Assessing and documenting fluid balance.

Concerns about inadequate patient hydration and suboptimal monitoring of fluid balance have been documented in recent reports. The Fluid Balance Improvement Project at Central Manchester University Hospitals NHS Foundation Trust was undertaken to identify risk factors influencing hydration and to implement a revised process to manage these risks, resulting in the development of a hydration pathway. This new approach to monitoring patient hydration, together with staff education and support, has resulted in improved compliance with fluid balance monitoring standards, as well as significant improvements in identifying patients at risk of dehydration, and an increase in patients with acute kidney injury commencing appropriate fluid balance monitoring.

Making the journey safe: recognising and responding to severe sepsis in accident and emergency.

Severe sepsis is a clinical emergency. Despite the nationwide recognition of the sepsis six treatment bundle as the first line emergency treatment for this presentation, compliance in sepsis six provision remains inadequately low. The project goals were to improve compliance with the implementation of the Sepsis Six in patients with severe sepsis and/or septic shock. In improving timely care delivery it was anticipated improvements would be made in relation to patient safety and experience, and reductions in length of stay (LoS) and mortality. The project intended to make the pathway for those presenting with sepsis safe and consistent, where sepsis is recognised and treated in a timely manner according to best practice. The aim of the project was to understand the what the barriers where to providing safe effective care for the patient presenting with severe sepsis in A&E. Using the Safer Clinical Systems (SCS) tools developed byte Health Foundation and Warwick University, the project team identified the hazards and associated risks in the septic patient pathway. The level of analysis employed enabled the project team to identify the major risks, themes, and factors of influence within this pathway. The analysis identified twenty nine possible interventions, of which six were chosen following option appraisal. Further interventions were recommended to the accident and emergency as part of a business case and further changes in process. Audits identified all severely septic patients presenting to A&E in October 2014 (n=67) and post intervention in September 2015 (n=93). Compared analysis demonstrated an increase in compliance with the implementation of the sepsis six care bundle from 7% to 41%, a reduction in LoS by 1.9 days and a decrease in 30 day mortality by 50%. Additional audit reviewed the management of 10 septic patients per week for the duration of the project to assess the real time impact of the selected interventions.

Maternal heart rate during the first 48h postpartum: a retrospective cross sectional study.

OBJECTIVES: 1) Describe the distribution of heart rate in the first 48h postpartum in women with no evidence of sepsis, anaemia or haemorrhage. 2) Investigate the relationship between postpartum heart rate and other maternal factors. STUDY DESIGN: A retrospective cross-sectional study of postpartum women who delivered between July 2012 and June 2015 in a tertiary hospital. Data was analysed from the local maternity system and electronic vital signs database. The main outcome measures: Heart rate at 6, 12, 24 and 48h postpartum. RESULTS: Data were obtained on 11401 women. After exclusion of women with possible sepsis, anaemia or haemorrhage, 7627 heart rate readings from 5164 women were analysed. Mean heart rate (+2SD/+3SD) at 6h was 83.6 (108.2/120.6), 12h 84.5 (109.4/121.9), 24h 85.4 (110.4/122.9), and 48h 84.3 (109.7/122.4). There was statistical correlation of post partum heart rate with body mass index (BMI), age and discharge haemoglobin. CONCLUSION: This study describes the distribution of maternal heart rate in the early postpartum period, in women with no evidence of sepsis, anaemia or major haemorrhage. This will facilitate identification and appropriate investigation of women with abnormal heart rates. Although correlation with BMI, age and discharge haemoglobin was demonstrated, the differences were small and not clinically meaningful. Further work investigating the relationship between postpartum heart rate and poor maternal outcomes is required.

Bedside electronic capture of clinical observations and automated clinical alerts to improve compliance with an Early Warning Score protocol.

BACKGROUND: Failure to comply with clinical protocols and failure of communication to ensure delivery of the most appropriate timely clinical responses to patients whose conditions are acutely deteriorating have been shown to be significant causative factors associated with inhospital adverse events. OBJECTIVE: To determine whether automated clinical alerts increase compliance with an Early Warning Score (EWS) protocol and improve patient outcomes. METHODS: We performed a historically controlled study of bedside electronic capture of observations and automated clinical alerts. The primary outcome measure was hospital length of stay (LOS); secondary outcome measures were compliance with the EWS protocol, cardiac arrest incidence, critical care utilisation and hospital mortality. RESULTS: Between baseline and intervention, 1481 consecutive patients were recruited generating 13 668 observation sets. There was a reduction in hospital LOS between the baseline and alert phase (9.7 days v 6.9 days, P < 0.001). EWS accuracy improved from 81% to 100% with electronic calculation. Clinical attendance to patients with EWS 3, 4 or 5 increased from 29% at baseline to 78% with automated alerts (P < 0.001). For patients with an EWS > 5, clinical attendance increased from 67% at baseline to 96% with automatic alerts (P < 0.001). CONCLUSIONS: Electronic recording of patient observations linked to a computer system that calculates patient risk and then issues automatic graded alerts can improve clinical attendance to unstable general medical ward patients.

