Evaluating the safety and efficacy of regional citrate compared to systemic heparin as anticoagulation for continuous renal replacement therapy in critically ill patients: A service evaluation following a change in practice.

Following the implementation of citrate anticoagulation for continuous renal replacement therapy, we evaluate its first year of use and compare it to the previously used heparin, to assess whether our patients benefit from the recently reported advantages of citrate. We retrospectively analysed 2 years of data to compare the safety and efficacy of citrate versus heparin. The results have shown that 43 patients received continuous renal replacement therapy with heparin, 37 patients with citrate. We found no significant difference in metabolic control of pH, urea and creatinine after 72 h. Filters anticoagulated with citrate had significantly longer median lifespan (33 h vs 17 h; p = 0.001), shorter downtime (0 h vs 5 h; p = 0.015) and less filter sets per patient day (0.37 vs 0.67; p = 0.002). Filters anticoagulated with heparin were commonly interrupted due to clotting (50% vs 16.4%), whereas filters anticoagulated with citrate were often stopped electively (53.4% vs 24.6%). Patients on heparin filters had significantly higher APPTs, some at potentially dangerous levels (>180 s), whilst patients on citrate filters had significantly higher levels of bicarbonate. Therefore, we conclude that citrate is superior in terms of safety and efficacy, with longer filter lifespan. It has become our first line anticoagulant for continuous renal replacement therapy.

Implementing a collaborative framework for academic support for registered nurses.

This paper describes the collaboration between a national health service acute hospital trust and a higher education institution, to implement a framework for academic support for registered nurses undertaking learning beyond registration. A small percentage of the educational budget was utilised to fund two academic staff (0.6 whole time equivalent) to work within the trusts' own learning and development department. The initial aim of the project was to maximise the utilisation of the funding available for learning beyond registration study. The focus of the project was at both a strategic level and with individual staff. Embedding within the culture of the trust was important for the academic staff to understand and gain the service/user perspective to some of the barriers or issues concerning learning beyond registration. Following a scoping exercise, the multiplicity of issues that required action led to the creation of an academic support framework. This framework identified potential for intervention in 4 phases: planning for study, application and access to learning, during study and outcome of study. Interventions were identified that were complimentary and adjuncts to the academic support provided by the higher education institution. New resources and services were also developed such as pathway planning support and study skill workshops. One important resource was a dedicated point of contact for staff. A "live" database also proved useful in tracking and following-up students.

Negotiated dying: a grounded theory of how nurses shape withdrawal of treatment in hospital critical care units.

BACKGROUND: The process of withdrawal of treatment in critical care environments has created ethical and moral dilemmas in relation to end of life care in the UK and elsewhere. Common within this discourse is the differing demands made on health professionals as they strive to provide care for the dying patient and family members. Despite reports that withdrawal of treatment is a source of tension between those nurses and doctors involved in the process, the role of the nurse in facilitating withdrawal of treatment has received relatively little attention. OBJECTIVES: To illustrate how differing dying trajectories impact on decision-making underpinning withdrawal of treatment processes, and what nurses do to shape withdrawal of treatment. DESIGN: Qualitative methods of enquiry using clinical vignettes and applying Charmaz's grounded theory method. METHODS AND SETTINGS: Single audio-recorded qualitative interviews with thirteen critical care nurses from four intensive care specialities: cardiac; general; neurological and renal were carried out. Interviews were facilitated by an end-of-life vignette developed with clinical collaborators. FINDINGS: Across critical care areas four key dying trajectories were identified. These trajectories were shaped by contested boundaries associated with delayed or stalled decision-making around how withdrawal of treatment should proceed. Nurses provided end of life care (including collaborative and action-oriented skills) to shape the dying trajectory of patients so as to satisfy the wishes of the patient and family, and their own professional aims. CONCLUSIONS: Differing views as to when withdrawal of treatment should commence and how it should be operationalised appeared to be underpinned by the requirements of the role that health professionals fulfil, with doctors focusing on making withdrawal of treatment decisions, and nurse's being tasked with operationalising the processes that constitute it. Multidisciplinary teams need a 'shared' understanding of each other's roles, responsibilities, aims, and motivations when planning and implementing the dying trajectory of withdrawal of treatment.