The burden of prenatal and early life maternal substance use among children at risk of maltreatment: A systematic review.

ISSUES: Although maternal substance use is a known risk factor for child maltreatment, evidence on the scale of substance use is needed to inform prevention responses. This systematic review synthesised prevalence estimates of maternal substance use during pregnancy and early life among children at risk of maltreatment. Ovid, Pubmed, CINAHL, PsychInfo and ProQuest databases were searched. We included observational studies that sampled children at risk of maltreatment in high-income countries and reported information on maternal substance use during pregnancy and/or the child's first year of life. We extracted study characteristics and data to calculate prevalence, assessed risk of bias and conducted a narrative synthesis; there were insufficient comparable populations or outcomes to quantitatively synthesise results. KEY FINDINGS: Thirty five of 14,084 titles were included. Fifteen studies had adequately sized and representative samples to estimate prevalence. Maternal substance use prevalence ranged from 2.4% to 40.6%. Maternal substance use was highest among infants referred to child protection at birth (40.6%) and children in out-of-home care (10.4% to 37.2%). Prevalence was higher when studies defined substance use more broadly and when maternal substance use was ascertained from both child and mother records. IMPLICATIONS: Supportive, coordinated responses to maternal substance use are needed from health and child protection services, spanning alcohol and other drug treatment, antenatal and postnatal care. CONCLUSIONS: Prenatal and early life maternal substance use is common among child maltreatment populations, particularly among younger children and those with more serious maltreatment.

Improving the handover of complex trauma patients by implementing a standardised process.

BACKGROUND: Patient handover continues to be an international health priority in the prevention of patient harm. Transitioning patients from the intensive care unit (ICU) to the ward is complex, particularly for trauma patients, due to the multifaceted aspects of their care requirements as a result of multiple injuries and different speciality teams. OBJECTIVES/AIM: To design, implement, and evaluate the efficacy of a standardised handover process and tool for the transfer of ICU trauma patients. METHODS: A multimethod before/after study design was used. This included observations before and after an implemented transfer process and semistructured interviews with ICU and ward nurses caring for trauma patients. Comparisons were made of data before and after the intervention. RESULTS: Eleven patient handovers were observed, and 21 nurses (11 from the ICU and 10 from the ward) were interviewed. Patients and family members were included during the handover following the intervention (n = 0/10 [0%] vs n = 4/11 [36%]) and the ward nurses were asked if they had any concerns (n = 5/10 [50%] vs n = 10/11 [91%]). Improvements in patient observations handed over were reported following the intervention. However, omissions remained in some key areas including patient introduction, patient identity, fluid balance, and allergies/alerts. Thematic analysis of interviews revealed that the new handover process was perceived advantageous by both ICU and ward nurses because of its structured and comprehensive approach. Identified future improvements included the need for hospital service managers to ensure integration of ICU and ward electronic health record systems. CONCLUSION: Precise, accurate, and complete handover remains a patient safety concern. Improvements were achieved using a standardised process and handover tool for the transfer of complex trauma patients. Further improvements are required to reduce the failure to hand over essential patient information.

Dying in intensive care: An analysis of the perspectives of families and clinicians on end-of-life care.

BACKGROUND: Despite a growing body of research into end-of-life care (EOLC) in intensive care units (ICUs), few studies have concurrently explored the perspectives of families and clinicians. OBJECTIVE: The objective of this study was to identify the characteristics of high-quality EOLC in the ICU from family and clinician perspectives and by examining the care documented in medical records. METHODS: A convergent mixed-methods study incorporating electronic health record audits (n = 20), structured interview surveys with families (n = 20), clinician surveys (n = 189), and focus groups (n = 10) was undertaken at a 30-bed, level 3 ICU at a metropolitan public adult teaching hospital in Australia. Descriptive statistics were calculated from quantitative data, and inductive thematic analysis was used to analyse qualitative data. RESULTS: Overall, families were very satisfied with EOLC and the quality of communication yet, felt that earlier, clearer communication that the patient was dying was required. Families spoke of the attentiveness, or lack thereof, by ICU clinicians and the opportunity to be present for the patient's death. The majority of ICU clinicians felt EOLC could be improved. Nurses highlighted communication challenges when family meetings were delayed. Some nurses expressed a lack of clarity of how to withdraw care, resulting in hesitancy to cease potentially inappropriate care, and to provide EOLC outside ICU practice norms. In many instances, observations, invasive monitoring, and interventions were documented after EOLC commenced. A lack of documented personal cares was also noted. CONCLUSIONS: This study provides new insights into EOLC from the dual perspectives of families and clinicians. There is a need for institutional guidelines to support ICU clinicians' EOLC practices and education to improve clinician confidence with communication.

