Respiratory support in the emergency department a systematic review and meta-analysis.

BACKGROUND: An estimated 20% of emergency department (ED) patients require respiratory support (RS). Evidence suggests that nasal high flow (NHF) reduces RS need. AIMS: This review compared NHF to conventional oxygen therapy (COT) or noninvasive ventilation (NIV) in adult ED patients. METHOD: The systematic review (SR) and meta-analysis (MA) methods reflect the Cochrane Collaboration methodology. Six databases were searched for randomized controlled trials (RCTs) comparing NHF to COT or NIV use in the ED. Three summary estimates were reported: (1) need to escalate care, (2) mortality, and (3) adverse events (AEs). RESULTS: This SR and MA included 18 RCTs (n = 1874 participants). Two of the five MA conclusions were statistically significant. Compared with COT, NHF reduced the risk of escalation by 45% (RR 0.55; 95% CI [0.33, 0.92], p = .02, NNT = 32); however, no statistically significant differences in risk of mortality (RR 1.02; 95% CI [0.68, 1.54]; p = .91) and AE (RR 0.98; 95% CI [0.61, 1.59]; p = .94) outcomes were found. Compared with NIV, NHF increased the risk of escalation by 60% (RR 1.60; 95% CI [1.10, 2.33]; p = .01); mortality risk was not statistically significant (RR 1.23, 95% CI [0.78, 1.95]; p = .37). LINKING EVIDENCE TO ACTION: Evidence-based decision-making regarding RS in the ED is challenging. ED clinicians have at times had to rely on non-ED evidence to support their practice. Compared with COT, NHF was seen to be superior and reduced the risk of escalation. Conversely, for this same outcome, NIV was superior to NHF. However, substantial clinical heterogeneity was seen in the NIV delivered. Research considering NHF versus NIV is needed. COVID-19 has exposed the research gaps and slowed the progress of ED research.

A practical approach to establishing a critical care outreach service: An expert panel research design.

BACKGROUND: For over two decades, nurse-led critical care outreach services have improved the recognition, response, and management of deteriorating patients in general hospital wards, yet variation in terms, design, implementation, and evaluation of such services continue. For those establishing a critical care outreach service, these factors make the literature difficult to interpret and translate to the real-world setting. AIM: The aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting. METHOD: An international expert panel of clinicians, managers, and academics with experience in implementing, developing, operationalising, educating, and evaluating critical care outreach services collaborated to synthesise evidence, experience, and clinical judgment to develop a practical approach for those establishing a critical care outreach service. A rapid review of the literature identified publications relevant to the study. A modified Delphi technique was used to achieve expert panel consensus particularly in areas where insufficient published literature or ambiguities existed. FINDINGS: There were 502 publications sourced from the rapid review, of which 104 were relevant and reviewed. Using the modified Delphi technique, the expert panel identified five key components needed to establish a critical care outreach service: (i) approaches to service delivery, (ii) education and training, (iii) organisational engagement, (iv) clinical governance, and (v) monitoring and evaluation. CONCLUSION: An expert panel research design successfully synthesised evidence, experience, and clinical judgement to provide a practical approach for those establishing a critical care outreach service. This method of research will likely be valuable in other areas of practice where terms are used interchangeably, and the literature is diverse and lacking a single approach to practice.

The comparison of the Nursing Activities Score and TrendCare to accurately measure critical care nursing workload: A prospective observational design.

INTRODUCTION: Intensive care units commonly use the Nursing Activities Score (NAS) to measure nursing workload, however, some settings use TrendCare. Historically 100 NAS points reflected one nurse, however research now suggests greater than 61 NAS points per nurse increases hospital mortality. OBJECTIVES: To determine if: 1) TrendCare accurately reflects critical care nursing workload as measured by the NAS and 2) the required nursing hours calculated by each of the scoring systems differed between indigenous and non-indigenous patients. METHODS: Using a prospective observational design, data were collected between 9 August - 25 November 2021. Nursing workload was assessed over three shifts using TrendCare and the NAS. RESULTS: Analysis included 183 patients and 829 TrendCare and NAS scores. The mean NAS for intensive care patients was >61 on all three shifts (morning M = 67.1 ± 18.2, afternoon M = 66.1 ± 18.1, night M = 64.0 ± 18.1). The mean NAS for high dependency patients (morning M = 46.1 ± 11.1, afternoon M 45.9 ± 11.0, night Mdn 46.1 [40.5-54.1]) identified a nurse:patient ratio of 1:2 reflected a NAS >90. The NAS and TrendCare found no difference in nursing hours between indigenous and non-indigenous patients, however higher scores for respiratory (H = 7.3, p = <.01), cardiovascular (H = 12.7, p = <.001) and renal (H = 12.7, p = <.001) support, and care for relatives and patients (H = 13.8, p = <.001) on some shifts were identified in indigenous patients. CONCLUSION: TrendCare nursing hours likely reflect a 1:1 nurse: patient ratio for intensive care patients but likely under-estimates high dependency care nursing workload. The NAS activities highlighted some activities required more time for indigenous patients on some shifts. IMPLICATIONS FOR CLINICAL PRACTICE: TrendCare likely reflects intensive care nursing workload but not high dependency nursing workload. A NAS of no greater than 61 points per nurse better reflects nursing workload in both the intensive and high dependency care units. Indigenous patients may require more nursing hours for nursing activities related to severity of illness.

