Improving the handover of complex trauma patients by implementing a standardised process.

BACKGROUND: Patient handover continues to be an international health priority in the prevention of patient harm. Transitioning patients from the intensive care unit (ICU) to the ward is complex, particularly for trauma patients, due to the multifaceted aspects of their care requirements as a result of multiple injuries and different speciality teams. OBJECTIVES/AIM: To design, implement, and evaluate the efficacy of a standardised handover process and tool for the transfer of ICU trauma patients. METHODS: A multimethod before/after study design was used. This included observations before and after an implemented transfer process and semistructured interviews with ICU and ward nurses caring for trauma patients. Comparisons were made of data before and after the intervention. RESULTS: Eleven patient handovers were observed, and 21 nurses (11 from the ICU and 10 from the ward) were interviewed. Patients and family members were included during the handover following the intervention (n = 0/10 [0%] vs n = 4/11 [36%]) and the ward nurses were asked if they had any concerns (n = 5/10 [50%] vs n = 10/11 [91%]). Improvements in patient observations handed over were reported following the intervention. However, omissions remained in some key areas including patient introduction, patient identity, fluid balance, and allergies/alerts. Thematic analysis of interviews revealed that the new handover process was perceived advantageous by both ICU and ward nurses because of its structured and comprehensive approach. Identified future improvements included the need for hospital service managers to ensure integration of ICU and ward electronic health record systems. CONCLUSION: Precise, accurate, and complete handover remains a patient safety concern. Improvements were achieved using a standardised process and handover tool for the transfer of complex trauma patients. Further improvements are required to reduce the failure to hand over essential patient information.

Fostering positive emotions, psychological well-being, and productive relationships in the intensive care unit: A before-and-after study.

BACKGROUND: Intensive care units (ICUs) are emotionally demanding workplaces. Exposure to stress can negatively impact ICU staff members' emotional resilience, health, and capacity to provide care. Despite recognition of the benefits of promoting "healthy workplaces", there are limited interventional studies aimed at improving the well-being of ICU staff. AIM: The aim of this study was to assess the effectiveness of a multifaceted intervention for improving well-being of staff working in a tertiary ICU. METHODS: A before-and-after interventional study was conducted over a 2-year period, between 2019 and 2021. Interventions included social activities, fitness, nutrition, and emotional support. An electronic version of the PERMA-Profiler questionnaire was used to assess the well-being of a convenience sample of ICU staff before (n = 96) and after (n = 137) the intervention. Ten focus groups (each involving 12-18 nurses) were held to explore nurses' perceptions of the intervention's effectiveness. RESULTS: After the intervention, a significantly greater proportion of participants described their work week as draining (32% vs 19%, χ2 = 4.4 df + 1, P = 0.03) and at least a bit harder than normal (38% vs 22%, χ2 = 6.4 df + 1, p = 0.01) compared to baseline surveys. However, well-being scores after the intervention (mean = 6.95, standard deviation = 1.28) were not statistically different (p = 0.68) from baseline scores (mean = 7.02, standard deviation = 1.29). Analysis of focus groups data revealed three key categories: boosting morale and fostering togetherness, supporting staff, and barriers to well-being. CONCLUSIONS: After the intervention, there was a preserved level of well-being from baseline despite a statistically significant increase in staff reporting the work week as draining and at least a little bit harder than normal. These findings must be considered in light of the COVID-19 pandemic, which started after baseline data collection and continues to impact the community, including staff workload and pressures in intensive care. The study findings may inform strategies for improving ICU staff members' well-being.

Dying in intensive care: An analysis of the perspectives of families and clinicians on end-of-life care.