Fostering positive emotions, psychological well-being, and productive relationships in the intensive care unit: A before-and-after study.

BACKGROUND: Intensive care units (ICUs) are emotionally demanding workplaces. Exposure to stress can negatively impact ICU staff members' emotional resilience, health, and capacity to provide care. Despite recognition of the benefits of promoting "healthy workplaces", there are limited interventional studies aimed at improving the well-being of ICU staff. AIM: The aim of this study was to assess the effectiveness of a multifaceted intervention for improving well-being of staff working in a tertiary ICU. METHODS: A before-and-after interventional study was conducted over a 2-year period, between 2019 and 2021. Interventions included social activities, fitness, nutrition, and emotional support. An electronic version of the PERMA-Profiler questionnaire was used to assess the well-being of a convenience sample of ICU staff before (n = 96) and after (n = 137) the intervention. Ten focus groups (each involving 12-18 nurses) were held to explore nurses' perceptions of the intervention's effectiveness. RESULTS: After the intervention, a significantly greater proportion of participants described their work week as draining (32% vs 19%, χ2 = 4.4 df + 1, P = 0.03) and at least a bit harder than normal (38% vs 22%, χ2 = 6.4 df + 1, p = 0.01) compared to baseline surveys. However, well-being scores after the intervention (mean = 6.95, standard deviation = 1.28) were not statistically different (p = 0.68) from baseline scores (mean = 7.02, standard deviation = 1.29). Analysis of focus groups data revealed three key categories: boosting morale and fostering togetherness, supporting staff, and barriers to well-being. CONCLUSIONS: After the intervention, there was a preserved level of well-being from baseline despite a statistically significant increase in staff reporting the work week as draining and at least a little bit harder than normal. These findings must be considered in light of the COVID-19 pandemic, which started after baseline data collection and continues to impact the community, including staff workload and pressures in intensive care. The study findings may inform strategies for improving ICU staff members' well-being.

Reproductive Outcomes in Young Breast Cancer Survivors Treated (15-39) in Ontario, Canada.

We conducted a population-based, retrospective, matched-cohort study to examine the impact of breast cancer diagnosis and treatment on fertility outcomes. Relative risks of infertility, childbirth, premature ovarian insufficiency (POI; age < 40) and early menopause (age < 45) were calculated using modified Poisson regression. Our primary cohort included young women (15-39) with early stage BC diagnosed 1995-2014. Five cancer-free patients were matched to each BC patient by birth year and census subdivision. The BC cohort was further divided by treatment with chemotherapy vs. no chemotherapy treatment. 3903 BC patients and 19,515 cancer-free women. BC patients treated with chemotherapy were at increased risk of infertility (RR 1.81; 95% CI 1.60-2.04), and POI (RR 6.25; 95% CI 5.15-7.58) and decreased childbirth (RR 0.85; 95% CI 0.75-0.96), compared to women without cancer. BC patients who did not receive chemotherapy were also at increased risk of infertility (RR 1.80 95% CI 1.48-2.18) and POI (RR 2.12 95% CI 1.37-3.28). All young BC survivors face an increased risk of diagnosed infertility and POI relative to women without cancer, independent of chemotherapy. These results emphasize the importance of pre-treatment fertility counselling for young women diagnosed with BC.

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.

Interruptions to Intensive Care Nurses and Clinical Errors and Procedural Failures: A Controlled Study of Causal Connection.

OBJECTIVES: Interruptions occur frequently in the intensive care unit (ICU) and are associated with errors. To date, no causal connection has been established between interruptions and errors in healthcare. It is important to know whether interruptions directly cause errors before implementing interventions designed to reduce interruptions in ICUs. The aim of the study was to investigate whether ICU nurses who receive a higher number of workplace interruptions commit more clinical errors and procedural failures than those who receive a lower number of interruptions. METHODS: We conducted a prospective controlled trial in a high-fidelity ICU simulator. A volunteer sample of ICU nurses from a single unit prepared and administered intravenous medications for a patient manikin. Nurses received either 3 (n = 35) or 12 (n = 35) scenario-relevant interruptions and were allocated to either condition in an alternating fashion. Primary outcomes were the number of clinical errors and procedural failures committed by each nurse. RESULTS: The rate ratio of clinical errors committed by nurses who received 12 interruptions compared with nurses who received 3 interruptions was 2.0 (95% confidence interval = 1.41-2.83, P < 0.001). The rate ratio of procedural failures committed by nurses who received 12 interruptions compared with nurses who were interrupted 3 times was 1.2 (95% confidence interval = 1.05-1.37, P = 0.006). CONCLUSIONS: More workplace interruptions during medication preparation and administration lead to more clinical errors and procedural failures. Reducing the frequency of interruptions may reduce the number of errors committed; however, this should be balanced against important information that interruptions communicate.

