017: epidemiology and ecology.

BACKGROUND: Bloodstream infections (BSIs) in patients in intensive care units (ICUs) are associated with increased morbidity, mortality and economic costs. Many BSIs are associated with central venous catheters (CVCs). The Infection in Critical Care Quality Improvement Programme (ICCQIP) was established to initiate surveillance of BSIs in English ICUs. METHODS: A web-based data capture system was launched on 1st May 2016 to collect all positive blood cultures (PBCs), patient-days and CVC-days. National Health Service (NHS) trusts in England were invited to participate in the surveillance programme. Data were linked to the antimicrobial resistance dataset maintained by Public Health England and to mortality data. FINDINGS: Between 1st May 2016 and 30th April 2017, 84 ICUs (72 adult ICUs, seven paediatric ICUs and five neonatal ICUs) based in 57 of 147 NHS trusts provided data. In total, 1474 PBCs were reported, with coagulase-negative staphylococci, Escherichia coli, Staphylococcus aureus and Enterococcus faecium being the most commonly reported organisms. The rates of BSI and ICU-associated CVC-BSI were 5.7, 1.5 and 1.3 per 1000 bed-days and 2.3, 1.0 and 1.5 per 1000 ICU-CVC-days in adult, paediatric and neonatal ICUs, respectively. There was wide variation in BSI and CVC-BSI rates within ICU types, particularly in adult ICUs (0-44.0 per 1000 bed-days and 0-18.3 per 1000 ICU-CVC-days). CONCLUSIONS: While the overall rates of ICU-associated CVC-BSIs were lower than 2.5 per 1000 ICU-CVC-days across all age ranges, large differences were observed between ICUs, highlighting the importance of a national standardized surveillance system to identify opportunities for improvement. Data linkage provided clinically important information on resistance patterns and patient outcomes at no extra cost to participating trusts.

Central venous catheter-related bloodstream infections: improving post-insertion catheter care.

Patients with central venous catheters (CVCs) are at increased risk of bloodstream infections and sepsis-related death. CVC-related bloodstream infections (CRBSIs) are costly and account for a significant proportion of hospital-acquired infections. The aim of this audit was to assess current practice and staff knowledge of CVC post-insertion care and therefore identify aspects of CVC care with potential for improvement. We conducted a prospective audit over 28 consecutive days at a university teaching hospital investigating current practice of CVC post-insertion care in wards with high CVC usage. A multiple choice questionnaire on best practice of CVC insertion and care was distributed among clinical staff. Rates of breaches in catheter care and CRBSIs were calculated and statistical significance assumed when P<0.05. Data was recorded from 151 CVCs in 106 patients giving a total of 721 catheter days. In all, 323 breaches in care were identified giving a failure rate of 44.8%, with significant differences between intensive care unit (ICU) and non-ICU wards (P<0.001). Dressings (not intact) and caps and taps (incorrectly placed) were identified as the major lapses in CVC care with 158 and 156 breaches per 1000 catheter days, respectively. During the study period four CRBSIs were identified, producing a CRBSI rate of 5.5 per 1000 catheter days (95% confidence interval: 0.12-10.97). There are several opportunities to improve CVC post-insertion care. Future interventions to improve reliability of care should focus on implementing best practice rather than further education.

Development of core competencies for an international training programme in intensive care medicine.

OBJECTIVE: The aim of this study was to define the core (minimum) competencies required of a specialist in adult intensive care medicine (ICM). This is the second phase of a 3-year project to develop an internationally acceptable competency-based training programme in ICM for Europe (CoBaTrICE). METHODOLOGY: Consensus techniques (modified Delphi and nominal group) were used to enable interested stakeholders (health care professionals, educators, patients and their relatives) to identify and prioritise core competencies. Online and postal surveys were used to generate ideas. A nominal group of 12 clinicians met in plenary session to rate the importance of the competence statements constructed from these suggestions. All materials were presented online for a second round Delphi prior to iterative editorial review. RESULTS: The initial surveys generated over 5,250 suggestions for competencies from 57 countries. Preliminary editing permitted us to encapsulate these suggestions within 164 competence stems and 5 behavioural themes. For each of these items the nominal group selected the minimum level of expertise required of a safe practitioner at the end of their specialist training, before rating them for importance. Individuals and groups from 29 countries commented on the nominal group output; this informed the editorial review. These combined processes resulted in 102 competence statements, divided into 12 domains. CONCLUSION: Using consensus techniques we have generated core competencies which are internationally applicable but still able to accommodate local requirements. This provides the foundation upon which an international competency based training programme for intensive care medicine can be built.