BACKGROUND: Despite a growing body of research into end-of-life care (EOLC) in intensive care units (ICUs), few studies have concurrently explored the perspectives of families and clinicians. OBJECTIVE: The objective of this study was to identify the characteristics of high-quality EOLC in the ICU from family and clinician perspectives and by examining the care documented in medical records. METHODS: A convergent mixed-methods study incorporating electronic health record audits (n = 20), structured interview surveys with families (n = 20), clinician surveys (n = 189), and focus groups (n = 10) was undertaken at a 30-bed, level 3 ICU at a metropolitan public adult teaching hospital in Australia. Descriptive statistics were calculated from quantitative data, and inductive thematic analysis was used to analyse qualitative data. RESULTS: Overall, families were very satisfied with EOLC and the quality of communication yet, felt that earlier, clearer communication that the patient was dying was required. Families spoke of the attentiveness, or lack thereof, by ICU clinicians and the opportunity to be present for the patient's death. The majority of ICU clinicians felt EOLC could be improved. Nurses highlighted communication challenges when family meetings were delayed. Some nurses expressed a lack of clarity of how to withdraw care, resulting in hesitancy to cease potentially inappropriate care, and to provide EOLC outside ICU practice norms. In many instances, observations, invasive monitoring, and interventions were documented after EOLC commenced. A lack of documented personal cares was also noted. CONCLUSIONS: This study provides new insights into EOLC from the dual perspectives of families and clinicians. There is a need for institutional guidelines to support ICU clinicians' EOLC practices and education to improve clinician confidence with communication.

Investigating the construct and concurrent validity of the Richards-Campbell Sleep Questionnaire with intensive care unit patients and home sleepers.

BACKGROUND: Sleep is vital to our wellbeing. Critically ill patients are vulnerable with effects of sleep deprivation including weakened immune function, decreased glucose tolerance, and increased sympathetic activity. Intensive care unit (ICU) patients' sleep evaluation is difficult and often not reliable. The most commonly used instrument for assessing ICU patients' perspective of their sleep, Richards-Campbell Sleep Questionnaire (RCSQ), has not been reported to have undergone known-group construct validity testing or concurrent validity testing with the criterion measure of feeling refreshed. OBJECTIVES: The aim of the study was to explore the construct validity of the RCSQ with known-groups technique and concurrent validity with the criterion measure of feeling refreshed on awakening. METHODS: A cross-sectional descriptive survey study using the RCSQ was conducted on people sleeping at home (n = 114) over seven nights. The results were compared with the RCSQ sleep scores of nonintubated alert oriented adult ICU patients (n = 114). Home sleepers were also asked to rate how refreshed they felt on awakening. The study was executed and reported in accordance with the STROBE checklist for observational studies. FINDINGS: RCSQ construct validity was supported because home sleepers' and ICU sleepers' sleep evaluations differed significantly. Home sleepers rated their sleep significantly better than ICU patients in all five sleep domains of the RCSQ. Concurrent validity was supported because the item "feeling refreshed on awakening" correlated strongly with all sleep domains. CONCLUSIONS: Sleep quality may be accurately measured using the RCSQ in alert people both in the ICU and at home. This study has added to the validity discussion around the RCSQ. The RCSQ can be used for sleep evaluation in ICUs to promote wellbeing and recovery.

Pressure injury prevalence in Australian intensive care units: A secondary analysis.

BACKGROUND: Pressure injuries (PIs) are an enduring problem for patients in the intensive care unit (ICU) because of their vulnerability and numerous risk factors. METHOD: This study reports Australian data as a subset of data from an international 1-day point prevalence study of ICU-acquired PI in adult patients. Patients aged 18 years or older and admitted to the ICU on the study day were included. The outcome measure was the identification of a PI by direct visual skin assessment on the study day. Data collected included demographic data and clinical risk factors, PI location and stage, and PI prevention strategies used. Descriptive statistics were used to describe PI characteristics, and odds ratios (ORs) were used to identify factors associated with the development of a PI. RESULTS: Data were collected from 288 patients from 16 Australian ICUs. ICU-acquired PI prevalence was 9.7%, with 40 PIs identified on 28 patients. Most PIs were of stage 1 and stage 2 (26/40, 65.0%). Half of the ICU-acquired PIs were found on the head and face. The odds of developing an ICU-acquired PI increased significantly with renal replacement therapy (OR: 4.25, 95% confidence interval [CI]: 1.49-12.11), impaired mobility (OR: 3.13, 95% CI: 1.08-9.12), fastest respiratory rate (OR: 1.05 [per breath per minute], 95% CI: 1.00-1.10), longer stay in the ICU (OR: 1.04 [per day], 95% CI: 1.01-1.06), and mechanical ventilation on admission (OR: 0.36, CI: 0.14-0.91). CONCLUSION: This study found that Australian ICU-acquired PI prevalence was 9.7% and these PIs were associated with many risk factors. Targeted PI prevention strategies should be incorporated into routine prevention approaches to reduce the burden of PIs in the Australian adult ICU patient population.

