Development and implementation of a clinical information system-based protocol to improve nurse satisfaction of end-of-life care in a single intensive care unit.

BACKGROUND: Patients treated in Australian intensive care units (ICUs) have an overall mortality rate of 5.05%. This is due to the critical nature of their disease, the increasing proportion of patients with multiple comorbidities, and advanced age. This has made treating patients during the end of life an integral part of intensive care practice and requires a high quality of care. With the increased use of electronic clinical information systems, a standardised protocol encompassing end-of-life care may provide an efficient method for documentation, communication, and timely delivery of comfort care. OBJECTIVE: The aim of the study was to determine if an electronic clinical information system-based end-of-life care protocol improved nurses' satisfaction with the practice of end-of-life care for patients in the ICU. DESIGN: This is a prospective single-centre observational study. SETTING: The study was carried out at a 20-bed cardiothoracic and general ICU between 2015 and 2017. PARTICIPANTS: The study participants were ICU nurses. INTERVENTION: Electronic clinical information-based end-of-life care protocol was used in the study. OUTCOME: The primary outcome was nurse satisfaction obtained by a survey. RESULTS: The number of respondents for the before survey and after survey was 58 (29%) and 64 (32%), respectively. There was a significant difference between the before survey and the after survey with regard to feeling comfortable in transitioning from curative treatment (median = 2 [interquartile range {IQR} = 2, 3] vs 3 [IQR = 2, 3], p = 0.03), feeling involved in the decision to move from curative treatment to end-of-life care (median = 2 [IQR = 2, 2] vs 2 [IQR 2, 3], p = 0.049), and feeling religious beliefs/rituals should be respected during the end-of-life process (median = 4 [IQR = 3, 4] vs. 4 [IQR = 4, 4], p = 0.02). There were some practices that had a low satisfaction rate on both the before survey and after survey. However, a high proportion of nurses were satisfied with many of the end-of-life care practices. CONCLUSION: The nurses were highly satisfied with many aspects of end-of-life care practices in this unit. The use of an electronic clinical information system-based protocol improved nurse satisfaction and perception of quality of end-of-life care practices for three survey questions.

Safety of Continuous Erector Spinae Catheters in Chest Trauma: A Retrospective Cohort Study.

BACKGROUND: The erector spinae block is an efficacious analgesic option for the management of rib fracture--related pain. Despite there being minimal published data specifically addressing the safety profile of this block, many societies have made statements regarding its safety and its use as an alternative to traditional regional anesthesia techniques in patients at risk of complications. The primary aim of this study was to characterize the safety profile of erector spinae plane block catheters by determining the incidence of early complications. The secondary aim of this study was to characterize the incidence of late adverse events, as well as the erector spinae plane block catheter failure rate. METHODS: We analyzed electronic medical record data of patients who had an erector spinae plane block catheter inserted for the management of rib fractures between November 2017 and September 2020. To assess early adverse events, data collection included hypotension, hypoxemia, local anesthetic systemic toxicity, and pneumothorax thought to be associated with erector spinae plane block catheter insertion. Late complications included catheter site infection and catheter site hematoma. RESULTS: A total of 224 patients received 244 continuous erector spinae catheters during the study period. After insertion of the erector spinae, there were no immediate complications such as hypotension, hypoxia, local anesthetic toxicity, or pneumothorax. Of all blocks inserted, 7.7% were removed due to catheter failure (8.4 per 100 catheters; 95% confidence interval [CI], 5.1-13.9 per 100 catheters). This resulted in a failure rate of 1.9 per 1000 catheter days (95% CI, 1.1-6.7 catheter days). Late complications included 2 erythematous catheter sites and 2 small hematomas not requiring intervention. The incidence of a minor late complication was 16.7 per 1000 catheters (95% CI, 6.1-45.5 per 1000 catheters). CONCLUSIONS: This study supports the statements made by regional anesthesia societies regarding the safety of the erector spinae plane block. Based on the results presented in this population of trauma patients, the erector spinae plane block catheter is a low-risk analgesic technique that may be performed in the presence of abnormal coagulation status or systemic infection.

