[Working at night in intensive care and resuscitation]. / Travailler de nuit en médecine intensive et réanimation.

The care teams working in the intensive care unit (ICU) most often practice on twelve-hour day-night cycles. Collaboration is close and regular, with a high level of trust shared between the professionnals to ensure the often complex care required by the patient's condition. While ICU practice is of great interest to caregivers who make it their specialty, it can also become less attractive over time due to the physical, family and social constraints of night work.

Epidemiology and outcome of pressure injuries in critically ill patients with chronic obstructive pulmonary disease: A propensity score adjusted analysis.

BACKGROUND: Pressure injuries are a frequent complication in intensive care unit (ICU) patients, especially in those with comorbid conditions such as chronic obstructive pulmonary disease (COPD). Yet no epidemiological data on pressure injuries in critically ill COPD patients are available. OBJECTIVE: To assess the prevalence of ICU-acquired pressure injuries in critically ill COPD patients and to investigate associations between COPD status, presence of ICU-acquired pressure injury, and mortality. STUDY DESIGN AND METHODS: This is a secondary analysis of prospectively collected data from DecubICUs, a multinational one-day point-prevalence study of pressure injuries in adult ICU patients. We generated a propensity score summarizing risk for COPD and ICU-acquired pressure injury. The propensity score was used as matching criterion (1:1-ratio) to assess the proportion of ICU-acquired pressure injury attributable to COPD. The propensity score was then used in regression modeling assessing the association of COPD with risk of ICU-acquired pressure injury, and examining variables associated with mortality (Cox proportional-hazard regression). RESULTS: Of the 13,254 patients recruited to DecubICUs, 1663 (12.5%) had documented COPD. ICU-acquired pressure injury prevalence was higher in COPD patients: 22.1% (95% confidence interval [CI] 20.2 to 24.2) vs. 15.3% (95% CI 14.7 to 16.0). COPD was independently associated with developing ICU-acquired pressure injury (odds ratio 1.40, 95% CI 1.23 to 1.61); the proportion attributable to COPD was 6.4% (95% CI 5.2 to 7.6). Compared with non-COPD patients without pressure injury, mortality was no different among patients without COPD but with pressure injury (hazard ratio [HR] 1.07, 95% CI 0.97 to 1.17) or COPD patients without pressure injury (HR 1.13, 95% CI 1.00 to 1.27). Mortality was higher among COPD patients with pressure injury (HR 1.35, 95% CI 1.15 to 1.58). CONCLUSION AND IMPLICATIONS: Critically ill COPD patients have a statistically significant higher risk of pressure injury. Moreover, those that develop pressure injury are at higher risk of mortality. As such, pressure injury may serve as a surrogate for poor prognostic status to help clinicians identify patients at high risk of death. Also, delivery of interventions to prevent pressure injury are paramount in critically ill COPD patients. Further studies should determine if early intervention in critically ill COPD patients can modify development of pressure injury and improve prognosis.

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study.

PURPOSE: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. METHODS: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. RESULTS: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9-27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6-16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score < 19, ICU stay > 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2-1.8), stage II (OR 1.6; 95% CI 1.4-1.9), and stage III or worse (OR 2.8; 95% CI 2.3-3.3). CONCLUSION: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat.

[How to promote the construction of knowledge in intensive care?] / Valoriser la construction des savoirs en réanimation.

The nursing profession is based on the acquisition of knowledge and skills. The rapid evolution of scientific knowledge requires regular updating of knowledge in order to base practice on solid and reliable data. The intensive care nurses point out the lack of adequacy between the initial training and the reality of daily life, which is sometimes a source of deviation from good practices. In intensive care, a field where care techniques evolve very rapidly, nurses must be able to update their knowledge and participate in the construction of new knowledge.

Expert consensus-based clinical practice guidelines management of intravascular catheters in the intensive care unit.