Challenges in the care of the acutely ill.

Health care providers, hospital administrators, and politicians face competing challenges to reduce clinical errors, control expenditure, increase access and throughput, and improve quality of care. The safe management of the acutely ill inpatient presents particular difficulties. In the first of five Lancet articles on this topic we discuss patients' safety in the acute hospital. We also present a framework in which responsibility for improvement and better integration of care can be considered at the level of patient, local environment, hospital, and health care system; and the other four papers in the series will examine in greater detail methods for measuring, monitoring, and improving inpatient safety.

An international survey of training in adult intensive care medicine.

OBJECTIVE: The aim of this international survey of training in adult intensive care medicine (ICM) was to characterise current structures, processes, and outcomes to determine the potential for convergence to a common competency-based training programme across national borders. This survey is the first phase of a 3 year project which will use consensus methods to build an international competency-based training programme in ICM in Europe (CoBaTrICE). METHODOLOGY: A survey by questionnaire, e-mail, and direct discussion was undertaken with national ICM representatives from seven geographical regions. RESULTS: Responses were obtained from 41 countries (countries which share common training programmes were grouped together; n=38). Fifty-four different training programmes were identified, 37 within the European region; three (6%) were competency-based. Twenty (53%) permitted multidisciplinary access to a common training programme; in nine (24%) training was only available within anaesthesia. The minimum duration of ICM training required for recognition as a specialist varied from 3 months to 72 months (mode 24 months). The content of most (75%) ICM programmes was standardised nationally. Work-based assessment of competence was formally documented in nineteen (50%) countries. An exam was mandatory in twenty-nine (76%). CONCLUSION: There are considerable variations in the structures and processes of ICM training worldwide. However, as competency-based training is an outcome strategy rather than a didactic process, these differences should not impede the development of a common international competency-based training programme in ICM.

Susceptibility to critical illness: reserve, response and therapy.

Risk of critical illness is determined both by genetic and environmental influences, particularly those relating to infectious and cardiovascular diseases. Physiologically-based scoring systems cannot measure prior risk because they do not quantify physiological reserve independently of the acute illness. Genetic profiling could be useful for risk assessment. Early detection of critical illness involves identifying physiological 'triggers' for referral; this requires the education of nursing and medical staff in their significance. Analysis of the relationship between risk factors and interventions may need complex modelling techniques. Therapeutic strategies depend on the nature of the underlying problem: the most useful are likely to be those which enhance tissue oxygen delivery and resistance to infection.

Intensive care training and specialty status in Europe: international comparisons. Task Force on Educational issues of the European Society of Intensive Care Medicine.

OBJECTIVE: To describe current arrangements for postgraduate training and speciality status for intensive care medicine in Europe, and to compare these with three other geographical regions: the Middle East, North America, and Australia and New Zealand. METHODS: An iterative survey, by questionnaire and direct discussion, of council members of the European Society of Intensive Care Medicine, national specialist societies with involvement in intensive care, and national experts, representing four geographical regions and 47 countries. RESULTS: For the purposes of analysis, countries with common training structures have been grouped together; the denominator therefore includes both countries and regions. Formal training programmes in intensive care medicine (ICM) are available in 18 (85%) of the 21 countries or regions surveyed. Twelve (57%) offer multidisciplinary access to intensive care training with a common core curriculum. In six (28%) training in ICM is available solely through anaesthesia. The duration of intensive care training required for recognition as a specialist in the 18 countries or regions with a formal programme ranges from 18 to 30 months, with a median of 24 months. All countries assess competence in intensive care, but methods for doing so vary widely. Eighteen countries or regions offer specialist registration (accreditation) in ICM; in 12 this is provided as dual accreditation in a base speciality and in ICM. CONCLUSIONS: There is substantial support for multidisciplinary training in ICM, as demonstrated by collaborative interspeciality developments in many countries. We propose that these national developments should be strengthened within Europe by the recognition of 'supra-speciality' status for ICM by the European Commission, and by the establishment of a multidisciplinary Board for training in ICM, with international agreement on core competencies and duration of training programmes, and a common approach to the assessment of competence through formal examination.