The Paediatric AirWay Suction (PAWS) appropriateness guide for endotracheal suction interventions.

BACKGROUND/OBJECTIVE: Endotracheal suction is an invasive and potentially harmful technique used for airway clearance in mechanically ventilated children. Choice of suction intervention remains a complex and variable process. We sought to develop appropriate use criteria for endotracheal suction interventions used in paediatric populations. METHODS: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop the Paediatric AirWay Suction appropriateness guide. This included defining key terms, synthesising current evidence, engaging an expert multidisciplinary panel, case scenario development, and two rounds of appropriateness ratings (weighing harm with benefit). Indications (clinical scenarios) were developed from common applications or anticipated use, current practice guidelines, clinical trial results, and expert consultation. RESULTS: Overall, 148 (19%) scenarios were rated as appropriate (benefit outweighs harm), 542 (67%) as uncertain, and 94 (11%) as inappropriate (harm outweighs benefit). Disagreement occurred in 24 (3%) clinical scenarios, namely presuction and postsuction bagging across populations and age groups. In general, the use of closed suction was rated as appropriate, particularly in the subspecialty population 'patients with highly infectious respiratory disease'. Routine application of 0.9% saline for nonrespiratory indications was more likely to be inappropriate/uncertain than appropriate. Panellists preferred clinically indicated suction versus routine suction in most circumstances. CONCLUSION: Appropriate use criteria for endotracheal suction in the paediatric intensive care have the potential to impact clinical decision-making, reduce practice variability, and improve patient outcomes. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment.

BACKGROUND: To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient. METHODS: Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care. RESULTS: A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves. CONCLUSION: The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival.

Exploring family participation in patient care on acute care wards: A mixed-methods study.

BACKGROUND: Patient- and family-centred care practices are a recommended part of contemporary care for the acutely ill hospitalized adult patients. However, how patient- and family-centred care is enacted in an adult hospital setting is not well understood. AIMS AND OBJECTIVES: The aim of this study is to explore the perceptions of patients, family members and nurses regarding family participation and collaboration in patient care within an acute care setting, including the barriers and facilitators. DESIGN: This study used a mixed-methods sequential design. METHODS: Observer-as-participant observations and semistructured interviews were undertaken. Integration of the data was achieved through triangulation. RESULTS: Triangulation revealed two metathemes. The first metatheme, 'continuum of family involvement', explained the central viewpoint of how family participation and collaboration in the care of acutely ill hospitalized adult patients was enacted. The second metatheme, 'nurses value family involvement', helped to explain and understand the barriers and facilitators to enacting family participation in the acute care setting. CONCLUSION: Promoting family participation in the acute care setting requires supporting multiple levels of engagement. Developing a relationship, clear communication and open sharing of information amongst patients, family members and nurses is critical to supporting family involvement.

The intensive care unit visiting study: A multisite survey of visitors.