Respiratory support of adults in the emergency department: A protocol for a prospective, observational, multicenter point prevalence study.

Background and Aims: Providing respiratory support (RS) to patients may improve their oxygenation and ventilation, reducing the work of breathing. Emergency department (ED) patients often need RS; COVID-19 has heightened this need. Patients receiving RS may need escalation of their treatment; hence, studies considering the prevalence of escalation are warranted. Method: This is a protocol for a prospective, observational, multicenter point prevalence study (PPS). Researchers will collect data over 2 days. All participants are adult ED patients needing RS. The setting is four EDs in New Zealand. The primary research question asks, "Which patients receiving RS require escalation of therapy in the ED?" For example, transitioning from conventional oxygen therapy (COT) to intubation is deemed an escalation of therapy. A sample size of 80 participants is required to resolve the primary research question. Secondary research questions: (1) Which patients receive nasal high flow (NHF) in the ED? (2) How is NHF therapy delivered in the ED? (3) What are the effects of NHF therapy on physiological and patient-centered outcomes? Research Electronic Data Capture (REDCap) will be used for data organization. Data will be imported for analysis from REDCap to IBM SPSS software (Statistics for Windows, Version 27.0). Data reporting on the primary outcome shall be considered by analysis of variance, regression modeling, and determination of two treatment effects: Odds Ratio and Number Needed to Treat. Statistical significance for inferential statistics shall use a two-sided α with p-values fixed at ≤0.05 level of significance and 95% confidence intervals. This protocol has ethical approval from Massey University, New Zealand. Conclusion: This novel PPS may reduce the evidence and clinical practice gap on RS delivery and ED patient outcomes, as evidenced by the emergence of COVID-19.

Removing modifications to the New Zealand Early Warning Score- does ethnicity matter? A multimethod research design.

BACKGROUND: Previous research on a modified New Zealand Early Warning Score (M-NZEWS) used in predominately medical ward patients identified removing the modifications would significantly reduce the number of M-NZEWSs triggering the medical emergency team (MET), particularly in Maori patients. AIM: To firstly, explore the impact of removing the modifications from the M-NZEWS on medical and surgical ward patients' early warning score MET triggers and secondly, determine if the M-NZEWS MET triggers resulted in MET activations and if the MET activations were a result of M-NZEWS MET triggers. METHOD: The study used a multimethod research design. Phase one analysed ward electronic vital sign data and phase two analysed MET and critical care outreach data from the critical care outreach data base. RESULTS: Data of 353 patients and 1004 M-NZEWS MET triggers were analysed. Removing the modifications would result in 26.9% fewer patients with MET triggers, with the biggest impact on Maori. Only 45.8% of M-NZEWS MET triggers were escalated to the MET with 58.9% escalated to critical care outreach. Review of the MET activations identified only 59.2% had M-NZEWSs triggering the MET recorded in the electronic vital sign system; however the critical care outreach data base identified most of the MET activations were because of M-NZEWS MET triggers. CONCLUSION: Removing the modifications would significantly reduce the number of MET triggers, particularly in Maori patients. Analysing solely electronic vital sign data may not reflect the number of medical emergency team triggers or activations.

The impact of a modified New Zealand Early Warning Score (M-NZEWS) and NZEWS on ward patients triggering a medical emergency team activation: A mixed methods sequential design.

INTRODUCTION: Limited research exists on the effectiveness of the New Zealand Early Warning Score (NZEWS). AIM: To determine the impact of a modified NZEWS (M-NZEWS) and NZEWS on ward patients' medical emergency team activation triggers. RESEARCH DESIGN: Mixed methods sequential design. METHODS: Three phases included: 1) review of M-NZEWS electronic data to determine the effect of a M-NZEWS and NZEWS on ward patients; 2) an in-depth review of 20 Maori patients allocated to lower escalation zones if the NZEWS were adopted and 3) the number of electronic medical emergency team activation triggers compared to the number of actual medical emergency team activations. RESULTS: 1255 patients and 3505 vital sign data sets were analysed. Adopting the NZEWS would result in 396 (26.8%) fewer patients triggering a medical emergency team activation. The biggest impact would be on Maori, with 38.6% of Maori allocated to a lower escalation zone. Only 51.2% of patients with a medical emergency team activation had vital signs triggering the response electronically documented. CONCLUSION: Changing from the M-NZEWS to NZEWS will reduce the number of medical emergency team activation triggers, with the biggest impact on Maori. Electronic vital sign data does not accurately reflect the number of ward medical emergency team triggers or activations.