Sickness scoring and response to treatment as predictors of outcome from critical illness.

A physiological sickness scoring system (SS), based on the APACHE II score, has been used to assess outcome from critical illness in 128 patients admitted to a general intensive care unit. Physiological data were collected on each patient from admission until death or discharge from the unit, and survival was recorded as survival to home. The admission SS correctly classified 80.6% of survivors, and 70.4% of non-survivors. Predictive power did not improve with time using the daily SS. However, when the proportional change in SS over time was included in the analysis, predictive power improved; and at day 4, 87.1% of survivors and 75% of non-survivors were correctly classified. At intermediate levels of sickness severity (admission score of 13-18), a reduction in SS of 30% by day 4 reduced the risk of death by 32%; at higher levels (greater than 18) a similar reduction in SS was associated with a 47% reduction in death-risk. Failure to obtain a reduction in score by day 4 was associated with increased risk of death. Survivors consistently showed a greater fall in SS by day 4 than non-survivors. The APACHE score and its modifications provide an accurate, unitary measure of physiological disturbance. Correction of abnormal physiology, and the measurement of responsiveness to therapy are important components in the prediction of outcome from critical illness.

Atracurium infusions in patients with fulminant hepatic failure awaiting liver transplantation.

OBJECTIVE: To determine the pharmacokinetics and pharmacodynamics of the neuromuscular blocking agent atracurium besylate in patients with fulminant hepatic failure (FHF). DESIGN: Open study of patients receiving atracurium infusions to facilitate mechanical ventilation. SETTING: Intensive care unit in a tertiary referral university teaching hospital. PATIENTS: Ten encephalopathic patients with FHF requiring mechanical ventilation while awaiting orthotopic liver transplantation. Three patients died before transplantation could be performed, three died after transplantation, and four survived following successful transplantation. METHODS: Plasma, urine and dialysate fluid were analysed for atracurium and its metabolites using HPLC. Neuromuscular blockade was measured using transcutaneous ulnar nerve stimulation and an accelerometer. Electroencephalography and liver function tests were performed daily. RESULTS: Patients received atracurium infusions for a period ranging from 38 to 217 h. Six patients required continuous arteriovenous haemodiafiltration (CAVHD) to replace renal function. Atracurium mean steady state clearance was 8.6 ml/min/kg, and train-of-four recovery ratio to 75% took 63 min (range 32-108). Laudanosine clearance was markedly reduced in the non-survivors; the half-life was 38.5 hrs compared with 5.3 h in the 4 patients who underwent successful transplantation. Laudanosine accumulation could be observed in all patients before transplantation, but kinetics returned to normal after successful transplantation. The highest laudanosine level recorded was 6,860 ng/ml. There was no evidence of adverse central neurological effects attributable to laudanosine. CAVHD did not contribute significantly to clearance of atracurium or its metabolites. CONCLUSIONS: Atracurium kinetics and dynamics are near-normal even in patients with fulminant hepatic failure and renal failure; laudanosine accumulation will occur, but this is not associated with measurable central neurological effects. Implantation of a functioning liver graft results in clearance of laudanosine, which seems to be independent of renal function. Atracurium is an appropriate choice for producing neuromuscular blockade for periods of several days in patients with fulminant hepatic failure and renal impairment.

Research priorities in critical care medicine in the UK.