A pilot randomised controlled trial of dressing and securement methods to prevent arterial catheter failure in intensive care.

BACKGROUND: Critically ill patients in an intensive care setting often require arterial catheters for blood pressure monitoring and arterial blood collection. Arterial catheter failure, which manifests in both mechanical and infective forms, remains common. Dressing and securement inadequacies may impact this failure; however, the best method for dressing and securing arterial catheters is yet to be determined. OBJECTIVES: The objective of this study was to establish the feasibility of a definitive randomised controlled trial comparing methods for dressing and securing arterial catheters and to prevent device failure in an adult intensive care setting. METHODS: A pilot, parallel-group, randomised controlled trial was conducted between April 2017 and June 2018. Patients receiving treatment in two adult intensive care units (Queensland, Australia) were eligible for inclusion and were allocated to receive either (i) an integrated securement dressing or (ii) a simple polyurethane dressing (with gauze/foam), applied to their newly inserted arterial catheters. MAIN OUTCOME MEASURES: Primary outcomes were (i) feasibility (defined by pre-established criteria: patient eligibility, consent, protocol adherence, retention, and staff acceptability) and (ii) all-cause arterial catheter failure (a composite of local and bloodstream infection, occlusion, dislodgement, infiltration/extravasation, arterial inflammation, thrombosis, and/or inaccurate trace). Secondary outcomes included: failure type, dwell time, dressing adhesion, adverse event profiles, and staff acceptability. RESULTS: In total, 109 patients were studied (n = 53 integrated securement dressing; n = 56 simple polyurethane). The feasibility criterion was met by most patients (including rates of consent [86%], protocol adherence [93%], and retention [100%]); however, the criteria for patient eligibility were not met (73%). All-cause device failure did not differ significantly between the integrated securement device group (n = 12/53, 23%) and the simple polyurethane group (n = 6/56, 11%) (hazard ratio = 2.39, 95% confidence interval = 0.89-6.37, p = 0.083). CONCLUSIONS: Findings indicate a larger study is feasible, with minor alterations to recruitment methods required. Arterial catheter failure remains unacceptably common; further research to determine optimal dressing/securement practices is urgently needed.

Handover practices of nurses transferring trauma patients from intensive care units to the ward: A multimethod observational study.

Poor-quality patient handover leads to adverse patient outcomes. Consequently, handover has been identified as a national and international priority for preventing patient harm. Risks are exacerbated during transfers of trauma intensive care unit (ICU) patients to a ward because of the complexity of their injuries coupled with a de-escalation in care and monitoring. This study assessed current handover practices for ICU trauma patients, identifying barriers and facilitators to best practice handover. A multimethod design was used, including naturalistic observations of clinical handover of trauma patients transferred to a ward and semistructured interviews with both the ICU and ward nurses caring for the trauma patient. The study was conducted at an Australian metropolitan public adult teaching hospital ICU. Purposive maximal sampling of patient handover opportunities was sought. Recruitment continued until data saturation was reached using thematic analysis. Ten ICU and ward nurses were recruited, with 10 observations of handover and 20 interviews conducted. Observations of the handovers identified multiple issues, including deficits and discrepancies in the information communicated that could impact patient safety, variable handover processes, and poor patient and family involvement. Interviews elicited two major themes around the handover: practices and processes. Nurses identified that interruptions, time, and workload pressures presented barriers to handover, whilst teamwork, using a structured and systematic approach, preparation time for handover, and communication before transfer facilitated effective handover and transfer. Nurses suggested a structured tool to aid handover. This study identified clinically significant deficits and discrepancies in the information communicated to the ward nurses. Nurses identified that interruptions, time, and workload pressures presented barriers to effective handover. Teamwork where preparation and the handover event are prioritised over other activities is needed. A minimum data set for handover in conjunction with patients and family members is recommended.