BACKGROUND: Being able to visit a critically ill relative provides comfort to family members and has recognised benefits to the patient. Limited research has been conducted on demographic characteristics and visiting behaviours of family members with a relative in the intensive care unit (ICU). OBJECTIVES: The objective was to provide an overview of local ICU visitor behaviours and practices across four metropolitan units in Australia. METHODS: A convenience sample of 440 participants from four ICUs across a metropolitan city in eastern Australia was required for the study. A descriptive 22-item self-report survey was used. Data were collected from four ICUs in a metropolitan city in eastern Australia. Sample characteristics and other variables were analysed using descriptive statistics. RESULTS: Data collection was undertaken from April 2018 to May 2019. Four hundred sixty-two (n = 462) ICU visitors responded. There were no significant differences between visitor characteristics across the four hospitals. The mean age of the respondents was 49 years, the youngest participant being 18 years and the oldest being 93 years, with most visitors being women (n = 312, 68%). The participants were more likely to be close relatives such as spouses (n = 117, 25%), parents (n = 113, 24%), or children (n = 79, 17%). Visitors reported different methods by which they received information about visiting policies across units and indicated that they would have visited more frequently if able. Although most respondents rated their ICU visiting experience favourably, some reported being frequently asked to leave the patient's bedside impacted their experience. CONCLUSIONS: This study has highlighted that families want to remain in close proximity when they have a relative in the ICU. Despite visiting hours being flexible, most families visit midmorning so that they can talk with staff. Data captured in this study can be used toward improving the ICU visiting experience for family members.

Application of the READY framework supports effective communication between health care providers and family members in intensive care.

Effective communication between intensive care health care providers and family is crucial to support surrogate or shared decision-making and to individualise care. Despite its importance in health care standards and policy, the quality of communication with families in intensive care is regarded as suboptimal. Furthermore, an intensive care admission is an extremely stressful event for families, which may impact their understanding and subsequent decision-making. Communicating with family members is a routine practice in intensive care; however, health care providers often receive no formal communication training. To date, family-focused communication interventions in intensive care have targeted end-of-life care and are not generalisable across all types of family-health care provider communication interactions. Mugweni et al. recently reported the results of a multiprofessional training intervention involving 26 health care professionals to improve the delivery of different news to families during pregnancy and at birth. A critique of this article has been undertaken to inform routine communication with critically ill family members and optimise the delivery of care in intensive care units.

Endotracheal suction interventions in mechanically ventilated children: An integrative review to inform evidence-based practice.

OBJECTIVE: The objective of this study was to review and critically appraise the evidence for paediatric endotracheal suction interventions. DATA SOURCES: A systematic search for studies was undertaken in the electronic databases CENTRAL, Medline, EMBASE, and EBSCO CINAHL from 2003. STUDY SELECTION: Included studies assessed suction interventions in children (≤18 ys old) receiving mechanical ventilation. The primary outcome was defined a priori as duration of mechanical ventilation. Secondary outcomes included adverse events and measures of gas exchange and lung mechanics. DATA EXTRACTION: Data extraction were performed independently by two reviewers. Study methodological quality was assessed using Cochrane's risk of bias tool for randomised trials or the Newcastle-Ottawa Scale for observational studies. Overall assessment of the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations criteria. RESULTS: Overall 17 studies involving 1618 children and more than 21,834 suction episodes were included in the review. The most common intervention theme was suction system (five studies; 29%). All included trials were at unclear or high risk of performance bias due to the inability to blind interventionists. Current evidence suggests that closed suction may maintain arterial saturations, normal saline leads to significant transient desaturation, and lung recruitment applied after suction offers short-term oxygenation benefit. LIMITATIONS: Lack of randomised controlled trials, inconsistencies in populations and interventions across studies, and imprecision and risk of bias in included studies precluded data pooling to provide an estimate of interventions effect. CONCLUSIONS: Based on the results of this integrative review, there is insufficient high-quality evidence to guide practice around suction interventions in mechanically ventilated children.

Normal saline and lung recruitment with paediatric endotracheal suction (NARES): A pilot, factorial, randomised controlled trial.

