Health Related Quality of Life and support needs for sub-arachnoid haemorrhage survivors in New South Wales Australia.

BACKGROUND: Subarachnoid haemorrhage (SAH) is commonly a devastating injury with long lasting physical and psychosocial consequences for survivors. Support after hospital discharge through chronic care services for this patient group is limited. This study aimed to measure Health Related Quality of Life (HRQoL) and needs of survivors after discharge from hospital. METHODS: A population of patients that were diagnosed with SAH were contacted, up to 2 years post discharge, to participate in a postal survey including the Short Stroke Specific Quality of Life Scale (SSQoL-12), a service utilisation questionnaire and attitudes towards participating in a support group. FINDINGS: There were 28 responders. HRQoL was lowest in the psychosocial domain and particularly in relation to fatigue and memory. Most notably many responders indicated they wanted to be interviewed but a support group was not favoured with few responders (n=11) indicating interest with most in favour of a face to face format (n=10). CONCLUSIONS: HRQoL was reduced particularly in the psychosocial domain. Although there was low utilisation of support services in the post-acute care phase, these patients may benefit from greater opportunities to participate in both physical and psychosocial rehabilitation programs.

Australian health service organisation assessment outcome data for the first 2 years of implementing the Comprehensive Care Standard.

Objective To review implementation of the Comprehensive Care Standard (CCS) by evaluating assessment outcome data of Australian health service organisations (HSOs) from January 2019. The CCS was introduced with the National Safety and Quality Health Service (NSQHS) Standards (second edition). It has 36 actions and over 40 resources to support implementation. Methods Retrospective assessment outcome data submitted by accrediting agencies were examined to gauge progress of CCS implementation by considering met or other ratings of the CCS actions. Results There were 495 assessments completed between January 2019 and December 2020. Most (71% n = 352) HSOs met the requirements of the CCS after initial assessment. Seventy-four (15%) of the HSOs did not meet all the requirements and a further 58 (12%) HSOs were provided with recommendations to meet the actions. Conclusions There was indication of underperformance related to some actions in the CCS. The assessment data highlighted common issues for organisations including difficulties implementing governance processes, demonstrating effective care planning, implementing the end-of-life care actions and some minimising harm actions. Future evaluation of the implementation of the CCS may benefit from strengthening links between other safety and quality programs.

Aseptic insertion of central venous lines to reduce bacteraemia.

OBJECTIVE: To reduce the rate of central line-associated bacteraemia (CLAB). DESIGN: A collaborative quality improvement project in intensive care units (ICUs) to promote aseptic insertion of central venous lines (CVLs). A checklist was used to record compliance with all aspects of aseptic CVL insertion, with maximal sterile barrier precautions for clinicians ("clinician bundle") and patients ("patient bundle"). CLAB was identified and reported using a standard surveillance definition. PARTICIPANTS AND SETTING: Patients and clinicians in 37 ICUs in New South Wales, July 2007-December 2008. MAIN OUTCOME MEASURES: Compliance with aseptic CVL insertion; rates of CLAB. RESULTS: 10 890 CVL checklists were reviewed for compliance with the clinician and patient bundles: compliance with aseptic CVL insertion improved significantly (P < 0.001). The CLAB rate dropped from 3.0 to 1.2 per 1000 line-days (P < 0.001). Regardless of CVL type, the relative risk (RR) of CLAB in patients with CVLs inserted by clinicians not compliant with the clinician bundle was 1.62 times greater (95% CI, 1.1-2.4; P = 0.018) than the RR with CVLs inserted by clinicians compliant with both bundles. Compliance with both the bundles was associated with a 50% reduction in risk of CLAB (RR, 0.5; 95% CI, 0.4-0.8; P = 0.004). CONCLUSIONS: Compliance with all aspects of aseptic CVL insertion significantly reduces the risk of CLAB. A difficulty we experienced was that most ICUs lacked the organisation and staff to support quality improvement and audit.

Antimicrobial prescription patterns and ventilator associated pneumonia: findings from a 10-site prospective audit.

OBJECTIVE: To examine anti-microbial prescribing practices associated with ventilator-associated pneumonia from data gathered during an audit of practice and outcomes in intensive care units (ICUs) in a previously published study. RESULTS: The patient sample of 169 was 65% male with an average age of 59.7 years, a mean APACHE II score of 20.6, and a median ICU stay of 11 days. While ventilator-associated pneumonia was identified using a specific 4-item checklist in 29 patients, agreement between the checklist and independent physician diagnosis was only 17%. Sputum microbe culture reporting was sparse. Approximately 75% of the sample was administered an antimicrobial (main indications: lung infection [54%] and prophylaxis [11%]). No clinical justification was documented for 20% of prescriptions. Piperacillin/tazobactam was most frequently prescribed (1/3rd of all antimicrobial prescriptions) with about half of those for prophylaxis. Variations in prescribing practices were identified, including apparent gaps in antimicrobial stewardship; particularly in relation to prescribing for prophylaxis and therapy de-escalation. Sputum microbe culture reports for VAP did not appear to contribute to prescribing decisions but physician suspicion of lung infection and empiric therapy rather than ventilator-associated pneumonia criteria and guideline concordance.

