Effects of a multifaceted intervention QI program to improve ICU performance.

BACKGROUND: To benefit from the increasing clinical evidence, organisational changes have been among the main drivers behind the reduction of ICU mortality during the last decade. Increasing demand, costs and complexity, amplifies the need for optimisation of clinical processes and resource utilisation. Thus, multidisciplinary teamwork and critical care processes needs to be adapted to profit from increased availability of human skill and technical resources in a cost-effective manner. Inadequate clinical performance and outcome data compelled us to design a quality improvement project to address current work processes and competence utilisation. METHODS: During revision period, clinical processes, professional performance and clinical competence were targeted using "scientific production management methodology" approach. As part of the project, an intensivist training program was instituted, and full time intensivist coverage was obtained in the process of creating multi-professional teams, composed of certified intensivists, critical care nurses, assistant nurses, physiotherapists and social counsellors. The use of staff resources and clinical work-processes were optimised in accordance with the outcome of a "value stream mapping". In this process, efforts to enhance the personal dynamics and performance within the teams were paramount. Clinical and economic outcome data were analysed during a seven year follow up period. RESULTS: • Consecutive reduced overall ICU (24%) and long-term (600 days) mortality. The effect on ICU mortality was especially pronounced in the subgroup of patients > 65 years (30%) • Consecutive reduced length of stay (43%, septic patients) and time on ventilator (for septic patients and patients > 65 years of age (23 resp.52%). • Substantial increase in life years gained (13,140 life years) as well as quality-adjusted life-years (9593 QALY: s) over the study period. • High cost-effectiveness as ICU costs were  reduced while patient outcomes were improved. Disregarding the cost reduction in ICU, the intervention is highly cost effective with cost- effectiveness ratios of (75€/QALY) and (55€ / life year) CONCLUSIONS: We have shown favourable results of a QI project aiming to improve the clinical performance and quality through the development of multi-professional interaction, teamwork and systematic revisions of work processes. The economic evaluation shows that the intervention is highly cost-effective and potentially dominating.

Driving for successful change processes in healthcare by putting staff at the wheel.

Purpose The purpose of this paper is to describe five salient factors that emerge in two successful change processes in healthcare. Organizational changes in healthcare are often characterized by problems and solutions that have been formulated by higher levels of management. This top-down management approach has not been well received by the professional community. As a result, improvement processes are frequently abandoned, resulting in disrupted and dysfunctional organizations. This paper presents two successful change processes where managerial leadership was used to coach the change processes by distributing mandates and resources. After being managerially initiated, both processes were driven by local agency, decisions, planning and engagement. Design/methodology/approach The data in the paper derive from two qualitative case studies. Data were collected through in-depth interviews, observations and document studies. The cases are presented as process descriptions covering the different phases of the change processes. The focus in the studies is on the roles and interactions of the actors involved, the type of leadership and the distribution of agency. Findings Five factors emerged as paramount to the successful change processes in the two cases: local ownership of problems; a coached process where management initiates the change process and the problem recognition, and then lets the staff define the problems, formulate solutions and drive necessary changes; distributed leadership directed at enabling and supporting the staff's intentions and long-term self-leadership; mutually formulated norms and values that serve as a unifying force for the staff; and generous time allocation and planning, which allows the process to take time, and creates room for reevaluation. The authors also noted that in both cases, reorganization into multi-professional teams lent stability and endurance to the completed changes. Originality/value The research shows how management can initiate and support successful change processes that are staff driven and characterized by local agency, decisions, planning and engagement. Empirical descriptions of successful change processes are rare, which is why the description of such processes in this research increases the value of the paper.

Clinical experience and incidence of ventilator-associated pneumonia using closed versus open suction-system.