The French Society of Intensive Care Medicine (SRLF), jointly with the French-Speaking Group of Paediatric Emergency Rooms and Intensive Care Units (GFRUP) and the French-Speaking Association of Paediatric Surgical Intensivists (ADARPEF), worked out guidelines for the management of central venous catheters (CVC), arterial catheters and dialysis catheters in intensive care unit. For adult patients: Using GRADE methodology, 36 recommendations for an improved catheter management were produced by the 22 experts. Recommendations regarding catheter-related infections' prevention included the preferential use of subclavian central vein (GRADE 1), a one-step skin disinfection(GRADE 1) using 2% chlorhexidine (CHG)-alcohol (GRADE 1), and the implementation of a quality of care improvement program. Antiseptic- or antibiotic-impregnated CVC should likely not be used (GRADE 2, for children and adults). Catheter dressings should likely not be changed before the 7th day, except when the dressing gets detached, soiled or impregnated with blood (GRADE 2- adults). CHG dressings should likely be used (GRADE 2+). For adults and children, ultrasound guidance should be used to reduce mechanical complications in case of internal jugular access (GRADE 1), subclavian access (Grade 2) and femoral venous, arterial radial and femoral access (Expert opinion). For children, an ultrasound-guided supraclavicular approach of the brachiocephalic vein was recommended to reduce the number of attempts for cannulation and mechanical complications. Based on scarce publications on diagnostic and therapeutic strategies and on their experience (expert opinion), the panel proposed definitions, and therapeutic strategies.

Interprofessional safety reporting and review of adverse events and medication errors in critical care.

BACKGROUND: The intensive care unit (ICU) environment is prone to the risk of adverse events (AEs) and medication errors (MEs). The objective of this work was to describe a multidisciplinary safety program focused on AE and ME reporting and review in an ICU over a 7-year period. METHODS: The program was implemented in an 18-bed medical ICU of a 2,200-bed university hospital. A multidisciplinary steering committee (intensivist, clinical pharmacist, nurses, and research assistants) met monthly. The first part of the meeting was dedicated to the review of events targeted through an internal voluntary reporting system, and the second part concerned the analysis of the previous month's events, according to a standardized method called Orion, inspired by the aeronautic industry. RESULTS: A total of 808 AEs were reported, mostly related to medication processes (30.3% and 33.4% for prescription and administration, respectively). Among these, 526 AEs were related to medications (65.1%), of which 464 were MEs (88.2%). These MEs concerned mostly anti-infective drugs (23.5%) and related to wrong doses (35.8%). Among all AEs reported, 58 (43 MEs [74.1%]) were analyzed further and found to be associated with anti-infective (16.1%) and vasoactive drugs (16.1%). According to National Coordinating Council for Medication Error Reporting and Prevention classification, most AEs caused no harm to patients (category A-D: 38 events, 65.5%). Nurses were most often involved in the analysis (50.7%), along with pharmacists (37.5%). Training was identified as the most frequent corrective action (45.1%). CONCLUSION: This program dedicated to AE and ME reporting, review, and analysis in ICU showed long-term engagement of the health care team in AE surveillance and helped in targeting measures for education, organization, and promoting teamwork and safety.

[Intensive care and new technologies]. / Réanimation et nouvelles technologies.

New technologies have a major impact on innovation in intensive care. They are accompanied by a greater openness of the units and challenging evolutions for paramedical professions, particularly concerning their practices. The consequence is an overall, higher quality care focused both on patients and families.

Dialysis Withdrawal: Impact and Evaluation of a Multidisciplinary Deliberation Within an Ethics Committee as a Shared-Decision-Making Model.

Since dialysis withdrawal in maintenance dialysis patients with limited life expectancy results always in short-term death, nephrologists need a referenced process to make their decision. This study reviews 8 years of operation of an Ethics Committee in Nephrology (ECN). The ECN, within a multidisciplinary team, once a month explores cases reported by caregivers when maintaining dialysis seems not to be in the patient's best interest. Discussion is required when the vital prognosis is engaged by the evolution of the chronic kidney disease (CKD) or the occurrence of an acute medical event. Data are analyzed using a discussion guide. The informed decision is completed with an appropriated palliative care project involving the patient, and recorded in their file. Since 2006, the ECN has deliberated yearly for 10 sessions on 6-18 cases, concerning 380 identified maintenance dialysis patients. Characteristics of the population, cases, sessions and proposals are recorded and analyzed. The only variable associated with dialysis withdrawal was having at least one new comorbid condition. End of life is supported with the help of the palliative care team in the hospital or exceptionally at home. The ECN, through a multidisciplinary deliberation and resolution process, proposes an ethical shared-decision-making model ensuring that dialysis withdrawal follows professional guidelines, and is registered as a method for evaluating professional practice (EPP). Annual activity reports are submitted to the Hospital's Medical Evaluation and Quality Unit. Benefits are individual and collective for patients, relatives and caregivers. Prospects for reducing non-implemented decisions and identifying cases earlier would improve the Committee effectiveness.

