Implementing work place based assessment: The modified direct observation of procedural skills (DOPS) across medical specialties - An experience from a developing country.

OBJECTIVE: To assess the skill level of residents regarding central venous catheterisation insertion, and to assess the reliability of scores in a simulated situation. METHODS: The quasi-experimental study with pre- and post-test design was conducted from February to June 2013 at the Aga Khan University, Karachi, and comprised four workshops attended by residents. The workshops were video-recorded for feedback and self-assessment. At the end of the workshops, knowledge and procedural skills were assessed using a self-generated 38-item, task-specific instrument after ensuring its content validity. Data was analysed using SPSS 19. RESULTS: There were 40 residents in the sample. The self-generated instrument was reliable with Cronbach's alpha value 0.83 and inter-rater coefficient 0.79. There was significant improvement in the skills level post-intervention compared to the baselines mean values (p=0.001). The subjects were satisfied with the workshops, as indicated by a mean score of 8.83±1.367. CONCLUSIONS: The workshops appeared to improve the central venous catheterisation insertion skills of the residents.

Nutrition in intensive care in adults review of the literature and development of evidence based feeding protocols.

The subject of nutrition in intensive care is broad.Thenutrition support therapy plays a crucial role in the management of critically ill patients. This review was carried out to address the existing controversies and to recognise the current practice guidelines for the management of nutrition in intensive care units (ICUs) in adults. A PubMed search was carried out for clinical trials addressing the current nutrition practice in ICUs, recommendations for calculating energy requirements and efficacy of an algorithmic approach to nutritional delivery in an ICU setting. Algorithms were developed and modified for the practice of nutrition in an adult ICU in a quaternary care hospital in Pakistan.

Sepsis management: An evidence-based approach.

The Surviving Sepsis Campaign (SSC) guidelines have outlined an early goal directed therapy (EGDT) which demonstrates a standardized approach to ensure prompt and effective management of sepsis. Having said that, there are barriers associated with the application of evidence-based practice, which often lead to an overall poorer adherence to guidelines. Considering the global burden of disease, data from low- to middle-income countries is scarce. Asia is the largest continent but most Asian countries do not have a well-developed healthcare system and compliance rates to resuscitation and management bundles are as low as 7.6% and 3.5%, respectively. Intensive care units are not adequately equipped and financial concerns limit implementation of expensive treatment strategies. Healthcare policy-makers should be notified in order to alleviate financial restrictions and ensure delivery of standard care to septic patients.

Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare.

BACKGROUND: Hand hygiene is a key measure in preventing infections. We evaluated healthcare worker (HCW) hand hygiene with the use of remote video auditing with and without feedback. METHODS: The study was conducted in an 17-bed intensive care unit from June 2008 through June 2010. We placed cameras with views of every sink and hand sanitizer dispenser to record hand hygiene of HCWs. Sensors in doorways identified when an individual(s) entered/exited. When video auditors observed a HCW performing hand hygiene upon entering/exiting, they assigned a pass; if not, a fail was assigned. Hand hygiene was measured during a 16-week period of remote video auditing without feedback and a 91-week period with feedback of data. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by electronic mail. RESULTS: During the 16-week prefeedback period, hand hygiene rates were less than 10% (3933/60 542) and in the 16-week postfeedback period it was 81.6% (59 627/73 080). The increase was maintained through 75 weeks at 87.9% (262 826/298 860). CONCLUSIONS: The data suggest that remote video auditing combined with feedback produced a significant and sustained improvement in hand hygiene.

Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome Patients Requiring Invasive Mechanical Ventilation in a Lower Middle-Income Country.