Local experience with the use of sustained low efficiency dialysis for acute renal failure.

Renal replacement therapy (RRT) is a common therapy used to treat critically ill patients in acute renal failure. Currently a number of dialysis modalities are used such as haemodialysis, continuous renal replacement therapy (CRRT), and sustained low efficiency dialysis (SLED). As SLED is a recently implemented RRT, very little literature is available on the nursing aspects of SLED. This paper shares the local nursing experience of using SLED, thus providing a nursing perspective. Between 2002 and 2006, 103 patients were treated with SLED resulting in 307 SLED treatments. Early problems encountered involved patient hypotension, dialysis catheter patency and water quality; all of which were overcome by initially commencing dialysis at a lower prescribed blood pump rate, using larger catheters and improving water quality. Nursing advantages of SLED over CRRT included being able to release the patient for nursing activities and patient transfer out of the ICU for investigations and procedures; reduced nursing workload related to less machine and patient monitoring during the dialysis procedure; and cost reduction. Disadvantages of SLED are related to poor water quality, accessibility of water supply and limited space to house the two machines required. SLED has proven to be a nurse friendly dialysis modality for critically ill patients with acute renal failure.

Patient and/or family activated rapid response service: Patients' perceptions of deterioration and need for a service.

BACKGROUND: Patient and/or family activated escalation may improve care to deteriorating patients. However, limited literature describes patients' and families' experience of deterioration and what barriers might restrict call activation. OBJECTIVE: This study explored patients' and families' experiences of acute ward deterioration, their perception of a need for a patient and/or family activated escalation service and barriers that may prevent them from using it. DESIGN: Using a qualitative cross sectional research design and a co-design approach, data were collected using face-to-face semi-structured interviews, field notes and reflective journaling. Between December 2015 and February 2016, purposeful sampling recruited 41 adult ward patients and family who either experienced a recent Medical Emergency team (MET) or Patient at Risk team (PART) escalation, or no recent MET or PART escalation. FINDINGS: Themes included: (1) patient awareness of their illness and deterioration, 2) the importance of returning to their normal lives, (3) reassurance on arrival of the PART and MET, (4) beliefs held to prevent use of such a service, and (5) support for a patient and/or family activated escalation service. CONCLUSION: Most participants supported a patient and/or family activated escalation service, however barriers may prevent some patients from using it.

The role and effectiveness of a nurse practitioner led critical care outreach service.

Research measuring the effectiveness of critical care outreach (CCOR) has been mixed. The objective of this paper is to describe the role and effectiveness of a nurse practitioner (NP) led critical care outreach service (CCORS). Using a comparative study design, data on the number of intensive care unit (ICU) readmissions <72h were analysed 12 months prior to, and 12 months following implementation of the service. Data was also collected on length of stay and APACHE II scores of ICU readmissions <72h, ICU patient acuity, ICU readmission mortality, and ward medical emergency team (MET) and cardiac arrest calls. Data on NP referrals were collected to identify NP activities. Data analysis was completed using descriptive statistics and run and control charts. There were 133 NP referrals, which resulted in 525 patient visits. The most common interventions completed by the NP during visits included requesting of diagnostic tests and prescribing. Following introduction of the NP CCORS, there was a sustained reduction in ICU readmissions <72h. In conclusion, a NP led CCORS has a positive effect on patient outcomes and supports development of further NP positions.

The level of knowledge of respiratory physiology articulated by intensive care nurses to provide rationale for their clinical decision-making.

The combination of intensive care knowledge, and the ability to articulate analytical decision-making processes to the interdisciplinary team, enhances the clinical credibility of the intensive care unit (ICU) nurse. The objective of this paper is to outline a study firstly, assessing ICU nurses' ability in articulating respiratory physiology to provide rationale for their clinical decision-making and secondly, the barriers that limit the articulation of this knowledge. Using an evaluation methodology, multiple methods were employed to collect data from 27 ICU nurses who had completed an ICU education programme and were working in one of two tertiary ICUs in New Zealand. Quantitative analysis showed that nurses articulated a low to medium level of knowledge of respiratory physiology. Thematic analysis identified the barriers limiting this use of respiratory physiology as being inadequate coverage of concepts in some ICU programmes; limited discussion of concepts in clinical practice; lack of clinical support; lack of individual professional responsibility; nurses' high reliance on intuitive knowledge; lack of collaborative practice; availability of medical expertise; and the limitations of clinical guidelines and protocols. These issues need to be addressed if nurses' articulation of respiratory physiology to provide rationale for their clinical decision-making is to be improved.