An assessment of the tolerability of the Cook staged extubation wire in patients with known or suspected difficult airways extubated in intensive care.

The Cook staged extubation set (Cook Medical) has been developed to facilitate management of the difficult airway. A guidewire inserted before tracheal extubation provides access to the subglottic airway should re-intubation be required. This prospective cohort study examines patients' tolerance of the guidewire and its impact on clinical status around tracheal extubation in the intensive care unit. Vital signs, incidence of symptoms and patient tolerance of the wire were recorded. Twenty-three patients were enrolled and 17 (73%) tolerated the wire for 4 h. Nasendoscopy was performed in 11 of these patients and revealed one wire was in the oesophagus. The most common symptom was a mild intermittent cough in 13 patients. There was no impact of the guidewire on nursing care in 16 patients, tolerable impact in five and severe impact necessitating removal of the wire in one patient.

The effect of Rapid Response System revision on standard and specific intensive care unit outcomes in a regional hospital.

Hospital systems for the recognition (afferent limb) and management (efferent limb) of deteriorating patients, or Rapid Response Systems (RRSs), are being mandated worldwide, in spite of conflicting evidence regarding their efficacy. We have evaluated the impact of an Adult Deterioration Detection System (Q-ADDS)-based RRS specifically on illness severity at intensive care unit (ICU) admission and ICU length of stay (LOS), as well as previously studied endpoints. We undertook a retrospective, single-centre observational study comparing equivalent 18-month periods before the Q-ADDS-based RRS, and after implementation. The primary endpoints of the study were illness severity of unplanned ICU admissions from the ward, ICU length of stay, and ICU mortality. Secondary endpoints were RRS call numbers, rate of unplanned ICU admissions, and ward-based cardiorespiratory arrests. Following the introduction of the new RRS, Acute Pain and Chronic Health Evaluation (APACHE) II (17 versus 21, P <0.001), APACHE III (64 versus 68, P=0.011) and Simplified Acute Physiology Score (35 versus 38, P=0.044) scores at ICU admission from the ward were reduced. Fewer patients were in the >50% predicted mortality range of APACHE II (16% versus 32%, P <0.001), APACHE III (18% versus 28%, P=0.012) and Simplified Acute Physiology Score (14% versus 24%, P=0.006). ICU mortality was unchanged (13.7% versus 13.8%, P=0.93). ICU LOS was reduced (3 versus 4 days, P=0.02); prolonged stay (>7 days) was not significantly changed (19% versus 27%, P=0.055). Unplanned ICU admissions, cardiorespiratory arrests and hospital mortality were unchanged. The frequency of RRS activation (48 versus 11 per 1,000 admissions, P <0.001) was markedly increased. This Q-ADDS form-based RRS has resulted in lower illness severity at ICU admission from the ward, and fewer patients with scores associated with a >50% predicted mortality. Overall, ICU length of stay was reduced. These specific outcomes may reliably reflect RRS efficacy, even in smaller centres.

Managing central venous catheters: a prospective randomised trial of two methods.

A randomised, prospective study was conducted to evaluate the impact on central venous catheter (CVC) infection when fluids and lines connected to a CVC were changed using a 'sterile' compared to an 'aseptic, non-touch' technique. The study sought to determine whether there were any differences in CVC tip colonisation (CTC) or CVC-related bacteraemia (CRB) as a result of the technique used for fluid and line changes. In the sterile technique (control) group, fluids and tubing were changed using full sterile technique. In the aseptic, non-touch (experimental) group, fluids and tubing attached to the CVC were changed using only a small sterile drape and a 2-minute clinical hand wash. When the CVC was removed, the tip was sampled and cultured using the semi-quantitative method. Blood cultures were also collected. In all, 111 samples from 79 patients were included in the trial: 61 in the sterile technique group and 50 in the non-touch, aseptic technique group. Results showed a CTC rate of 31 per cent in the control group and 14 per cent in the experimental group, while the CRB rate was 8.2 per cent and 6 per cent respectively. The most common organisms cultured were Staphylococcus aureus and S. epidermis respectively. This study indicates that it is safe to change fluids and lines attached to CVCs using the aseptic, non-touch technique, which has resulted in significant financial savings through less use of equipment and less nursing time required to perform fluid and line changes.