Assessment of the accuracy of continuous cardiac output and pulse contour cardiac output in tracking cardiac index changes induced by volume load.

OBJECTIVE: To assess the ability to track changes in cardiac index (Delta CI) induced by volume loading using continuous pulsed heat thermodilution (CCO), and pulse contour (PCCO) cardiac output (CO) with transpulmonary thermodilution (TD(tp)) CO as reference. DESIGN: Prospective observational clinical trial. SETTING: Intensive care unit. PATIENTS: Twelve ventilated and sedated post-operative cardiac surgery patients. MEASUREMENTS AND RESULTS: Each patient had a 7.5F CCO pulmonary artery catheter (Edwards Lifesciences) and a 5F, 20 cm PCCO femoral artery catheter (Pulsion Medical Systems). Forty-five data sets were taken before and after 25 volume loadings of 5 mL/kg of 4% albumin. Volume loading resulted in an increase in CI (2.84 L/(min m(2)) versus 3.12L/(min m(2)), p<.05) although only nine volume loadings changed CI (Delta CI)> or =14%. The change in CI using PCCO (Delta PCCI) was correlated with Delta CI (TD(tp)) (R(2)=.50, p<.0001), whilst Delta CI using CCO (Delta CCI) was not (R(2)=.14). The bias and limits of agreement (LOA) between Delta TD(tp)CI and Delta PCCI was 6.2% (95% CI, +/-5.8%) and 28.4% (95% CI, +/-38.2%) respectively. Delta TD(tp)CI and Delta CCI has a bias of 2.6% (95% CI, +/-8.3%) and LOA of 39.6% (95% CI, +/-63%). Both Delta PCCI and Delta CCI reliably tracked Delta CI> or =14%. CONCLUSION: In this small group of patients the continuous cardiac output methods tracked changes in CI, although, in individual cases they did not change in the same direction as the thermodilution method. Critical care nurses need to critically appraise the accuracy and clinical relevance of continuous CO data within the clinical context.

Comparison of dynamic measurements of pulse contour with pulsed heat continuous cardiac output in postoperative cardiac surgical patients.

Cardiac output (CO) can be measured using bolus thermodilution via a pulmonary artery catheter (PAC) and as continuous cardiac output (CCO), using pulsed heat thermoditution. Pulse contour cardiac output (PCCO) measures continuous CO by analysis of the arterial waveform after calibration with thermodilution CO. The Pulsion Medical Systems (PiCCO system) achieves this by transpulmonary aortic thermodilution (TDtpa). There is uncertainty regarding the agreement between TDtpa, CCO, and PCCO CO measurements in situations of rapid haemodynamic changes. We studied the agreement of the measures by comparing digital recordings of cardiac index (CI) determined by PCCO and CCO (PCCI and CCI, respectively) made during periods of haemodynamic instability. After ethics committee approval we studied four post-coronary artery bypass graft patients, in the immediate postoperative period. Each patient had a 7.5F CCO catheter (Edwards Lifesciences) and a 5F, 20cm PCCO femoral artery catheter. Digital recordings were obtained for the first 12-18 postoperative hours. Six epochs of instability were identified in the first two to three postoperative hours, and at the commencement of inotropic or vasoactive drugs. Notable features, despite frequent PCCO calibrations, were the marked difference of PCCI compared to CCI. In contradistinction, they tracked very closely during a period of stability. Limitations of both methods were noted. Whilst PCCO responded to rapid change, it developed significant error during haemodynmamic instability and requires frequent recalibration. CCO on the other hand has a considerable time lag in responding to changes in CO. The way a monitor measures CO must be taken into account when using the data in clinical management.

An examination of covert observation and solution audit as tools to measure the success of hand hygiene interventions.

BACKGROUND: Many studies have examined hand hygiene (HH) frequency and adherence in response to various interventions. This study used 2 methods to determine HH frequency and adherence to see how well the outcomes correlated. METHODS: HH frequency was measured over 4, 1-month periods (phases 1-4), using 2 methods: an audit of HH solution used during each phase adjusted for patient-days and covert observation of HH adherence. The number of x-ray technician contacts with patients (a known quantity) across the study period was retrospectively compared with the number of observations made of x-ray technicians' HH behavior to see what proportion of contacts were observed. RESULTS: HH solution use doubled in phase 2 and was 65% and 55% higher than the baseline level in phases 3 and 4, respectively. Observed HH adherence fell from 51% to 37% in phase 2 and then rose to 58% in phases 3 and 4. Three percent of x-ray technicians' patient contacts were observed across the 4 phases. CONCLUSION: Observation of HH may not adequately sample patient contacts to provide an accurate measure of HH adherence. Further studies are needed to confirm this finding.