BACKGROUND/OBJECTIVE: Endotracheal suction is one of the most common and harmful procuedres performed on mechanically ventilated children. The aim of the study was to establish the feasibility of a randomised controlled trial (RCT) examining the effectiveness of normal saline instillation (NSI) and a positive end-expiratory pressure recruitment manoeuvre (RM) with endotracheal suction in the paediatric intensive care unit. METHODS: Pilot 2 × 2 factorial RCT. The study was conducted at a 36-bed tertiary paediatric intensive care unit in Australia. Fifty-eight children aged less than 16 years undergoing tracheal intubation and invasive mechanical ventilation. (i) NSI or no NSI and (ii) RM or no RM with endotracheal suction . The primary outcome was feasibility; secondary outcomes were ventilator-associated pneumonia (VAP), change in end-expiratory lung volume assessed by electrical impedance tomography, dynamic compliance, and oxygen saturation-to-fraction of inspired oxygen (SpO2/FiO2) ratio. RESULTS/FINDINGS: Recruitment, retention, and missing data feasibility criteria were achieved. Eligibility and protocol adherence criteria were not achieved, with 818 patients eligible and 58 enrolled; cardiac surgery was the primary reason for exclusion. Approximately 30% of patients had at least one episode of nonadherence. Children who received NSI had a reduced incidence of VAP; however, this did not reach statistical significance (incidence rate ratio = 0.12, 95% confidence interval = 0.01-1.10; p = 0.06). NSI was associated with a significantly reduced SpO2/FiO2 ratio up to 10 min after suction. RMs were not associated with a reduced VAP incidence (incidence rate ratio = 0.31, 95% confidence interval = 0.05-1.88), but did significantly improve end-expiratory lung volume at 2 and 5 min after suction, dynamic compliance, and SpO2/FiO2 ratio. CONCLUSION: RMs provided short-term improvements in end-expiratory lung volume and oxygenation. NSI with suction led to a reduced incidence of VAP; however, a definitive RCT is needed to test statistical differences. A RCT of study interventions is worthwhile and may be feasible with protocol modifications including the widening of participant eligibility.

A pilot randomised controlled trial of dressing and securement methods to prevent arterial catheter failure in intensive care.

BACKGROUND: Critically ill patients in an intensive care setting often require arterial catheters for blood pressure monitoring and arterial blood collection. Arterial catheter failure, which manifests in both mechanical and infective forms, remains common. Dressing and securement inadequacies may impact this failure; however, the best method for dressing and securing arterial catheters is yet to be determined. OBJECTIVES: The objective of this study was to establish the feasibility of a definitive randomised controlled trial comparing methods for dressing and securing arterial catheters and to prevent device failure in an adult intensive care setting. METHODS: A pilot, parallel-group, randomised controlled trial was conducted between April 2017 and June 2018. Patients receiving treatment in two adult intensive care units (Queensland, Australia) were eligible for inclusion and were allocated to receive either (i) an integrated securement dressing or (ii) a simple polyurethane dressing (with gauze/foam), applied to their newly inserted arterial catheters. MAIN OUTCOME MEASURES: Primary outcomes were (i) feasibility (defined by pre-established criteria: patient eligibility, consent, protocol adherence, retention, and staff acceptability) and (ii) all-cause arterial catheter failure (a composite of local and bloodstream infection, occlusion, dislodgement, infiltration/extravasation, arterial inflammation, thrombosis, and/or inaccurate trace). Secondary outcomes included: failure type, dwell time, dressing adhesion, adverse event profiles, and staff acceptability. RESULTS: In total, 109 patients were studied (n = 53 integrated securement dressing; n = 56 simple polyurethane). The feasibility criterion was met by most patients (including rates of consent [86%], protocol adherence [93%], and retention [100%]); however, the criteria for patient eligibility were not met (73%). All-cause device failure did not differ significantly between the integrated securement device group (n = 12/53, 23%) and the simple polyurethane group (n = 6/56, 11%) (hazard ratio = 2.39, 95% confidence interval = 0.89-6.37, p = 0.083). CONCLUSIONS: Findings indicate a larger study is feasible, with minor alterations to recruitment methods required. Arterial catheter failure remains unacceptably common; further research to determine optimal dressing/securement practices is urgently needed.

The use of factor analysis and abductive inference to explore students' and practitioners' perspectives of feedback: divergent or congruent understanding?

