The introduction of a sound reduction bundle in the intensive care unit and its impact on sound levels and patients.

BACKGROUND: ICU outcomes are continuing to improve. However, this has not been matched by similar improvements of the ICU bedspace environment, which can detrimentally impact on patient outcomes. Excessive sound and noise, especially, has been linked with adverse and potentially preventable patient outcomes and staff errors. There are many sources of sound in the ICU, with alarms from bedside equipment frequently listed as a main source. The number of alarms is increasing in parallel with the introduction of new and more sophisticated technologies to monitor and support patients. However, most alarms are not accurate or critical and are commonly ignored by staff. OBJECTIVE: The objective of this study was to evaluate the impact of a sound reduction bundle on sound levels, number of alarms, and patients' experience and perceived quality of sleep in the ICU. METHODS: This was a pre-post, quasi-experimental study investigating the impact of three study interventions implemented sequentially (staff education, visual warnings when sound levels exceeded the preset levels, and monitor alarm reconfigurations). Effects of staff education were evaluated using pre-education and post-education questionnaires, and the impact on patients was evaluated via self-report questionnaires. A sound-level monitor was used to evaluate changes in sound levels between interventions. Alarm audits were completed before and after alarm reconfiguration. RESULTS: Staff knowledge improved; however, sound levels did not change across interventions. The number of monthly monitor alarms reduced from 600,452 to 115,927. No significant differences were found in patients' subjective rating of their experience and sleep. CONCLUSION: The interventions did not lead to a sound-level reduction; however, there was a large reduction in ICU monitor alarms without any alarm-related adverse events. As the sources of sound are diverse, multidimensional interventions, including staff education, alarm management solutions, and environmental redesign, are likely to be required to achieve a relevant, lasting, and significant sound reduction.

Does longer peripheral intravenous catheter length optimise antimicrobial delivery? Protocol for the LEADER study.

BACKGROUND: Hospitalised patients receiving intravenous antimicrobial therapy require a reliable device through which this is delivered. Short peripheral intravenous catheters (PIVCs) are the default device for antimicrobial therapy but up to half fail before therapy completion, leading to suboptimal drug dosing, patient distress from repeated insertions, and increased healthcare costs. This study will investigate the use of long PIVCs to determine if they are more reliable at delivering antimicrobial therapy. METHODS: A two-arm, parallel randomised controlled trial of hospitalised adults requiring at least 3 days of peripherally compatible intravenous antimicrobials. Participants will be randomised to a short (<4 cm) or long (4.5-6.4 cm) PIVC. After interim analysis ( n=70) for feasibility and safety, 192 participants will be recruited. Primary outcome is disruption to antimicrobial administration from all-cause PIVC failure. Secondary outcomes include: number of devices to complete therapy, patient-reported pain and satisfaction, and a cost analysis. Ethical and regulatory approvals have been received.

A protocol of an international validation study to assess the clinical accuracy of the eDIS-ICU delirium screening tool.