Incidence of ventilator-associated pneumonia in Australasian intensive care units: use of a consensus-developed clinical surveillance checklist in a multisite prospective audit.

OBJECTIVES: With disagreements on diagnostic criteria for ventilator-associated pneumonia (VAP) hampering efforts to monitor incidence and implement preventative strategies, the study objectives were to develop a checklist for clinical surveillance of VAP, and conduct an audit in Australian/New Zealand intensive care units (ICUs) using the checklist. SETTING: Online survey software was used for checklist development. The prospective audit using the checklist was conducted in 10 ICUs in Australia and New Zealand. PARTICIPANTS: Checklist development was conducted with members of a bi-national professional society for critical care physicians using a modified Delphi technique and survey. A 30-day audit of adult patients mechanically ventilated for >72 h. PRIMARY AND SECONDARY OUTCOME MEASURES: Presence of items on the screening checklist; physician diagnosis of VAP, clinical characteristics, investigations, treatments and patient outcome. RESULTS: A VAP checklist was developed with five items: decreasing gas exchange, sputum changes, chest X-ray infiltrates, inflammatory response, microbial growth. Of the 169 participants, 17% (n=29) demonstrated characteristics of VAP using the checklist. A similar proportion had an independent physician diagnosis (n=30), but in a different patient subset (only 17% of cases were identified by both methods). The VAP rate per 1000 mechanical ventilator days for the checklist and clinician diagnosis was 25.9 and 26.7, respectively. The item 'inflammatory response' was most associated with the first episode of physician-diagnosed VAP. CONCLUSIONS: VAP rates using the checklist and physician diagnosis were similar to ranges reported internationally and in Australia. Of note, different patients were identified with VAP by the checklist and physicians. While the checklist items may assist in identifying patients at risk of developing VAP, and demonstrates synergy with the recently developed Centers for Disease Control (CDC) guidelines, decision-making processes by physicians when diagnosing VAP requires further exploration.

Memories of intensive care and experiences of survivors of a critical illness: an interview study.

Recovery from a critical illness can be a complex and protracted process. It is known that for some, health-related quality of life (HRQOL) does not return to pre-illness levels for many months, and in some disease processes this may be longer. This study was undertaken as part of a larger project examining the pain and health status of survivors of a critical illness. The aims of the qualitative aspect of the study were to examine the participants' memories of intensive care and hospitalisation at 6 months post-discharge, and to explore the impact of the critical illness experience on their recovery. Purposive sampling was used to enable rich descriptions of the experience of recovery from those patients best able to articulate their experiences. Three common themes were found with our six participants: recollections, responses, and comfort/discomfort. Recovery from their critical illness continued to affect the participants and carers, some profoundly so. Better integration of services and continued support is required for survivors of a critical illness up to and beyond 6 months.

The use of activated protein C (drotrecogin alfa (activated)) in the treatment of severe sepsis.

Advances in intensive care have allowed many critically ill patients to survive their initial insult. These patients may later demonstrate multiple organ dysfunction and failure, the genesis of which appears to be the body's reaction to critical illness, manifested by an imbalance and failure of inflammatory and immune system homeostasis. The manifestation of multiple organ dysfunction in the critically ill has been termed multiple organ dysfunction syndrome (MODS). MODS mortality is high and remains a leading cause of death in intensive care units (ICUs). The understanding of the pathophysiology of severe sepsis and MODS has moved from a focus on inflammation to include an understanding of the associated anti-inflammatory responses. Loss of homeostasis can manifest as malignant inflammation or immune paralysis. Increased emphasis is emerging on the role of loss of immune homeostasis and disordered coagulation as a cause of organ injury and dysfunction. Treatment of severe sepsis is based upon aggressive resuscitation, source control and support for failing organs. Novel therapies directed at the modifying the inflammatory response have, up to now, not proven beneficial. However, a new agent, drotrecogin alfa (activated) has been shown, in a phase III randomised controlled trial, to be of benefit in the treatment of severe sepsis. This new agent affects both the inflammatory and coagulation dimensions of severe sepsis. The developing concepts of the pathophysiology of sepsis and the emergence of a new therapy increases the complexity of the already complex demands of providing nursing care for the patient with severe sepsis and MODS. This article reviews pathophysiological processes in sepsis, reviews clinical data on activated protein C and illustrates the utility of this therapy in a case study.

The effect of chronic pain on health related quality of life amongst intensive care survivors.