Background: COVID-19 related acute respiratory distress syndrome (ARDS) requires intensive care, which is highly expensive in lower-income countries. Outcomes of COVID-19 patients requiring invasive mechanical ventilation in Pakistan have not been widely reported. Identifying factors forecasting outcomes will help decide optimal care levels and prioritise resources. Methods: A single-centre, retrospective study on COVID-19 patients requiring invasive mechanical ventilation was conducted from 1st March to 31st May 2020. Demographic variables, physical signs, laboratory values, ventilator parameters, complications, length of stay, and mortality were recorded. Data were analysed in SPSS ver.23. Results: Among 71 study patients, 87.3% (62) were males, and 12.7% (9) were females with a mean (SD) age of 55.5(13.4) years. Diabetes mellitus and hypertension were the most common comorbidities in 54.9% (39) patients. Median(IQR) SOFA score on ICU admission and at 48 hours was 7(5-9) and 6(4-10), and median (IQR) APACHE-II score was 15 (11-24) and 13(9-23), respectively. Overall, in-hospital mortality was 57.7%; 25% (1/4), 55.6% (20/36) and 64.5% (20/31) in mild, moderate, and severe ARDS, respectively. On univariate analysis; PEEP at admission, APACHE II and SOFA score at admission and 48 hours; Acute kidney injury; D-Dimer>1.5 mg/L and higher LDH levels at 48 hours were significantly associated with mortality. Only APACHE II scores at admission and D-Dimer levels> 1.5 mg/L were independent predictors of mortality on multivariable regression (p-value 0.012 & 0.037 respectively). Admission APACHE II scores, Area under the ROC curve for mortality was 0.80 (95%CI 0.69-0.90); sensitivity was 77.5% and specificity 70% (cut-off ≥13.5). Conclusion: There was a high mortality rate in severe ARDS. The APACHE II score can be utilised in mortality prediction in COVID-19 ARDS patients. However, larger-scale studies in Pakistan are required to assess predictors of mortality.

The impact of a palliative care unit on mortality rate and length of stay for medical intensive care unit patients.

OBJECTIVE: This study evaluates the impact of a 10-bed inpatient palliative care unit (PCU) on medical intensive care unit (MICU) mortality and length of stay (LOS) for terminally ill patients following the opening of an inpatient PCU. We hypothesized that MICU mortality and LOS would be reduced through the creation of a more appropriate location of care for critically ill MICU patients who were dying. METHOD: We performed a retrospective electronic database review of all MICU discharges from January 1, 2006 through December 31, 2009 (5,035 cases). Data collected included MICU mortality, MICU LOS, and mean age. The PCU opened on January 1, 2008. We compared location of death for MICU patients during the 2-year period before and the 2-year period after the opening of the PCU. RESULTS: Our data showed that the mean MICU mortality and MICU LOS both significantly decreased following the opening of the PCU, from 21 to 15.8% (p = 0.003), and from 4.6 to 4.0 days (p = 0.014), respectively. SIGNIFICANCE OF RESULTS: The creation of an inpatient PCU resulted in a statistically significant reduction in both MICU mortality rate and MICU LOS, as terminally ill patients were transitioned out of the MICU to the PCU for end-of-life care. Our data support the hypothesis that a dedicated inpatient PCU, capable of providing care to patients requiring mechanical ventilation or vasoactive agents, can protect terminally ill patients from an ICU death, while providing more appropriate care to dying patients and their loved ones.

Palliative medicine consultation impacts DNR designation and length of stay for terminal medical MICU patients.

OBJECTIVE: The purpose of this study was to assess the impact of a palliative medicine consultation on medical intensive care unit (MICU) and hospital length of stay, Do Not Resuscitate (DNR) designation, and location of death for MICU patients who died during hospitalization. METHOD: A comparison of two retrospective cohorts in a 17-bed MICU in a tertiary care university-affiliated hospital was conducted. Patients admitted to the MICU between January 1, 2003 and June 30, 2004 (N = 515) were compared to MICU patients who had had a palliative medicine consultation between January 1, 2005 and June 1, 2009 (N = 693). To control for disease severity, only patients in both cohorts who died during their hospitalization were considered for this study. RESULTS: Palliative medicine consultation reduced time until death during the entire hospitalization (log-rank test, p < 0.01). Time from MICU admission until death was also reduced (log-rank test, p < 0.01), further demonstrating the impact of the palliative care consultation on the duration of dying for hospitalized patients. The intervention group contained a significantly higher percentage of patients with a DNR designation at death than did the control group (86% vs. 68%, χ2 test, p < 0.0001). SIGNIFICANCE OF RESULTS: Palliative medicine consultation is associated with an increased rate of DNR designation and reduced time until death. Patients in the intervention group were also more likely to die outside the MICU as compared to controls in the usual care group.

Risk factors for intensive care unit admission and mortality in hospitalized COVID-19 patients.