Dressing disruption is a major risk factor for catheter-related infections.

OBJECTIVE: Major catheter-related infection includes catheter-related bloodstream infections and clinical sepsis without bloodstream infection resolving after catheter removal with a positive quantitative tip culture. Insertion site dressings are a major mean to reduce catheter infections by the extraluminal route. However, the importance of dressing disruptions in the occurrence of major catheter-related infection has never been studied in a large cohort of patients. DESIGN: A secondary analysis of a randomized multicenter trial was performed in order to determine the importance of dressing disruption on the risk for development of catheter-related bloodstream infection. MEASUREMENTS AND MAIN RESULTS: Among 1,419 patients (3,275 arterial or central-vein catheters) included, we identified 296 colonized catheters, 29 major catheter-related infections, and 23 catheter-related bloodstream infections. Of the 11,036 dressings changes, 7,347 (67%) were performed before the planned date because of soiling or undressing. Dressing disruption occurred more frequently in patients with higher Sequential Organ Failure Assessment scores and in patients receiving renal replacement therapies; it was less frequent in males and patients admitted for coma. Subclavian access protected from dressing disruption. Dressing cost (especially staff cost) was inversely related to the rate of disruption. The number of dressing disruptions was related to increased risk for colonization of the skin around the catheter at removal (p < .0001). The risk of major catheter-related infection and catheter-related bloodstream infection increased by more than three-fold after the second dressing disruption and by more than ten-fold if the final dressing was disrupted, independently of other risk factors of infection. CONCLUSION: Disruption of catheter dressings was common and was an important risk factor for catheter-related infections. These data support the preferential use of the subclavian insertion site and enhanced efforts to reduce dressing disruption in postinsertion bundles of care.

Economic evaluation of chlorhexidine-impregnated sponges for preventing catheter-related infections in critically ill adults in the Dressing Study.

BACKGROUND: The randomized two-way factorial Dressing Study (1,636 patients, 28,931 catheter days) showed that a chlorhexidine-impregnated sponge decreased the incidence of major catheter-related infections from 1.4‰ to 0.6‰ catheter days, and that scheduled dressing changes every 7 days was not inferior to scheduled changes every 3 days. Here, we assessed the cost benefits of chlorhexidine-impregnated sponge use. METHODS: Costs directly related to major catheter-related infections and the costs of chlorhexidine-impregnated sponge and contact dermatitis were calculated prospectively using microcosting methods during the original study. The added length of stay in the intensive care unit due to major catheter-related infection was estimated using the disability model and assuming a cost of $2,118/intensive care unit day. The cost of each strategy was estimated based on all costs and on the probability of major catheter-related infection according to the Dressing Study results. INTERVENTIONS: None. RESULTS: Median direct cost of major catheter-related infection was $792. Estimated added length of stay due to major catheter-related infection was 11 days (95% confidence interval [-2 days; 26 days]). Overall cost of major catheter-related infection was $24,090/episode. Each dressing cost $9.08 (146 observations) and each chlorhexidine-impregnated sponge cost $9.73. Assuming a baseline major catheter-related infection incidence of 1.4‰ catheter days, chlorhexidine-impregnated sponge use saved $197 per patient with the 3-day chlorhexidine-impregnated sponge dressing change strategy, and $83 with the 7-day standard dressing change strategy. Chlorhexidine-impregnated sponge use remained cost saving assuming a baseline major catheter-related infection incidence as low as 0.35‰ catheter days, or an overall cost per major catheter-related infections of up to $4,400. CONCLUSION: Chlorhexidine-impregnated sponge for arterial and central venous catheters saves money by preventing major catheter-related infections, even in intensive care units with low baseline major catheter-related infection levels. TRIAL REGISTRATION: Clinicaltrials.gov number, NCT00417235.

Interventions to decrease tube, line, and drain removals in intensive care units: the FRATER study.