Intensive care unit (ICU) survivors report reductions in health-related quality of life (HR-QOL), whilst chronic pain is common in the general population. However, it is unknown whether there are associations between the experience of ICU and the incidence of chronic pain. A questionnaire--Pain Scale, Pain Self-Efficacy Questionnaire (PSEQ), Centre of Epidemiology Study Depression Scale (CES-D Scale) and the Short Form Health Survey (SF-36)--was sent to 99 consenting patients who had been in the ICU for >48 hours. Sixty-six and 52 questionnaires were returned at 1 and 6 months respectively. There was a general limitation in activities of daily living; younger ages (36-65 years) experienced a decease in work performance and other physical activities. Bodily pain increased, general health diminished, and engagements in social activities were severely affected. There was a decline in mental health for those 36-65 years of age. HR-QOL improved over time; 28% experienced chronic pain and had longer hospital length of stay (LOS), tended to have longer ICU LOS and were ventilated for longer. Those with chronic pain had significant reductions in physical function, bodily pain, general health and vitality. Ventilator hours and hospital LOS were associated with risk of chronic pain (OR 1.09, p=0.033 and OR 1.27, p=0.046). HR-QOL in ICU survivors declined, although there was a general improvement from 1-6 months. This decline in HR-QOL affected younger people (less than 65 years) more than older people. Chronic pain is a significant issue post ICU and is associated with poorer HR-QOL.

Nurse-led central venous catheter insertion-procedural characteristics and outcomes of three intensive care based catheter placement services.

BACKGROUND: Nurse-led central venous catheter placement is an emerging clinical role internationally. Procedural characteristics and clinical outcomes is an important consideration in appraisal of such advanced nursing roles. OBJECTIVES: To review characteristics and outcomes of three nurse-led central venous catheter insertion services based in intensive care units in New South Wales, Australia. DESIGN: Using data from the Central Line Associated Bacteraemia project in New South Wales intensive care units. Descriptive statistical techniques were used to ascertain comparison rates and proportions. PARTICIPANTS: De-identified outcome data of patients who had a central venous catheter inserted as part of their therapy by one of the four advanced practice nurses working in three separate hospitals in New South Wales. RESULTS: Between March 2007 and June 2009, 760 vascular access devices were placed by the three nurse-led central venous catheter placement services. Hospital A inserted 520 catheters; Hospital C with 164; and Hospital B with 76. Over the study period, insertion outcomes were favourable with only 1 pneumothorax (1%), 1 arterial puncture (1%) and 1 CLAB (1%) being recorded across the three groups. The CLAB rate was lower in comparison to the aggregated CLAB data set [1.3 per 1000 catheters (95% CI=0.03-7.3) vs. 7.2 per 1000 catheters (95% CI=5.9-8.7)]. CONCLUSION: This study has demonstrated safe patient outcomes with nurse led CVC insertion as compared with published data. Nurses who are formally trained and credentialed to insert CVCs can improve organisational efficiencies. This study adds to emerging data that developing clinical roles that focus on skills, procedural volume and competency can be a viable option in health care facilities.

Assessment of the clinical utility of an ultrasonic monitor of cardiac output (the USCOM) and agreement with thermodilution measurement.

OBJECTIVE: To assess the clinical utility of an ultrasonic monitor of cardiac output (USCOM), its reliability in tracking cardiac output (CO) changes and agreement with thermodilution (TD) measurements of CO. DESIGN: Prospective comparison study. SETTING AND PARTICIPANTS: 55 adults undergoing thermodilution (TD) CO monitoring in a cardiothoracic or general intensive care unit between December 2006 and December 2007. MAIN OUTCOME MEASURES: USCOM and TD measurements of CO on two occasions in each patient were compared by Bland-Altman analysis for bias and limit of agreement. A mean percentage error <30% was considered acceptable. Per cent change in cardiac index (CI) was determined by each method. Doppler profiles obtained by the USCOM were assessed against an ideal standard ("acceptable"). RESULTS: 55 patients had measurements on 110 occasions, but Doppler waveforms were not obtained on 18 of these (16%), leaving 39 patients with paired comparisons for analysis (including 27 men; mean age, 64.7 [SD, 14.5] years). Mean TD CI was 3.4 +/-1.0L/min/m(2) (range, 2.0-6.0L/min/m(2)). The bias was 0.6L/min/m(2) (95% confidence limits [CLs], 0.4-0.8 L/min/m(2)), and the mean percentage error was 56% (95% CLs, 45%-65%). Twenty-two Doppler profiles (28%) were classed as acceptable; the mean percentage error for these was 62% (95% CLs, 38%-65%). On 15/19 occasions (74%) where TD CI changed > 15%, USCOM CI also changed >15%, but three of these changes (16%) were in the opposite direction. USCOM CI changed >15% on 9/20 occasions (45%) when TD CI did not. CONCLUSIONS: Poor agreement with TD and a substantial rate of failure to obtain an USCOM measurement suggest that this device is unsuitable as a monitoring tool in intensive care.