BACKGROUND: Delirium is a common, yet underdiagnosed neuropsychiatric complication of intensive care unit (ICU) admission, associated with significant mortality and morbidity. Delirium can be difficult to diagnose, with gold standard assessments by a trained specialist being impractical and rarely performed. To address this, various tools have been developed, enabling bedside clinicians to assess for delirium efficiently and accurately. However, the performance of these tools varies depending on factors including the assessor's training. To address the shortcomings of current tools, electronic tools have been developed. AIMS AND OBJECTIVES: The aims of this validation study are to assess the feasibility, acceptability, and generalisability of a recently developed and pilot-tested electronic delirium screening tool (eDIS-ICU) and compare diagnostic concordance, sensitivity, and specificity between eDIS-ICU, Confusion Assessment Method for the ICU (CAM-ICU), and the Diagnostic and Statistical Manual of Mental Disorders - 5th edition (DSM-V) gold standard in diverse ICU settings. METHODS: Seven hundred participants will be recruited across five sites in three countries. Participants will complete three assessments (eDIS-ICU, CAM-ICU, and DSM-V) twice within one 24-h period. At each time point, assessments will be completed within one hour. Assessments will be administered by three different people at any given time point, with the assessment order and assessor for eDIS-ICU and CAM-ICU randomly allocated. Assessors will be blinded to previous and concurrent assessment results. RESULTS: The primary outcome is comparing diagnostic sensitivity of eDIS-ICU and CAM-ICU against the DSM-V. RELEVANCE TO CLINICAL PRACTICE: This protocol describes a definitive validation study of an electronic diagnostic tool to assess for delirium in the ICU. Delirium remains a common and difficult challenge in the ICU and is linked with multiple neurocognitive sequelae. Various challenges to routine assessment mean many cases are still unrecognised or misdiagnosed. An improved ability for bedside clinicians to screen for delirium accurately and efficiently will support earlier diagnosis, identification of underlying cause(s) and timely treatments, and ultimately improved patient outcomes. CLINICAL TRIAL REGISTRATION NUMBER: This study was prospectively registered on the Australian New Zealand Clinical Trials Registry (ANZCTR) on 8th February 2022 (ACTRN12622000220763).

Securing jugular central venous access devices with dressings fixed to a liquid adhesive in an intensive care unit population: a randomised controlled trial.

BACKGROUND: Central venous access devices (CVADs) can have high rates of failure due to dressing-related complications. CVADs placed in the internal jugular vein are at particular risk of dressing failure-related complications, including catheter-associated bloodstream infection and medical adhesive-related skin injury. Application of Mastisol liquid adhesive (MLA) may reduce CVAD dressing failure and associated complications, by reducing the frequency of dressing changes. The aim of this study is to investigate whether, in an intensive care unit (ICU) population, standard dressing care with or without the addition of MLA, improves internal jugular CVAD dressing adherence. METHODS: This two-arm, parallel group randomised controlled trial will be conducted in three Australian ICUs. A total of 160 patients (80 per group) will be enrolled in accordance with study inclusion and exclusion criteria. Patients will be randomised to receive either (1) 'standard' (in accordance with local hospital policy) CVAD dressings (control) or (2) 'standard' dressings in addition to MLA (intervention). Patients will be followed from the time of CVAD insertion to 48 h after CVAD removal. The primary outcome is 'dressing failure' defined as requirement for initial CVAD dressing to be replaced prior to seven days (routine replacement). DISCUSSION: This study will be the first randomised controlled trial to evaluate the clinical effectiveness of MLA in the adult intensive care unit population and will also provide crucial data for patient-important outcomes such as infection and skin injury. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621001012864 . Registered on 2 August 2021.

Unnecessary removal of vascular access devices due to suspected infection in Australian intensive care units.

BACKGROUND: Vascular access devices suspected of infection are often removed unnecessarily and frequently require replacement. The aim of this study was to identify the prevalence and economic impact of premature, unnecessary device removal due to suspected infection in adult patients admitted to the intensive care unit. METHODS: Secondary data analysis of a prospectively collected data set detailing central venous catheters and peripheral arterial catheters in 1458 adult patients was conducted in nine Australian intensive care units. Data extracted from the parent database included patient demographics, device, and infection-specific data including the reason for device removal. Cost estimates were based on a recently published review of device utilisation and associated costs in Queensland public hospitals. RESULTS: A total of 6144 central venous catheter days and 4696 arterial catheter days were studied. Median device dwell time was 7.2 (interquartile range: 5.6-9.0) days for central venous catheters and 6.5 (interquartile range: 4.8-8.5) days for arterial catheters. Device removal due to suspected infection occurred at a rate of 25.7 and 15.3 episodes/1000 catheter days in central venous and arterial catheters, respectively. Central venous and arterial catheter-related bloodstream infections occurred at a rate of 1.8 and 0.2 episodes/1000 catheter days, respectively. Central line-associated bloodstream infection occurred at a rate of 3.3 episodes/1000 catheter days. Local central venous and arterial catheter infection occurred at 0.16 and 0.02 episodes/1000 catheter days, respectively. The difference in incidence between devices suspected of infection and those responsible for infection resulted in AUD$67,087 unnecessarily spent on device replacement. CONCLUSIONS: Unnecessary device removal due to suspected infection presents a substantial clinical problem which is costly for the healthcare organisation and time-consuming for clinicians and places the patient at an increased risk of iatrogenic complications. There is a need for robust evidence and clinical practice guidelines to inform clinical decision-making to reduce unnecessary device removal.