BACKGROUND: Studies have shown a decreasing ventilator-associated pneumonia (VAP) incidence after prophylactic interventions bundles. The use of closed suction systems (CSS) has been suggested beneficial as a prophylactic measure. AIM: To investigate the effects of a CSS on VAP incidence, suction circuit contamination and adverse events (AEs) compared to an open suction system (OSS) approach in a general mixed intensive care unit (ICU). METHODS: Adult patients on mechanical ventilation were consecutively included. Data were collected during four 1-month periods where CSS and OSS were used on an alternating basis. Airway cultures were obtained at intubation, after 72 h and every Monday. After changing CSS and at extubation, the catheter tip was cultured. AEs and desaturation events during suction were monitored. ANALYSE: Descriptive analysis and differences between the groups were analysed using comparative methods. RESULTS: No differences in airway colonization at admission between the groups were detected (Table 2). The CSS group had a higher Simplified Acute Physiology Score (SAPS) III and also a non-significant increase in VAP incidence. Positive cultures were obtained in 50% of all the retrieved CSS catheters. There was no inter-patient contamination in either group. Six AEs versus one (CSS/OSS) related to tube-occlusion and secretion clogging was seen. Desaturations at suctioning were rare in both groups. CONCLUSION: No beneficial effects were seen on VAP incidence or inter-patient contamination compared to OSS. A high frequency of circuit contamination in the CSS group paralleled with experienced secretions clearance problems seem unfavourable and in concordance with previous studies.

Preferred content and usefulness of a photodiary as described by ICU-patients--a mixed method analysis.

UNLABELLED: Many ICU-patients have memory-gaps which may affect their recovery. A tool in the recovery can be an ICU-diary to explain and clarify thoughts and events from the ICU-period. There are different standards for the content in the ICU-diary. The aim of this study was to identify the preferred content and usefulness of an ICU-diary as described by ICU-patients. METHOD: A descriptive, exploratory cohort design with a mixed method approach. The patients answered a questionnaire (n=115) and participated in an interview (n=15) six months after the ICU-stay. Data analysis was carried out in three stages; the questionnaire was analysed by descriptive statistics and categorised by content (four open-ended questions) and the interviews were analysed by manifest content analysis. RESULTS: The patients were explained that detailed information about daily activities and medical facts had to be included to understand and give a sense of coherence of what had happened. The content in the ICU-diary had to be chronological in order to follow the process in which photos were an important part. The patients re-read the ICU-diary during the recovery which helped them to fill in the memory gaps and used it as a tool for communication. CONCLUSION: To construct a coherent story, it was essential that the ICU-diary was complete and were amplified by photos, all appearing in a chronological order. The results of this study could form a basis for further developments of standards and guidelines for ICU-diaries.

Psychometric evaluation of 3-set 4P questionnaire.

This is a further development of a specific questionnaire, the 3-set 4P, to be used for measuring former ICU patients' physical and psychosocial problems after intensive care and the need for follow-up. The aim was to psychometrically test and evaluate the 3-set 4P questionnaire in a larger population. The questionnaire consists of three sets: "physical", "psychosocial" and "follow-up". The questionnaires were sent by mail to all patients with more than 24-hour length of stay on four ICUs in Sweden. Construct validity was measured with exploratory factor analysis with Varimax rotation. This resulted in three factors for the "physical set", five factors for the "psychosocial set" and four factors for the "follow-up set" with strong factor loadings and a total explained variance of 62-77.5%. Thirteen questions in the SF-36 were used for concurrent validity showing Spearman's r(s) 0.3-0.6 in eight questions and less than 0.2 in five. Test-retest was used for stability reliability. In set follow-up the correlation was strong to moderate and in physical and psychosocial sets the correlations were moderate to fair. This may have been because the physical and psychosocial status changed rapidly during the test period. All three sets had good homogeneity. In conclusion, the 3-set 4P showed overall acceptable results, but it has to be further modified in different cultures before being considered a fully operational instrument for use in clinical practice.

Extravascular lung water index improves the diagnostic accuracy of lung injury in patients with shock.

INTRODUCTION: The diagnosis of acute lung injury (ALI) may be more robust if more accurate physiological markers can be identified. Extravascular lung water (EVLW) is one possible marker, and it has been shown to correlate with respiratory function and mortality in patients with sepsis. Whether EVLW confers diagnostic value in a general population with shock, as well as which index performs best, is unclear. We investigated the diagnostic accuracy of various EVLW indices in patients with shock. METHODS: We studied a prospective, observational cohort of 51 patients with shock admitted to a tertiary ICU. EVLW was measured within 6 hours of ICU admission and indexed to actual body weight (EVLW/ABW), predicted body weight (EVLW/PBW) and pulmonary blood volume (EVLW/PBV). The relationship of these indices to the diagnosis and severity of lung injury and ICU mortality were studied. Positive and negative likelihood ratios, pre- and posttest odds for diagnosis of lung injury and mortality were calculated. RESULTS: All EVLW indices were higher among patients with lung injury and significantly correlated with respiratory parameters. Furthermore, all EVLW indices were significantly higher in nonsurvivors. The use of EVLW improves the posttest OR for the diagnosis of ALI, acute respiratory distress syndrome (ARDS) and severe lung injury (sLI) by up to eightfold. Combining increased EVLW and a diagnosis of ALI, ARDS or sLI increases the posttest odds of ICU mortality. EVLW/ABW and EVLW/PBV demonstrated the best diagnostic performance in this population. CONCLUSIONS: EVLW was associated with degree of lung injury and mortality, regardless of the index used, confirming that it may be used as a bedside indicator of disease severity. The use of EVLW as a bedside test conferred added diagnostic value for the identification of patients with lung injury.