BACKGROUND: This study investigated the clinical features and outcome of hospitalized coronavirus disease 2019 (COVID-19) patients admitted to our quaternary care hospital. METHODS: In this retrospective cohort study, we included all adult patients with COVID-19 infection admitted to a quaternary care hospital in Pakistan from March 1 to April 15, 2020. The extracted variables included demographics, comorbidities, presenting symptoms, laboratory tests and radiological findings during admission. Outcome measures included in-hospital mortality and length of stay. RESULTS: Sixty-six COVID-19 patients were hospitalized during the study period. Sixty-one percent were male and 39% female; mean age was 50.6±19.1 years. Fever and cough were the most common presenting symptoms. Serial chest X-rays showed bilateral pulmonary opacities in 33 (50%) patients. The overall mortality was 14% and mean length of stay was 8.4±8.9 days. Ten patients (15%) required intensive care unit (ICU) care during admission, of which six (9%) were intubated. Age ≥60 years, diabetes, ischemic heart disease, ICU admission, neutrophil to lymphocyte ratio ≥3.3, and international normalized ratio ≥1.2 were associated with increased risk of mortality. CONCLUSIONS: We found a mortality rate of 14% in hospitalized COVID-19 patients. COVID-19 cases are still increasing exponentially around the world and may overwhelm healthcare systems in many countries soon. Our findings can be used for early identification of patients who may require intensive care and aggressive management in order to improve outcomes.

Frequency and Cause of Readmissions in Sepsis Patients Presenting to a Tertiary Care Hospital in a Low Middle Income Country.

Hospital readmissions are known to be common after sepsis but unfortunately, in a developing country like Pakistan, very little is known of the frequency or cause of these readmissions in sepsis patients and even less about how they can be prevented. To our knowledge, this is the first-ever long-term follow-up study in a developing country in which frequency and cause of readmissions are being evaluated in sepsis patients. DESIGN: This retrospective study evaluated sepsis patients admitted at the Aga Khan University Hospital in 2017. Outcome measures included in-hospital mortality and readmission within 180 days. SETTING: Aga Khan University Hospital, Karachi, Pakistan. SUBJECTS: Four-hundred thirty-nine sepsis patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Respiratory infections were the most common cause of sepsis (172 [39%]) followed by urinary tract infections (86 [20%]). Mortality in sepsis was 42% (183/439) and associated risk factors included ICU admission (odds ratio, 1.57; 95% CI, 1.05-2.35; p = 0.027), malignancy(odds ratio, 3.50; 95% CI, 1.70-7.19; p = 0.001), acute kidney injury (odds ratio, 1.86; 95% CI, 1.25-2.77; p = 0.002), septic shock (odds ratio, 4.75; 95% CI, 3.04-7.35; p = 0.001), and serum lactate greater than or equal to 4 mmol (odds ratio, 5.11; 95% CI, 3.00-8.73; p = 0.001). Of the 256 patients that survived, 31% (79/256) were readmitted within 180 days. Infections accounted for 67% (53/79) of these readmissions. Half of these infections were new infections while an additional 26% were unclear since cultures were negative in at least one of the hospitalizations. CONCLUSIONS: We concluded that mortality rates in sepsis are alarmingly high and even those who manage to survive are still at a great risk of getting readmitted due to a new infection in the near future. Given the limited resources available in developing countries, prevention of these infections should be given utmost importance. Unfortunately, reliable interventions to identify high-risk patients for readmissions are still inadequately characterized. Hence, we hope this study becomes a platform for larger multicenter studies in developing countries for early prediction of potential readmissions and developing precise interventions to prevent them.

Validating a point of care lactate meter in adult patients with sepsis presenting to the emergency department of a tertiary care hospital of a low- to middle-income country.

BACKGROUND: Timely identification of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care (POC) testing is being increasingly utilized in the emergency department (ED). We examined the accuracy and time-saving effect of a handheld POC lactate device for the measurement of fingertip and whole blood lactate as compared with reference laboratory blood testing in septic ED patients. METHODS: A convenience sample of adult ED patients receiving serum lactate testing were enrolled prospectively in the ED of a multidisciplinary tertiary care hospital serving the population of one of the major cities of Pakistan. Participants underwent fingertip POC lactate measurement with a portable device simultaneous whole blood sampling for analysis by both the POC lactate device and standard laboratory method. Lactate measurements were compared by intraclass correlation (ICC) and Bland and Altman plots. RESULTS: Forty-three septic patients were included in the study. The fingertip POC & whole blood POC lactate measurements each correlated tightly with the reference method (ICC=0.93 & ICC=0.92, respectively). Similarly at 6 hours, the fingertip POC & whole blood POC lactate measurements demonstrated satisfactory correlation with the reference method (ICC=0.95 & ICC=0.97, respectively). CONCLUSION: Fingertip POC lactate measurement is an accurate method to determine lactate levels in septic ED patients.