PURPOSES: To evaluate the incidence of unintended tube, line, and drain removals (UTRs) in our ICU, to identify system factors associated with UTRs, and to evaluate interventions designed to decrease UTR occurrence. METHODS: Interventional study in the 18-bed medical ICU of a French general university hospital. We prospectively determined the incidence and circumstances of UTRs in our ICU over a 2-year period. Demographic and clinical data were collected for consecutively admitted patients, and additional information was recorded about patients experiencing UTRs. Investigators analyzed UTR data twice a month to identify possible causes and developed interventions to decrease UTRs (mainly securing tubes and sedation protocol). Conditional logistic regression stratified on length of stay was used to identify risk factors for UTRs and segmented linear regression analysis to test the effects of interventions. RESULTS: Of 2,007 admitted patients (12,256 patient days), 193 (9.6%) experienced 270 UTRs (22/1,000 patient days). Clinical or therapeutic consequences occurred for 17% of UTRs. Three factors were independently associated with UTR; two were risk factors, namely, admission for coma [OR, 2.68; 95% CI (1.87; 3.84); P < 0.0001] and mechanical ventilation in over 65% of all ICU patients [OR = 1.65 (1.19; 2.29); P = 0.003], and one was protective, namely, mean SAPS II >45 in all ICU patients [OR, 0.54; 95% CI (0.39; 0.75); P = 0.0003]. Segmented regression analysis showed a 67.4% drop [95% CI (17.2%; 117.3%); P = 0.009] in the UTR rate after the first intervention was introduced. System factors played a major role in UTR occurrence. CONCLUSION: UTRs are common. A continuous quality-improvement program can reduce UTR rates in the ICU.

Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial.

CONTEXT: Use of a chlorhexidine gluconate-impregnated sponge (CHGIS) in intravascular catheter dressings may reduce catheter-related infections (CRIs). Changing catheter dressings every 3 days may be more frequent than necessary. OBJECTIVE: To assess superiority of CHGIS dressings regarding the rate of major CRIs (clinical sepsis with or without bloodstream infection) and noninferiority (less than 3% colonization-rate increase) of 7-day vs 3-day dressing changes. DESIGN, SETTING, AND PATIENTS: Assessor-blind, 2 x 2 factorial, randomized controlled trial conducted from December 2006 through June 2008 and recruiting patients from 7 intensive care units in 3 university and 2 general hospitals in France. Patients were adults (>18 years) expected to require an arterial catheter, central-vein catheter, or both inserted for 48 hours or longer. INTERVENTIONS: Use of CHGIS vs standard dressings (controls). Scheduled change of unsoiled adherent dressings every 3 vs every 7 days, with immediate change of any soiled or leaking dressings. MAIN OUTCOME MEASURES: Major CRIs for comparison of CHGIS vs control dressings; colonization rate for comparison of 3- vs 7-day dressing changes. RESULTS: Of 2095 eligible patients, 1636 (3778 catheters, 28,931 catheter-days) could be evaluated. The median duration of catheter insertion was 6 (interquartile range [IQR], 4-10) days. There was no interaction between the interventions. Use of CHGIS dressings decreased the rates of major CRIs (10/1953 [0.5%], 0.6 per 1000 catheter-days vs 19/1825 [1.1%], 1.4 per 1000 catheter-days; hazard ratio [HR], 0.39 [95% confidence interval {CI}, 0.17-0.93]; P = .03) and catheter-related bloodstream infections (6/1953 catheters, 0.40 per 1000 catheter-days vs 17/1825 catheters, 1.3 per 1000 catheter-days; HR, 0.24 [95% CI, 0.09-0.65]). Use of CHGIS dressings was not associated with greater resistance of bacteria in skin samples at catheter removal. Severe CHGIS-associated contact dermatitis occurred in 8 patients (5.3 per 1000 catheters). Use of CHGIS dressings prevented 1 major CRI per 117 catheters. Catheter colonization rates were 142 of 1657 catheters (7.8%) in the 3-day group (10.4 per 1000 catheter-days) and 168 of 1828 catheters (8.6%) in the 7-day group (11.0 per 1000 catheter-days), a mean absolute difference of 0.8% (95% CI, -1.78% to 2.15%) (HR, 0.99; 95% CI, 0.77-1.28), indicating noninferiority of 7-day changes. The median number of dressing changes per catheter was 4 (IQR, 3-6) in the 3-day group and 3 (IQR, 2-5) in the 7-day group (P < .001). CONCLUSIONS: Use of CHGIS dressings with intravascular catheters in the intensive care unit reduced risk of infection even when background infection rates were low. Reducing the frequency of changing unsoiled adherent dressings from every 3 days to every 7 days modestly reduces the total number of dressing changes and appears safe. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00417235.