Polyhexamethylene biguanide discs versus unmedicated dressings for prevention of central venous catheter-associated infection in the intensive care unit: A pilot randomised controlled trial to assess protocol safety and feasibility.

BACKGROUND: Central venous catheters are prone to infectious complications, affecting morbidity, mortality and healthcare costs. Polyhexamethylene biguanide-impregnated discs at the catheter insertion site may prevent local and bloodstream infection; however, efficacy has not been established in a critical care setting. OBJECTIVE: The objective of this study was to pilot test polyhexamethylene biguanide-impregnated discs compared to standard unmedicated dressings for central venous catheter infection prevention in critically ill patients. METHODS: This was a single-centre pilot randomised controlled trial. Adults admitted to intensive care requiring a central venous catheter for >72 h were eligible. Patients with a current bloodstream infection, concurrent central venous catheter, chlorhexidine or polyhexamethylene biguanide allergy, or sensitive skin were excluded. Patients were randomised to receive standard central venous catheter dressings with/without polyhexamethylene biguanide discs. OUTCOME MEASURES: The primary outcome was feasibility, defined by patient eligibility, recruitment, retention, protocol adherence, missing data, and staff satisfaction. Secondary outcomes included: central line-associated infection; primary bloodstream infection; local infection; skin complications; device/dressing dwell time; serious adverse events, and cost-effectiveness. RESULTS: Of 309 patients screened, 80 participants were recruited with 98% (n = 78) receiving an internal jugular catheter which dwelled for a median of 5 days (interquartile range = 4.0, 6.0). Feasibility criteria were predominantly met (recruitment 88%; retention 100%; protocol fidelity 91%); however, eligibility criteria were not met (32%; most commonly owing to short predicted catheter dwell). Staff acceptability criteria were met, with 83% of staff scoring dressing application and removal ≥7 on a numerical rating scale. There were no central line-associated bloodstream infections and no local infections. Insertion site itch occurred in 4% (control [n = 0], intervention [n = 3]) of participants, while 32% (24/76) reported pain, and 46% (35/76) tenderness. CONCLUSIONS: Polyhexamethylene biguanide discs appear safe for central venous catheter infection prevention. Feasibility of a large efficacy trial was established with some modifications to screening processes. Large, adequately powered randomised controlled trials are needed to test the infection prevention hypotheses.

Pressure injury prevalence in Australian intensive care units: A secondary analysis.

BACKGROUND: Pressure injuries (PIs) are an enduring problem for patients in the intensive care unit (ICU) because of their vulnerability and numerous risk factors. METHOD: This study reports Australian data as a subset of data from an international 1-day point prevalence study of ICU-acquired PI in adult patients. Patients aged 18 years or older and admitted to the ICU on the study day were included. The outcome measure was the identification of a PI by direct visual skin assessment on the study day. Data collected included demographic data and clinical risk factors, PI location and stage, and PI prevention strategies used. Descriptive statistics were used to describe PI characteristics, and odds ratios (ORs) were used to identify factors associated with the development of a PI. RESULTS: Data were collected from 288 patients from 16 Australian ICUs. ICU-acquired PI prevalence was 9.7%, with 40 PIs identified on 28 patients. Most PIs were of stage 1 and stage 2 (26/40, 65.0%). Half of the ICU-acquired PIs were found on the head and face. The odds of developing an ICU-acquired PI increased significantly with renal replacement therapy (OR: 4.25, 95% confidence interval [CI]: 1.49-12.11), impaired mobility (OR: 3.13, 95% CI: 1.08-9.12), fastest respiratory rate (OR: 1.05 [per breath per minute], 95% CI: 1.00-1.10), longer stay in the ICU (OR: 1.04 [per day], 95% CI: 1.01-1.06), and mechanical ventilation on admission (OR: 0.36, CI: 0.14-0.91). CONCLUSION: This study found that Australian ICU-acquired PI prevalence was 9.7% and these PIs were associated with many risk factors. Targeted PI prevention strategies should be incorporated into routine prevention approaches to reduce the burden of PIs in the Australian adult ICU patient population.