Increased plasma levels of heparin-binding protein in patients with shock: a prospective, cohort study.

OBJECTIVE: Heparin-binding protein (HBP) is a potent inducer of increased vascular permeability. The purpose of this study was to examine plasma levels of HBP in patients with shock. DESIGN: Fifty-three consecutive patients with septic and non-septic shock at a mixed-bed intensive care unit were included, as well as 20 age-matched controls. Patients with local infections but without signs of shock served as infectious controls. Enzyme-linked immunosorbent assay was used to determine plasma levels of HBP. RESULTS: There were no differences in serum HBP levels between healthy controls and those with local infections, including urinary tract infections, pneumonia and gastroenteritis, without shock. Levels of HBP were higher in patients with non-septic shock and septic shock than healthy controls. However, there was no difference in serum HBP levels between patients with septic shock and those with non-septic shock. Moreover, HBP levels were not different between patients with low and high APACHE II scores. Plasma levels of HBP were similar in surviving and non-surviving patients with shock. CONCLUSIONS: HBP is elevated in patients with shock from septic and non-septic etiologies. Future investigations are required to define the functional role of HBP in patients with shock.

Assessing left ventricular systolic function in shock: evaluation of echocardiographic parameters in intensive care.

INTRODUCTION: Assessing left ventricular (LV) systolic function in a rapid and reliable way can be challenging in the critically ill patient. The purpose of this study was to evaluate the feasibility and reliability of, as well as the association between, commonly used LV systolic parameters, by using serial transthoracic echocardiography (TTE). METHODS: Fifty patients with shock and mechanical ventilation were included. TTE examinations were performed daily for a total of 7 days. Methods used to assess LV systolic function were visually estimated, "eyeball" ejection fraction (EBEF), the Simpson single-plane method, mean atrioventricular plane displacement (AVPDm), septal tissue velocity imaging (TDIs), and velocity time integral in the left ventricular outflow tract (VTI). RESULTS: EBEF, AVPDm, TDIs, VTI, and the Simpson were obtained in 100%, 100%, 99%, 95% and 93%, respectively, of all possible examinations. The correlations between the Simpson and EBEF showed r values for all 7 days ranging from 0.79 to 0.95 (P < 0.01). the Simpson correlations with the other LV parameters showed substantial variation over time, with the poorest results seen for TDIs and AVPDm. The repeatability was best for VTI (interobserver coefficient of variation (CV) 4.8%, and intraobserver CV, 3.1%), and AVPDm (5.3% and 4.4%, respectively), and worst for the Simpson method (8.2% and 10.6%, respectively). CONCLUSIONS: EBEF and AVPDm provided the best, and Simpson, the worst feasibility when assessing LV systolic function in a population of mechanically ventilated, hemodynamically unstable patients. Additionally, the Simpson showed the poorest repeatability. We suggest that EBEF can be used instead of single-plane Simpson when assessing LV ejection fraction in this category of patients. TDIs and AVPDm, as markers of longitudinal function of the LV, are not interchangeable with LV ejection fraction.

Use and practice of patient diaries in Swedish intensive care units: a national survey.