BACKGROUND: The importance of feedback in workplace-based settings cannot be underestimated. Approaches that evaluate feedback reflect either the sender's or receiver's viewpoint in isolation of each other. This study investigated prevailing student and practitioner views of feedback resulting from development and testing of a survey about feedback. METHOD: This study used a cross-sectional design, incorporating use of expert consultation and factor analysis of surveys. Fifty-two items based on identified attributes for effective feedback from current research were developed and reviewed through expert consultation. Surveys developed from the items were completed by students (n = 209) and practitioners (n = 145). The juxtaposition of items based on students' and practitioners' responses to the surveys were examined through use of exploratory factor analysis. RESULTS: Separate student and practitioner surveys resulted. Each survey contained 23 items that clustered into factors. The item statements were different across practitioner and student groups Only nine items were shared across factors identified for both groups. The resulting factors represented different notions of feedback-namely, practitioners had a process-oriented focus in comparison with students' outcome focus. CONCLUSION: While students and practitioners view feedback differently this does not necessarily mean they are incongruous.

Partnership between Nurse Navigators and adult persons living with complex chronic disease-An exploratory study.

AIMS AND OBJECTIVES: The aim of this study was to explore nurse navigators and consumers' experience of partnership. BACKGROUND: The nurse navigator has recently emerged as an advanced practice role in the care of persons with complex and chronic disease states. Self-care is an important principle in chronic disease models of care, requiring healthcare practitioners to partner with clients in their care. How nurse navigators and consumers [clients and family] experience partnership has not been explored. DESIGN: An interpretive exploratory qualitative approach was used. Semi-structured interviews were conducted with seven nurse navigators working with adults with complex disease states and eleven of their clients. Interviews were analysed using descriptive content analysis. (COREQ checklist Data S1). RESULTS: Five themes about partnership emerged. Three themes from nurse navigators were as follows: establishing and sustaining relationships, nurse-led planning and aligning care with clients' needs. The two consumer themes were as follows: regular contact means access to the health system and nurse presence is valued. The secondary analysis revealed two themes about partnership between the nurse and consumer: establishing relationships require nursing effort to be established and partnerships are person-focused and nurse-led. CONCLUSIONS: Partnership begins with a relationship, largely driven by the nurse navigator through regular communication and personal contact that was valued by consumers. The nurse-led partnership reduced opportunities for consumers to learn to manage their treatments, particularly how and when to access services, meaning that self-care may not be fully achieved. Client navigation occurs over long periods, which could lead to the navigators being overwhelmed, raising an issue of sustainability. RELEVANCE TO CLINICAL PRACTICE: Nurse navigators establish a client relationship as a foundation for partnership. This partnership needs a focus on promoting client self-care, self-management of treatment, including when and how to access available services, to ensure the sustainability of the nurse navigator model of care.

Early mobilisation of ventilated patients in the intensive care unit: A survey of critical care clinicians in an Australian tertiary hospital.

INTRODUCTION: Mobilising mechanically ventilated patients is safe and beneficial and improves outcomes. However, early mobilisation is not widely practiced and barriers to its implementation still exist. OBJECTIVE: The objective of this study was to assess clinician perceptions, knowledge, attitudes, and behaviours towards mobilising critically ill ventilated patients in the intensive care unit, as well as perceived barriers and facilitators towards mobilisation. METHODS: A prospective questionnaire based on three existing questionnaires was administered to nurses, physicians, and physiotherapists from a single mixed medical/surgical intensive care unit in an Australian tertiary hospital. The 32-item questionnaire focused on knowledge, attitudes, behaviour, and perceived facilitators and barriers. Various response options were used, and data were analysed using descriptive statistics. RESULTS: The overall response rate was 56.6% (82 of 145). Overall, clinicians' knowledge score was 4.1 (standard deviation = 1.4) out of a possible score of 6. Early mobilisation was not perceived as a top priority by 40.2% of participants. One important facilitator was that majority of the participants perceived early mobilisation was important. The most common perceived barriers to early mobilisation were medical instability, delirium, sedation, and limited staffing. Clinicians' opinions varied on the timing and appropriateness for instituting early mobilisation. CONCLUSIONS: Clinicians had various levels of knowledge on early mobilisation as a therapy for critically ill patients. Most clinicians believed that early mobility was important and were willing to reduce sedation; however, several key barriers were identified which need to be addressed by using targeted interventions. This will reduce or close the gap between knowledge and practice.

Handover practices of nurses transferring trauma patients from intensive care units to the ward: A multimethod observational study.