OBJECTIVES: To establish priorities for research in critical care medicine in the UK using survey and nominal group (NG) techniques. DESIGN: The senior doctor and nurse from 325 intensive care units (ICUs) in the UK were invited to contribute up to ten research questions relevant to intensive care organisation, practice or outcomes. These were then ranked twice using a Likert scale by a panel (nominal group) consisting of ten doctors (two trainees) and two nurses from university teaching and district general (community) hospitals. The first ratings were performed privately, and the second after group discussion. Thirty questions, ten each with strong, moderate or weak support, were then returned for rating by the originating ICU staff and the results compared with those of the NG. RESULTS: One hundred eighty-five respondents (35.6 % university teaching, 62.1% district general, 2.3 % not stated) provided 811 questions of which 722 were research hypotheses. The most frequently identified topics were the evaluation of high dependency care, ICU characteristics, treatments for acute lung injury and acute renal failure, nurse:patient ratios, pulmonary artery catheterisation, aspects of medical and nursing practice, protocol evaluation, and interhospital transfers. These were condensed into 100 topics for consideration by the NG. Discussion and re-rating by the group resulted in strong support being offered for 37 topics, moderate support for 48, and weak support for 21. Following circulation of ten questions from each category, nine questions achieved strong support from both ICU staff and the NG. These were the effect on outcomes from critical illness of early intervention, high dependency care, nurse:patient ratios, interhospital transfers, early enteral feeding, optimisation of perioperative care, hospital type, regionalisation of paediatric intensive care and the use of pulmonary artery catheters. The absence of any questions relating to interventions targetting mediators of the immuno-inflammatory response could be a consequence of the failure of recent studies in sepsis to demonstrate benefits in outcome. CONCLUSIONS: The intensive care community in the UK appears to prioritise research into organisational aspects of clinical practice and practical aspects of organ-system support. Health services research and the biological sciences need to develop collaborative methods for evaluating interventions and outcomes.

Sedation in intensive care: morphine and renal function.

Intravenous morphine infusions have been administered to 12 critically-ill patients during controlled ventilation. Acute oliguric renal failure was present in 4 patients, who were treated with a combination of haemofiltration and haemodialysis. Severity of physiological disturbance was assessed using a modified APACHE Score, level of sedation by a linear-analogue scale, and blood morphine levels by high-pressure liquid chromatography. Morphine clearance was impaired in renal failure, and was dependent on haemofiltration volumes; accumulation of morphine did not occur during this form of treatment. Conscious level was clearly more closely related to the degree of physiological disturbance than blood morphine levels; and for a given blood morphine level, depression of consciousness was more pronounced the greater the degree of physiological disturbance. Use of a physiological sickness score may help to clarify some of the factors influencing cerebral function during critical illness. Careful clinical monitoring of level of sedation is important in patients with oliguric renal failure receiving morphine, and haemofiltration appears to reduce the risk of morphine accumulation in these patients.

Antibiotic-induced release of endotoxin from bacteria in vitro.

The ability of cefotaxime, ciprofloxacin, piperacillin and tobramycin to cause release of endotoxin was examined in vitro with cultures of Enterobacter cloacae and Escherichia coli. Endotoxin was measured by a quantitative limulus amoebocyte lysate assay and its presence was confirmed by silver staining of the lipopolysaccharide moiety following SDS-PAGE. The morphology of the bacteria during antibiotic exposure was examined by scanning electronmicroscopy. Cefotaxime, ciprofloxacin and piperacillin caused significant endotoxin release, correlating with their ability to affect cell-wall morphology, causing filamentation, wall breakage and cell lysis. In contrast, little endotoxin was released when bacteria were exposed to tobramycin and no morphological changes were observed when bacteria were exposed to bactericidal concentrations of this aminoglycoside. Its antimicrobial spectrum and bactericidal activity make tobramycin an appropriate agent for treatment of sepsis caused by gram-negative bacteria and its lack of propensity to elicit excessive release of endotoxin may avoid exacerbation of endotoxin-related shock in sepsis.

Carbapenem-resistant Acinetobacter and role of curtains in an outbreak in intensive care units.