AIMS AND OBJECTIVES: To describe and compare the extent and application of patients' diaries in Sweden. BACKGROUND: Since 1991, patient diaries have been used in intensive care unit (ICU) follow-up in Sweden. There is paucity of relevant data evaluating the effect of this tool and also on what premises patients are enrolled. Likewise, data are sparse on the diaries' design, content structure and the use of photographs. DESIGN: Descriptive explorative design by a semi-structured telephone interview. METHODS: The interview results were analysed with descriptive statistics and differences between the ICU levels were explored by chi(2) analysis. Qualitative manifest content analysis was performed to explore the purpose of diary writing. RESULTS: Of all ICUs (n = 85), 99% responded and 75% used diaries. The source of inspiration was collegial rather than from scientific data. The main reason for keeping a diary was to help the patient to recapitulate the ICU stay. Discrepancies between the different levels of ICUs were detected in patient selection, dedicated staff for follow-up and the use of photographs. Comparison between the chi(2) analysis and the content analysis outcome displayed incongruence between the set unit-goals and the activities for achievement but did not explain the procedural differences detected. CONCLUSION: The uses of diaries in post ICU follow up were found to be common in Sweden. A majority used defined goals and content structure. However, there were differences in practice and patient recruitment among the levels of ICUs. These discrepancies seemed not to be based on evidence-based data nor on ongoing research or evaluation but merely on professional judgement. As ICU follow-up is resource intense and time consuming, it is paramount that solid criteria for patient selection and guidelines for the structure and use of diaries in post-ICU follow-up are defined.

Platelet-derived CD40L (CD154) mediates neutrophil upregulation of Mac-1 and recruitment in septic lung injury.

OBJECTIVE: To define the role of CD40L in abdominal sepsis. BACKGROUND: Platelets promote sepsis-induced pulmonary recruitment of neutrophils. However, the identity of the platelet-derived molecule regulating neutrophil infiltration is not known. The hypothesis of the present study was that platelet-derived CD40L might be responsible for platelet-mediated activation and accumulation of neutrophils in sepsis. METHODS: Wild-type C57BL/6 mice and CD40L gene-deficient mice were exposed to cecal ligation and puncture (CLP). Lung edema, bronchoalveolar neutrophils, CD40L and macrophage inflammatory protein-2 (MIP-2) plasma levels, myeloperoxidase activity and Mac-1 expression were determined up to 24 hours after CLP induction. For platelet depletion was an anti-GP1balpha antibody administered before CLP. RESULTS: Plasma levels of soluble CD40L increased and surface expression of CD40L on platelets decreased in CLP mice. Platelet depletion reduced CLP-induced CD40L levels by 90%. CLP-provoked Mac-1 expression on neutrophils was abolished in CD40L-deficient mice. Interestingly, CLP-induced edema and myeloperoxidase activity in the lung as well as neutrophil infiltration in the broncoalveolar space were markedly reduced in mice lacking CD40L. In vitro experiments showed that CD40L was not capable of directly increasing Mac-1 levels on neutrophils. Instead, CLP-induced plasma levels of MIP-2 were significantly reduced in CD40L-deficient mice and inhibition of the MIP-2 receptor (CXCR2) decreased Mac-1 expression on neutrophils in septic animals. CONCLUSIONS: CD40L derived from platelets is a potent activator of neutrophils and mediates sepsis-induced neutrophil recruitment and lung edema. The neutrophil activating mechanism of CD40L is indirect and mediated via MIP-2 formation and CXCR2 signaling. Targeting CD40L may be an effective approach to limit pulmonary damage in abdominal sepsis.

Development of the 3-SET 4P questionnaire for evaluating former ICU patients' physical and psychosocial problems over time: a pilot study.

BACKGROUND: Current studies reveal a lack of consensus for the evaluation of physical and psychosocial problems after ICU stay and their changes over time. OBJECTIVES: The aim was to develop and evaluate the validity and reliability of a questionnaire for assessing physical and psychosocial problems over time for patients following ICU recovery. PATIENTS: Thirty-nine patients completed the questionnaire, 17 were retested. METHODS AND RESULTS: The questionnaire was constructed in three sets: physical problems, psychosocial problems and follow-up care. Face and content validity were tested by nurses, researchers and patients. The questionnaire showed good construct validity in all three sets and had strong factor loadings (explained variance >70%, factor loadings >0.5) for all three sets. There was good concurrent validity compared with the SF 12 (r(s)>0.5). Internal consistency was shown to be reliable (Cronbach's alpha 0.70-0.85). Stability reliability on retesting was good for the physical and psychosocial sets (r(s)>0.5). CONCLUSION: The 3-set 4P questionnaire was a first step in developing an instrument for assessment of former ICU patients' problems over time. The sample size was small and thus, further studies are needed to confirm these findings.