Acute dapsone overdose: the effects of continuous veno-venous haemofiltration on the elimination of dapsone.

A 15-year-old girl presented after intentional ingestion of dapsone (7.2 g) and small quantities of azathioprine, methotrexate and prednisolone. The resulting methaemoglobinaemia and lactic acidosis persisted despite treatment with methylene blue, multiple-dose activated charcoal and ascorbic acid. Continuous veno-venous haemofiltration for 75 hours was used to treat the dapsone overdose. The patient's serum dapsone concentrations were measured during and after continuous veno-venous haemofiltration. The rate of elimination of dapsone was over three times higher during, compared to after, continuous veno-venous haemofiltration. Continuous renal replacement therapy successfully reduced toxic dapsone concentrations in this patient with a good outcome.

Estimating the net effect of unmeasured ions in human extracellular fluid using a new mathematical model. Part II: Practical issues.

Building on the theoretical considerations developed in Part I of this two-part series, a population range was established for a new extracellular fluid acid-base parameter using Monte Carlo simulation. This new parameter the unmeasured ion excess, had a normal range of +/- 2.50 mEq/l which was slightly narrower than the normal range for the standard base excess at +/- 3.20 mmol/l. In both cases, most of this variation occurred as a result of the estimation of the bicarbonate concentration. Finally, several short clinical vignettes were explored to highlight the differences between the unmeasured ion excess and the standard base excess.

Estimating the net effect of unmeasured ions in human extracellular fluid using a new mathematical model. Part I: Theoretical considerations.

A theoretical framework for the formulation of a derived variable to be used for the prediction of the net effect of unmeasured charged species present in human extracellular fluid was explored. This new variable was based on contemporary strong ion and classical buffer base theories and tested against the standard base excess using simulation. It proved to be more accurate in predicting the existence of unmeasured charged species in the extracellular fluid when disturbances of either strong ions, weak acids or both were present.

An assessment of the population variance of the strong ion gap using Monte Carlo simulation.

The strong ion gap is a derived parameter used to quantify clinically significant but unmeasured charged species in human plasma. In the general population the strong ion gap has a mean value of approximately 0.0 mEq/l, but at present no reference range exists. This severely limits its clinical application. In order to establish a reference range, a 95% confidence interval around the population mean must be calculated. As each of the variables that make up the strong ion gap have their own unique and different means and standard deviations, simple methods of pooled variance can not be used to calculate this interval. In place of a direct solution, Monte Carlo methodology was employed using known reference standard deviations to construct a large sample of a simulated population. In addition, the partial correlation between the plasma concentrations of sodium and chloride was included in the calculations. Sample sets of 20,000 were simulated, each giving a normally distributed strong ion gap. A 95% confidence interval of 3.9+/-6.4 mEq/l was derived. Depending on the degree of strong ion correlation, minima and maxima for this reference range were calculated as 3.9+/-5.1 mEq/l and 3.9+/-7.6 mEq/l respectively. Reasons for the positive bias in the mean strong ion gap result are examined briefly.

Near-hanging as presenting to hospitals in Queensland: recommendations for practice.

Near-hanging is an increasing presentation to hospitals in Australasia. We reviewed the clinical management and outcome of these patients as they presented to public hospitals in Queensland. A retrospective clinical record audit was made at five public hospitals between 1991 and 2000. Of 161 patients enrolled, 82% were male, 8% were indigenous and 10% had made a previous hanging attempt. Chronic medical illnesses were documented in 11% and previous psychiatric disorders in 42%. Of the 38 patients with a Glasgow Coma Scale score (GCS) of 3 on arrival at hospital, 32% returned to independent living and 63% died. Fifty-two patients received CPR, of whom 46% had an independent functional outcome. Independent predictors of mortality were a GCS on hospital arrival of 3 (AOR 150, CI 95% 12.4-1818, P<0.001), taking plain X-rays of the cervical spine (AOR 0.06, CI 95% 0.004-0.97, P=0.047) and contact with the ground (AOR 0.03, CI 95% 0.002-0.62, P=0.02). Only 66% had imaging of the cervical spine performed with other imaging performed infrequently. There were three laryngeal, two hyoid bone and three cervical spine injuries and one carotid dissection. The number of cervical spine X-rays required to find a significant cervical spine fracture was 54. Near-hanging presenting to hospital with a poor conscious state or even cardiac arrest can have a favourable clinical outcome. Radiological investigations are infrequently performed despite a low GCS precluding early accurate assessment. Given the general favourable outcome, an aggressive approach to searching for correctable injuries is recommended.