Poor-quality patient handover leads to adverse patient outcomes. Consequently, handover has been identified as a national and international priority for preventing patient harm. Risks are exacerbated during transfers of trauma intensive care unit (ICU) patients to a ward because of the complexity of their injuries coupled with a de-escalation in care and monitoring. This study assessed current handover practices for ICU trauma patients, identifying barriers and facilitators to best practice handover. A multimethod design was used, including naturalistic observations of clinical handover of trauma patients transferred to a ward and semistructured interviews with both the ICU and ward nurses caring for the trauma patient. The study was conducted at an Australian metropolitan public adult teaching hospital ICU. Purposive maximal sampling of patient handover opportunities was sought. Recruitment continued until data saturation was reached using thematic analysis. Ten ICU and ward nurses were recruited, with 10 observations of handover and 20 interviews conducted. Observations of the handovers identified multiple issues, including deficits and discrepancies in the information communicated that could impact patient safety, variable handover processes, and poor patient and family involvement. Interviews elicited two major themes around the handover: practices and processes. Nurses identified that interruptions, time, and workload pressures presented barriers to handover, whilst teamwork, using a structured and systematic approach, preparation time for handover, and communication before transfer facilitated effective handover and transfer. Nurses suggested a structured tool to aid handover. This study identified clinically significant deficits and discrepancies in the information communicated to the ward nurses. Nurses identified that interruptions, time, and workload pressures presented barriers to effective handover. Teamwork where preparation and the handover event are prioritised over other activities is needed. A minimum data set for handover in conjunction with patients and family members is recommended.

Adverse events and practice variability associated with paediatric endotracheal suction: An observational study.

OBJECTIVE: The objective of this study was to determine the incidence of endotracheal tube (ETT) suction-related adverse events (AEs) and to examine associations between AEs and patient and suction characteristics. Secondary objectives were to describe ETT suction practices in an Australian paediatric intensive care unit (PICU). METHODS: A prospective, observational study was undertaken in a mixed cardiac and general PICU. Children were eligible for inclusion if they were intubated and mechanically ventilated. Data on patient and suction variables (indication for ETT suction, number of suction episodes per mechanical ventilation episode, indication for normal saline instillation [NSI] and NSI dose) including potential predictive variables (age, Paediatric Index of Mortality 3 [PIM3], NSI, positive end-expiratory pressure, and hyperoxygenation) were collected. The main outcome variable was a composite measure of any AE. MAIN RESULTS: A total of 955 suction episodes were recorded in 100 children. AEs occurred in 211 (22%) ETT suctions. Suction-related AEs were not associated with age, diagnostic category, or index of mortality score. Desaturation was the most common AE (180 suctions; 19%), with 69% of desaturation events requiring clinician intervention. Univariate logistic regression showed the odds of desaturation decreased as the internal diameter of the ETT increased (odds ratio [OR]: 0.59; 95% confidence interval [CI]: 0.37-0.95; p = 0.028). Multivariable modelling revealed NSI was significantly associated with an increased risk of desaturation (adjusted OR [aOR]: 3.23; 95% CI: 1.99-5.40; p < 0.001) and the occurrence of an AE (aOR: 2.76; 95% CI: 1.74-4.37; p < 0.001). Presuction increases in fraction of inspired oxygen (FiO2) was significantly associated with an increased risk of experiencing an AE (aOR: 2.0; 95% CI: 1.27-3.15; p = 0.003). CONCLUSIONS: ETT suction-related AEs are common and associated with NSI and the requirement for pre-suction increases in FiO2. Clinical trial data are needed to identify high-risk patient groups and to develop interventions which optimise practice and reduce the occurrence of ETT suction-related AEs.

Feasibility and acceptability of conducting a partially randomised controlled trial examining interventions to improve psychological health after discharge from the intensive care unit.