Staff perceptions of a patient at risk team: A survey design.

INTRODUCTION: Whilst research demonstrates the benefits of critical care outreach, limited research describes staffs' perspective of these teams. OBJECTIVE: This study examined ward nurses' and doctors' perceptions of the service provided by a nurse-led 24hours a day, seven days a week Patient at Risk team. DESIGN: Using an exploratory survey research design and a previously used instrument, data were collected between January and March (2016). The instruments' reliability was assessed using Cronbach's alpha (a=0.90). RESULTS: 339 participants, including 255 nurses and 84 doctors, completed the questionnaire (70.48% response rate). Most participants agreed the Patient at Risk team 1) were accessible and approachable, 2) recognised deterioration and reduced serious events, 3) provided ward staff teaching and coaching and 4) aided allied health referral and improved transfer of patients from critical care. More nurses than doctors perceived the team's role more positively in some aspects of the service they provided. Whilst most comments were positive, some comments identified improvements could be made to the service. CONCLUSION: Ward nurses' and doctors' perceived the Patient at Risk team contributed to improving care of deteriorating ward patients. The instrument used in this study may be useful to other outreach teams to identify service improvements.

Nasal high flow oxygen therapy in the ward setting: A prospective observational study.

BACKGROUND: Whilst research demonstrates the benefits of nasal high flow oxygen in the intensive care setting, limited literature exists on its benefits in ward patients. OBJECTIVES: This study evaluated the use of nasal high flow oxygen in adult ward patients with respiratory failure or at risk of respiratory deterioration. Primary outcome was an improvement in pulmonary function as indicated by decreases in respiratory and heart rates and an increase in arterial oxygen saturation via pulse oximetry. RESEARCH METHODOLOGY: Using a prospective observational research design, purposeful sampling recruited 67 adult ward patients receiving nasal high flow oxygen between May and July 2015 (inclusive). All recruited patients were included in the data analysis. RESULTS: The median age was 71.0 years (q25, q75=58.0, 78.0) and most patients were medical specialty patients (n=46, 68.7%). After commencing nasal high flow oxygen, respiratory rate (t=2.79, p=<0.01) and heart rate (t=2.23, p=0.03) decreased and arterial oxygen saturation via pulse oximetry increased (t=4.08, p=<0.001). CONCLUSION: Nasal high flow oxygen appears effective in a selective group of ward patients with respiratory failure, or at risk of respiratory deterioration, and may reduce demand on critical care beds; this warrants further research.

Documentation of cardiopulmonary resuscitation decisions in a New Zealand hospital: A prospective observational study.

INTRODUCTION: Documentation of cardiopulmonary resuscitation (CPR) decisions is often poor. Lack of documented decisions risks inappropriate CPR and staff, patient and family distress. OBJECTIVE: To examine documented evidence of CPR decisions. METHOD: Using a prospective observational design, case notes of current patients in 16 wards were reviewed for documented evidence of CPR decisions. Data were collected over a consecutive two-day period in April 2015. RESULTS: 151 patients case notes were reviewed; 41 (27.2%) patients had documented decisions and 110 (72.8%) had no decisions documented. When compared to patients with no documented decisions, those with documented decisions were older (p≤0.001), had a greater number of admission days at time of data collection (p=0.02) and more comorbidities (p≤0.001). In those with documented decisions, advancing age was related to a greater number of comorbidities (p=0.02) but not to an increased number of admission days at time of data collection (p=0.81). In the non-documented group advancing age was related to both an increased number of admission days at time of data collection (p≤0.001) and a greater number of comorbidities (p≤0.001). CONCLUSION: Documentation of CPR decisions is suboptimal. Improving documentation reduces staff, patient and family distress and allows appropriate and dignified end of life care.

Local experience with the use of nasal bubble CPAP in infants with bronchiolitis admitted to a combined adult/paediatric intensive care unit.

Bronchiolitis is an acute inflammatory disease of the lower small airways predominantly occurring in infants younger than 1 year of age. As a result of the respiratory distress associated with bronchiolitis, infants frequently require admission to an intensive care unit for respiratory support. Thirty-five infants diagnosed with bronchiolitis were admitted to a combined adult/paediatric tertiary intensive care unit over a 2-year period for nasal bubble continuous positive airway pressure (CPAP). Following this therapy, 20 (57.14%) of these infants could be transferred to the medical ward of the onsite paediatric hospital. The remainder required transfer to the national paediatric intensive care unit (PICU) for ongoing observation and/or positive pressure ventilation. Nasal bubble CPAP is a simple therapy that can be easily set up at the bedside. The use of nasal bubble CPAP enabled infants to remain in their geographical area, thus improving family visiting access and reducing the demand for paediatric beds in the national PICU.