The accuracy of in vivo P50 at high haemoglobin saturation.

The in vivo P50 (P50iv) provides a useful index of haemoglobin-oxygen affinity and is calculated according to software algorithms incorporated into commercial blood gas analysers. These algorithms are known to be inaccurate at high haemoglobin saturation (SpO2 > 97%) although just how inaccurate has not been documented. This study examines the arterial blood gas profiles of patients admitted to a busy secondary referral Intensive Care Unit and stratifies them according to haemoglobin saturation in order to quantify the accuracy and potential clinical utility of the Siggaard-Andersen algorithm (SAA) for assessing P50iv in blood with SpO2 > 90%. Sicker patients, as identified by plasma pH < 7.35 or [lactate] > 2.0 mmol/l, were substratified and the SAA assessed as before. In both groups, the results show not only that the SAA is completely unreliable above 97% saturation, a fact acknowledged by Siggaard-Andersen in 1984, but it is also inaccurate in the range 92% < or = SpO2 < or = 97%, thus rendering P50iv calculations suspect in 90% of the patients in each of the study groups.

A new model for the oxyhaemoglobin dissociation curve.

This paper describes a new model for the oxygen-haemoglobin dissociation curve in humans. The model is based on the known structural alterations that occur in the quaternary haemoglobin molecule during oxygenation and deoxygenation. The two alternative structures, tense and relaxed, are described using hyperbolic tangent curves and linked with a probability function to obtain the completed mathematical description of the oxygen-haemoglobin dissociation curve. Model accuracy is assessed by a bias/precision analysis of calculated logit (S) and P50 against gold standard data. A mechanism for the transition between the two structures involving the chloride ion as a major allosteric effector is proposed. Results were analysed against the Siggaard-Andersen model for bias, precision and calculated P50 in four saturation ranges--0.00 < SO2 < 1.00, 0.20 < SO2 < 0.80, 0.90 < SO2 < 1.00 and 0.97 < SO2 < 1.00. In each range except for 0.20 < SO2 < 0.80, bias, precision and calculated P50 for the new model are significantly better (P < 0.05). Analysis of calculated P50 across the entire saturation range revealed significant drift out of the acceptable range in the Siggaard-Andersen model for SO2 > 0.92. The new model remained within tolerance across the saturation range 0.00 < SO2 < 1.00. The new model is significantly more accurate than the popular Siggaard-Andersen model, particularly in the range SO2 > 0.90.

Dietary exposure of finfish to aromatic contaminants and tissue distribution.

Large rainbow trout (400 g) were exposed to food pellets spiked with four polycyclic aromatic compounds (PACs). Muscle, liver, internal organs, fatty tissue, and blood were analyzed after 5, 10, 15, and 19 weeks for PAC, lipid, and moisture content. At all collection times, concentrations expressed on a per gram basis were higher in fatty tissue and internal organs, followed by liver and muscle, and lowest levels were observed in blood. When examining the tissue burden, the highest bioaccumulations of carbazole, dibenzofuran, dibenzothiophene, and fluorene were in muscle and internal organs, intermediate in fatty tissue, and lowest in blood and liver. Carbazole with the lowest log K(OW) showed the lowest concentration within any tissue. Levels in tissues were significantly correlated to log K(OW) (> 5% level of significance), especially with longer exposure, and were more highly correlated when examining muscle, fatty tissue, and internal organs (> 0.05%). Different tissues displayed different time trends, and ratios between organs help determine the length of exposure. The most striking change in levels observed with time was in internal organs relative to other tissues, particularly when compared to daily exposure. The elimination of contaminants in feces and gallbladder bile was also compared, because they represent additional tools to assess recent exposure.