Multiple-antibiotic-resistant Acinetobacter baumanii, including meropenem resistance, was first isolated from a patient in the general intensive care unit of a tertiary-referral university teaching hospital in Birmingham in December 1998. Similar strains were subsequently isolated from 12 other patients, including those on another intensive care unit within the hospital. The outbreak followed an increase in the use of meropenem in both the units. Environmental screening revealed the presence of the multiple-resistant Acinetobacter species on fomite surfaces in the intensive care unit and bed linen. The major source appeared to be the curtains surrounding patients' beds. Typing by pulsed field gel electrophoresis demonstrated that the patients' isolates and those from the environment were indistinguishable. Rigorous infection control measures including increased frequency of cleaning of the environment with hypochlorite (1000 ppm) and twice-weekly changing of curtains were implemented, along with restriction of meropenem use in the units. Isolation of the multiple-resistant Acinetobacter spp. subsequently diminished and it was not detected over a follow-up period of 18 months. To our knowledge, this is the first reported outbreak of carbapenem-resistant Acinetobacter spp. from the UK. This outbreak also highlights environmental sources, particularly dry fabrics such as curtains, as an important reservoir for dissemination of acinetobacters.

Basic life support training for health care students.

This paper describes a novel method for delivering basic life support training to undergraduate healthcare students. A comprehensive 8 h programme is organised and delivered by undergraduate students to their peers. These students have undergone training as basic life support instructors validated by the Royal Life Saving Society UK. The course is delivered to multiprofessional groups of medical, dental, physiotherapy, biomaterial and nursing undergraduates. It has been well received by students and academic staff and provides a solution to reduce the workload of over burdened clinical staff while at the same time enhancing quality. It forms part of an overall strategy for improving resuscitation training for undergraduates from all disciplines.

International comparisons of critical care outcome and resource consumption.

Though there are reasonable data to suggest that certain countries, such as the United States, spend considerably more money on the provision of critical care services than others, there is little information regarding the added benefits accrued with this additional expense. Studies to date have suggested little if no difference in outcome but have been limited in their size, design, and choice of outcome measures. Furthermore, significant underlying societal priorities and philosophy may dictate that the optimal critical care delivery system is different for different countries. With the increasing availability of large patient databases, however, it will be more feasible in the future to design and conduct assessments of critical care delivery systems between countries taking appropriate account of the choice of study design, definition of at-risk populations, and choice of valuable measures of output and cost. The results of such assessments will hopefully drive wiser decision making in the design and management of critical care delivery systems worldwide.

Use of consensus development to establish national research priorities in critical care.

OBJECTIVES: To test the feasibility of using a nominal group technique to establish clinical and health services research priorities in critical care and to test the representativeness of the group's views. DESIGN: Generation of topics by means of a national survey; a nominal group technique to establish the level of consensus; a survey to test the representativeness of the results. SETTING: United Kingdom and Republic of Ireland. SUBJECTS: Nominal group composed of 10 doctors (8 consultants, 2 trainees) and 2 nurses. MAIN OUTCOME MEASURE: Level of support (median) and level of agreement (mean absolute deviation from the median) derived from a 9 point Likert scale. RESULTS: Of the 325 intensive care units approached, 187 (58%) responded, providing about 1000 suggestions for research. Of the 106 most frequently suggested topics considered by the nominal group, 37 attracted strong support, 48 moderate support and 21 weak support. There was more agreement after the group had met-overall mean of the mean absolute deviations from the median fell from 1.41 to 1.26. The group's views represented the views of the wider community of critical care staff (r=0.73, P<0.01). There was no significant difference in the views of staff from teaching or from non-teaching hospitals. Of the 37 topics that attracted the strongest support, 24 were concerned with organisational aspects of critical care and only 13 with technology assessment or clinical research. CONCLUSIONS: A nominal group technique is feasible and reliable for determining research priorities among clinicians. This approach is more democratic and transparent than the traditional methods used by research funding bodies. The results suggest that clinicians perceive research into the best ways of delivering and organising services as a high priority.