BACKGROUND: Interventions to support psychological recovery after critical illness, including information provision via an intensive care unit (ICU) diary or discharge summary, have been widely adopted in some regions, albeit without strong empirical evidence. OBJECTIVE: The objective of this study was to examine the feasibility and acceptability, for patients, family members, and clinicians, of information provision via an ICU diary or discharge summary to support psychological recovery for critical illness survivors. METHODS: This was a pilot, partially randomised patient preference study in a mixed ICU in a tertiary hospital in Australia. Eligible patients were those in the ICU for >24 h and who were able to converse in English. Interventions were ICU diary or discharge summary compared with usual care. Feasibility was assessed throughout the study process, and acceptability assessed 3 and 6 months after hospital discharge, with data analysed descriptively and thematically. RESULTS: Sixty-one patients were recruited; 45 completed 3-month follow-up (74%), and 37 (61%), 6-month follow-up. Participants were medical (39%), surgical (30%), and trauma (31%) patients; aged 55 [interquartile range (IQR): 36-67] years; and stayed in the ICU for 7 [IQR: 3-13] days and hospital for 23 [IQR: 14-32] days. Within the partially randomised framework, 34 patients chose their intervention - four chose usual care, 10 ICU diary, and 20 discharge summary. The remaining 27 patients were randomised - nine usual care, 10 ICU diary, and seven discharge summary. The majority (>90%) considered each intervention helpful during recovery; however, a significant proportion of patients reported distress associated with reading the ICU diary (42%) or discharge summary (15%). Clinicians reported they were hesitant to make diary entries. CONCLUSIONS: When given a choice, more patients chose a discharge summary over the ICU diary or usual care. Participants considered both interventions acceptable. Given the reports of distress associated with information provision, clear empirical evidence is required to determine effectiveness, optimal timing, support needed, and for whom they should be used. CLINICAL TRIAL REGISTRATION NUMBER: ACTRN12615001079538.

Central venous access device Securement and dressing effectiveness: The CASCADE pilot randomised controlled trial in the adult intensive care.

INTRODUCTION: Central venous access devices (CVADs) are a vital medical device for intensive care (ICU) patients; however, complications and failure are common, yet potentially prevented through effective dressings and securement. OBJECTIVES/AIMS: The objective of this study was to test the feasibility of a randomised controlled trial (RCT) comparing standard care with three dressing and securement products to prevent CVAD failure. Secondary aims included comparing dressing and securement products on CVAD failure, microbial colonisation, and intervention costs. METHODS: A single-centre pilot RCT of ICU adult patients requiring CVADs for >24 h were randomised to four groups: (i) sutures plus chlorhexidine gluconate (CHG) dressing (standard care); (ii) standard care plus tissue adhesive (TA); (iii) two sutureless stabilisation devices (SSD) plus CHG dressing; (iv) sutures, CHG disc plus integrated securement dressing (ISD). Descriptive statistics assessed feasibility. Incidence rates (IRs) of CVAD failure were reported, with group differences compared using the Fisher exact and log-rank tests. Cox regression explored univariable risks for failure. A substudy examined bacterial colonisation of catheter tips, dressings, and skin. Cost estimates of the intervention were compared. RESULTS: A total of 121 participants were randomised. Study feasibility was established with no withdrawal and moderate staff acceptability; however, recruitment was low at 12%. Overall CVAD failure was seen in 14 of 114 (12%) CVADs (19 per 1000 catheter-days); highest in the SSD group (IR: 27.3 per 1000 catheter-days [95% confidence interval {CI}: 11.4-65.6]), followed by the standard care group (IR: 22.3 per 1000 catheter-days [95% CI: 8.38-59.5]) and TA group (IR: 20.6 per 1000 catheter-days [95% CI: 6.66-64.0]), and lowest in the ISD group (IR: 8.8 per 1000 catheter-days [95% CI: 2.19-35.0]). The majority of complications (11/14, 79%) were suspected central line-associated bloodstream infection (CLABSI), of which only one was laboratory confirmed (standard care group). The cost per patient was lowest in the standard care group by an average difference of AUD $14. CONCLUSION(S): A large multisite RCT examining forms of securement and dressing is feasible. ISD is the highest priority to test further as it had the lowest failure rate. TRIAL REGISTRATION: ACTRN12615000667516 PROTOCOL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 368765.