The outcome of tactile touch on stress parameters in intensive care: a randomized controlled trial.

The study aimed to investigate the effects of a five-day tactile touch intervention in order to find new and unconventional measures to moderate the detrimental influence of patients' stressors during intensive care. The hypothesis was that tactile touch would decrease stress indicators such as anxiety, glucose metabolism, blood pressure, heart rate and requirements of sedative drugs and noradrenalin. A randomized controlled trial was undertaken with 44 patients, which were assigned either to tactile touch or standard treatment (a rest hour). Observations of the stress indicators were made before, during and after the intervention or standard treatment. The study showed that tactile touch led to significantly lower levels of anxiety. The circulatory parameters suggested increased circulatory stability indicated by a reduction in noradrenalin requirement. The results need to be further validated through studies with larger sample sizes.

[Therapeutic hypothermia after cardiac arrest. A cold intravenous fluid, a cooling helmet and a cooling blanket efficiently reduce body temperature]. / Terapeutisk hypotermi efter hjärtstopp. Kall intravenös vätska, mössa och dräkt sänker kroppstemperaturen effektivt.

Two controlled randomized trials have shown that mild systemic hypothermia after cardiac arrest is beneficial for neurological outcome and one of the studies shows an improved survival rate. A pilot study was performed to evaluate a model of induced hypothermia after cardiac arrest, using cold intravenous fluids and surface cooling with a cold helmet and a coldwater blanket (Thermowrap). The main purpose was to evaluate our cooling method regarding efficacy, safety and usability. Five unconscious patients after cardiac arrest were treated with induced hypothermia of whom three survived with good recovery to six-month follow up. Two patients died in the ICU without regaining consciousness. There were no adverse events during treatment. We conclude that our method is reasonably fast compared to other published methods, it is easy to perform and it offers a good temperature control during cooling and rewarming. Routines for evaluating prognosis and neurological outcome after cardiac arrest and hypothermia treatment need to be revised.

International EMS Systems: the Nordic countries.

Emergency medicine service (EMS) systems in the five Nordic countries have more similarities than differences. One similarity is the involvement of anaesthesiologists as pre-hospital physicians and their strong participation for all critically ill and injured patients in-hospital. Discrepancies do exist, however, especially within the ground and air ambulance service, and the EMS systems face several challenges. Main problems and challenges emphasized by the authors are: (1) Denmark: the dispatch centres are presently not under medical control and are without a national criteria based system. Access to on-line medical advice of a physician is not available; (2) Finland: the autonomy of the individual municipalities and their responsibility to cover for primary and specialised health care, as well as the EMS, and the lack of supporting or demanding legislation regarding the EMS; (3) Iceland is the only country that has emergency medicine (EM) as a recognised speciality but there is a need for more fully trained specialists in EM; (4) Norway: the ordinary ground ambulance is pointed out as the weakest link in the EM chain and a health reform demands extensive co-operation between the new health enterprises to re-establish a nation-wide air ambulance service; (5) Sweden: to create evidence based medicine standards for treatment in emergency medicine, a better integration of all part of the chain of survival, a formalised education in EM and a nation wide physician staffed helicopter EMS (HEMS) cover.

Chronic hyperbaric exposure activates proinflammatory mediators in humans.

Decompression illness (DCI) is an illness affecting divers subjected to reductions in ambient pressure. Besides a mechanical explanation to DCI, an inflammatory mechanism has been suggested. In this study, levels of interleukin (IL)-8, IL-6, IL-1 receptor antagonist (IL-1ra), secretory leukocyte protease inhibitor (SLPI), and neutrophil gelatinase-associated lipocalcin (NGAL) were measured in divers before and after a 2-mo period of daily diving. The divers were military conscripts and completed their diving period with no clinical symptoms of DCI. We found no change in IL-6 and IL1-ra but did find an increase in IL-8 and NGAL together with a decrease in SLPI levels. The findings suggest an inflammatory activation. This activation is not severe because no changes in IL-6 or IL-1ra were found. The increase in NGAL and IL-8 levels were interpreted as a sign of leukocyte activation. The decreased SLPI levels suggest an influence on the inflammatory defense mechanism. All in all, the findings of this study show a compensated activation of the inflammatory defense mechanism without loss of homeostasis of the inflammatory system.