Returning home after intensive care: a comparison of symptoms of anxiety and depression in ICU and elective cardiac surgery patients and their relatives.

OBJECTIVE: This study gathered data on symptoms of anxiety and depression in patients and relatives after discharge from intensive care and examined whether the intensive care population differ from an elective cardiac surgery group with regards to their anxiety and depression symptom reporting. DESIGN AND SETTING: A single measurement point matched group comparison study in an ICU follow-up programme. PATIENTS AND PARTICIPANTS: Twenty ICU patients and their relatives and a matched comparison group of 15 elective cardiac surgery patients and their relatives. MEASUREMENTS AND RESULTS: Patients and relatives completed the Hospital Anxiety and Depression Scale. Relatives answered an open question to explore the perceived impact of Intensive care/cardiac surgery on their lives. ICU patients' relatives reported significantly higher number of symptoms of anxiety than did ICU patients, higher number of symptoms of depression than cardiac surgery patients' relatives, and more troubling and life-altering experiences than the relatives of cardiac surgery patients. CONCLUSIONS: Relatives of ICU patients also suffer anxiety and depression, and services should address this need. Group differences suggest that ICU patients' relatives have "unique" characteristics of depression symptom reporting.

Post-traumatic stress disorder-related symptoms in relatives of patients following intensive care.

OBJECTIVE: To evaluate the effectiveness of the provision of information in the form of a rehabilitation program following critical illness in reducing psychological distress in the patients' close family. DESIGN: Randomised controlled trial, blind at follow-up with final assessment at 6 months. SETTING: Two district general hospitals and one teaching hospital. PATIENTS AND PARTICIPANTS: The closest family member of 104 recovering intensive care unit (ICU) patients. INTERVENTIONS: Ward visits, ICU clinic appointments at 2 and 6 months. Relatives and patients received the rehabilitation program at 1 week after ICU discharge. The program comprised a 6-week self-help manual containing information about recovery from ICU, psychological information and practical advice. MEASUREMENTS AND RESULTS: Psychological recovery of relatives was assessed by examining the rate of depression, anxiety, and post-traumatic stress disorder (PTSD)-related symptoms by 6 months after ICU. The proportion of relatives scoring in the range >19 on the Impact of Events Scale (cause for concern) was high in both groups at 49% at 6 months. No difference was shown in the rate of depression, anxiety, or PTSD-related symptoms between the study groups. CONCLUSION: A high incidence of psychological distress was evident in relatives. Written information concerning recovery from ICU provided to the patient and their close family did not reduce this. High levels of psychological distress in patients were found to be correlated with high levels in relatives.

Rehabilitation after critical illness: a randomized, controlled trial.

OBJECTIVE: To evaluate the effectiveness of a rehabilitation program following critical illness to aid physical and psychological recovery. DESIGN: Randomized controlled trial, blind at follow-up with final assessment at 6 months. SETTING: Two district general hospitals and one teaching hospital. PATIENTS: Patients were 126 consecutively admitted intensive care patients meeting the inclusion criteria. INTERVENTIONS: Control patients received ward visits, three telephone calls at home, and clinic appointments at 8 wks and 6 months. Intervention patients received the same plus a 6-wk self-help rehabilitation manual. MEASUREMENTS AND MAIN RESULTS: We measured levels of depression and anxiety (Hospital Anxiety and Depression Scale), phobic symptoms (Fear Index), posttraumatic stress disorder (PTSD)-related symptoms (Impact of Events Scale), and scores on the Short-Form Health Survey physical dimension 8 wks and 6 months after intensive care unit (ICU) treatment. Memory for ICU was assessed at 2 wks post-ICU discharge using the ICU Memory Tool.The intervention group improved, compared with the control patients, on the Short-Form Health Survey physical function scores at 8 wks and 6 months (p =.006), and there was a trend to a lower rate of depression at 8 wks (12% vs. 25%). However, there were no differences in levels of anxiety and PTSD-related symptoms between the groups. The presence of delusional memories was correlated significantly with both anxiety and Impact of Events Scale scores. CONCLUSIONS: A self-help rehabilitation manual is effective in aiding physical recovery and reducing depression. However, in those patients recalling delusional memories from the ICU, further psychological care may be needed to reduce the incidence of anxiety and PTSD-related symptoms.