Tissue adhesives for bacterial inhibition in extracorporeal membrane oxygenation cannulae.

BACKGROUND: One of the most serious complications of extracorporeal membrane oxygenation (ECMO) therapy is ECMO cannulae infection, which can occur at quadruple the rate of central venous catheter infections, and significantly impact morbidity and paediatric mortality. The objective of this in vitro observational study was to assess antimicrobial properties of two n-butyl-2-octyl cyanoacrylate tissue adhesive (TA) formulations for bacterial inhibition at peripheral ECMO cannulae insertion sites. METHODS: Antimicrobial properties were assessed using modified agar disk-diffusion (n = 3) and simulated agar cannulation insertion site (n = 20) models. Both assays used Staphylococcus epidermidis which was seeded at the edge of the TA or dressing. Microorganism inhibition was visually inspected and evidenced by the presence or absence of a TA bacterial inhibition zone at 24 and 72 h. RESULTS: Both TAs provided effective barriers to bacterial migration under cannula dressings, to cannula insertion sites and down cannula tunnels. Additionally, both TAs demonstrated distinct zones of inhibition produced when left to polymerise onto agar plates seeded with S. epidermidis. CONCLUSIONS: N-Butyl-2-octyl cyanoacrylate TA appears to inhibit bacterial growth and migration of S. epidermidis. Application of TA to cannulae insertion sites may therefore be a potential bedside strategy for infection prevention in ECMO cannulae, but requires further testing before being used clinically for this purpose.

In vitro testing of cyanoacrylate tissue adhesives and sutures for extracorporeal membrane oxygenation cannula securement.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO), an invasive mechanical therapy, provides cardio-respiratory support to critically ill patients when maximal conventional support has failed. ECMO is delivered via large-bore cannulae which must be effectively secured to avoid complications including cannula migration, dislodgement and accidental decannulation. Growing evidence suggests tissue adhesive (TA) may be a practical and safe method to secure vascular access devices, but little evidence exists pertaining to securement of ECMO cannulae. The aim of this study was to determine the safety and efficacy of two TA formulations (2-octyl cyanoacrylate and n-butyl-2-octyl cyanoacrylate) for use in peripherally inserted ECMO cannula securement, and compare TA securement to 'standard' securement methods. METHODS: This in vitro project assessed: (1) the tensile strength and flexibility of TA formulations compared to 'standard' ECMO cannula securement using a porcine skin model, and (2) the chemical resistance of the polyurethane ECMO cannulae to TA. An Instron 5567 Universal Testing System was used for strength testing in both experiments. RESULTS: Securement with sutures and n-butyl-2-octyl cyanoacrylate both significantly increased the force required to dislodge the cannula compared to a transparent polyurethane dressing (p = 0.006 and p = 0.003, respectively) and 2-octyl cyanoacrylate (p = 0.023 and p = 0.013, respectively). Suture securement provided increased flexibility compared to TA securement (p < 0.0001), and there was no statistically significant difference in flexibility between 2-octyl cyanoacrylate and n-butyl-2-octyl cyanoacrylate (p = 0.774). The resistance strength of cannula polyurethane was not weakened after exposure to either TA formulation after 60 min compared to control. CONCLUSIONS: Tissue adhesive appears to be a promising adjunct method of ECMO cannula insertion site securement. Tissue adhesive securement with n-butyl-2-octyl cyanoacrylate may provide comparable securement strength to a single polypropylene drain stitch, and, when used as an adjunct securement method, may minimise the risks associated with suture securement. However, further clinical research is still needed in this area.