Feasibility and acceptability of conducting a partially randomised controlled trial examining interventions to improve psychological health after discharge from the intensive care unit.

BACKGROUND: Interventions to support psychological recovery after critical illness, including information provision via an intensive care unit (ICU) diary or discharge summary, have been widely adopted in some regions, albeit without strong empirical evidence. OBJECTIVE: The objective of this study was to examine the feasibility and acceptability, for patients, family members, and clinicians, of information provision via an ICU diary or discharge summary to support psychological recovery for critical illness survivors. METHODS: This was a pilot, partially randomised patient preference study in a mixed ICU in a tertiary hospital in Australia. Eligible patients were those in the ICU for >24 h and who were able to converse in English. Interventions were ICU diary or discharge summary compared with usual care. Feasibility was assessed throughout the study process, and acceptability assessed 3 and 6 months after hospital discharge, with data analysed descriptively and thematically. RESULTS: Sixty-one patients were recruited; 45 completed 3-month follow-up (74%), and 37 (61%), 6-month follow-up. Participants were medical (39%), surgical (30%), and trauma (31%) patients; aged 55 [interquartile range (IQR): 36-67] years; and stayed in the ICU for 7 [IQR: 3-13] days and hospital for 23 [IQR: 14-32] days. Within the partially randomised framework, 34 patients chose their intervention - four chose usual care, 10 ICU diary, and 20 discharge summary. The remaining 27 patients were randomised - nine usual care, 10 ICU diary, and seven discharge summary. The majority (>90%) considered each intervention helpful during recovery; however, a significant proportion of patients reported distress associated with reading the ICU diary (42%) or discharge summary (15%). Clinicians reported they were hesitant to make diary entries. CONCLUSIONS: When given a choice, more patients chose a discharge summary over the ICU diary or usual care. Participants considered both interventions acceptable. Given the reports of distress associated with information provision, clear empirical evidence is required to determine effectiveness, optimal timing, support needed, and for whom they should be used. CLINICAL TRIAL REGISTRATION NUMBER: ACTRN12615001079538.

Central venous access device Securement and dressing effectiveness: The CASCADE pilot randomised controlled trial in the adult intensive care.

INTRODUCTION: Central venous access devices (CVADs) are a vital medical device for intensive care (ICU) patients; however, complications and failure are common, yet potentially prevented through effective dressings and securement. OBJECTIVES/AIMS: The objective of this study was to test the feasibility of a randomised controlled trial (RCT) comparing standard care with three dressing and securement products to prevent CVAD failure. Secondary aims included comparing dressing and securement products on CVAD failure, microbial colonisation, and intervention costs. METHODS: A single-centre pilot RCT of ICU adult patients requiring CVADs for >24 h were randomised to four groups: (i) sutures plus chlorhexidine gluconate (CHG) dressing (standard care); (ii) standard care plus tissue adhesive (TA); (iii) two sutureless stabilisation devices (SSD) plus CHG dressing; (iv) sutures, CHG disc plus integrated securement dressing (ISD). Descriptive statistics assessed feasibility. Incidence rates (IRs) of CVAD failure were reported, with group differences compared using the Fisher exact and log-rank tests. Cox regression explored univariable risks for failure. A substudy examined bacterial colonisation of catheter tips, dressings, and skin. Cost estimates of the intervention were compared. RESULTS: A total of 121 participants were randomised. Study feasibility was established with no withdrawal and moderate staff acceptability; however, recruitment was low at 12%. Overall CVAD failure was seen in 14 of 114 (12%) CVADs (19 per 1000 catheter-days); highest in the SSD group (IR: 27.3 per 1000 catheter-days [95% confidence interval {CI}: 11.4-65.6]), followed by the standard care group (IR: 22.3 per 1000 catheter-days [95% CI: 8.38-59.5]) and TA group (IR: 20.6 per 1000 catheter-days [95% CI: 6.66-64.0]), and lowest in the ISD group (IR: 8.8 per 1000 catheter-days [95% CI: 2.19-35.0]). The majority of complications (11/14, 79%) were suspected central line-associated bloodstream infection (CLABSI), of which only one was laboratory confirmed (standard care group). The cost per patient was lowest in the standard care group by an average difference of AUD $14. CONCLUSION(S): A large multisite RCT examining forms of securement and dressing is feasible. ISD is the highest priority to test further as it had the lowest failure rate. TRIAL REGISTRATION: ACTRN12615000667516 PROTOCOL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 368765.