Medication safety and transfusion errors in the ICU and beyond.

The modern day intensive care unit (ICU) is a place in which patients can receive continuous monitoring of physiologic variables with concentrated patient observation and care. Despite the "intensive care," errors do occur. This article reviews medication and transfusion errors, including the different types, causes, and possible solutions to prevent these errors from occurring in ICUs and the hospital at large.

Replicating changes in hand hygiene in a surgical intensive care unit with remote video auditing and feedback.

Using remote video auditing (RVA) and real-time feedback, we replicated health care workers hand hygiene in a second intensive care unit. During the first 4 weeks using RVA without feedback, the compliance rate was 30.42%. The rate during the 64-week postfeedback period (initial 16 and 48 weeks maintenance) with RVA and feedback exceeded 80% on average. These data demonstrate that improved hand hygiene was achieved and sustained with the use of RVA and feedback.

Validating a point of care lactate meter in adult patients with sepsis presenting to the emergency department of a tertiary care hospital of a low- to middle-income country / 世界急诊医学杂志（英文）

@#BACKGROUND: Timely identification of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care (POC) testing is being increasingly utilized in the emergency department (ED). We examined the accuracy and time-saving effect of a handheld POC lactate device for the measurement of fingertip and whole blood lactate as compared with reference laboratory blood testing in septic ED patients. METHODS: A convenience sample of adult ED patients receiving serum lactate testing were enrolled prospectively in the ED of a multidisciplinary tertiary care hospital serving the population of one of the major cities of Pakistan. Participants underwent fingertip POC lactate measurement with a portable device and simultaneous whole blood sampling for analysis by both the POC lactate device and standard laboratory method. Lactate measurements were compared by intraclass correlation (ICC) and Bland and Altman plots. RESULTS: Forty-three septic patients were included in the study. The fingertip POC & whole blood POC lactate measurements each correlated tightly with the reference method (ICC=0.93& ICC=0.92, respectively). Similarly at 6 hours, the fingertip POC & whole blood POC lactate measurements demonstrated satisfactory correlation with the reference method (ICC=0.95 &ICC=0.97, respectively). CONCLUSION: Fingertip POC lactate measurement is an accurate method to determine lactate levels in septic ED patients.

Expanding a performance improvement initiative in critical care from hospital to system.

BACKGROUND: Concern about the expense and effects of intensive care prompted the development and implementation of a hospital-based performance improvement initiative in critical care at North Shore University Hospital, Manhasset, New York, a 730-bed acute care teaching hospital. THE HOSPITAL-BASED PERFORMANCE IMPROVEMENT INITIATIVE IN CRITICAL CARE: The initiative was intended to use a uniform set of measurements and guidelines to improve patient care and resource utilization in the intensive care units (ICUs), to establish and implement best practices (regarding admission and discharge criteria, nursing competency, unplanned extubations, and end-of-life care), and to improve performance in the other hospitals in the North Shore-Long Island Jewish Health System. In the medical ICU, the percentage of low-risk (low-acuity) patients was reduced from 42% to 22%. ICU length of stay was reduced from 4.6 days to 4.1 days. IMPLEMENTING THE CRITICAL CARE PROJECT SYSTEMWIDE: A system-level critical care committee was convened in 1996 and charged with replicating the initiative. By and large, system efforts to integrate and implement policies have been successful. The critical care initiative has provided important comparative data and information from which to gauge individual hospital performance. DISCUSSION: Changing the critical care delivered on multiple units at multiple hospitals required sensitivity to existing organizational cultures and leadership styles. Merging organizational cultures is most successful when senior leadership set clear expectations that support the need for change. The process of collecting, trending, and communicating quality data has been instrumental in improving care practices and fostering a culture of safety throughout the health care system.