Changing the liver transplant assessment process from inpatient to a day-case and outpatient approach to reduce inpatient bed utlisation.

The liver transplant assessment process involves a complex set of tests and clinical reviews to determine suitability for liver transplantation. We had an assessment process involving a 3-day inpatient stay and often experienced difficulties admitting patients to the prebooked bed due to a lack of inpatient bed availability.We aimed to change the process from a 3-day and 2-night inpatient stay to a 1-day day-case stay to reduce the demand for inpatient beds.Planning the new assessment process involved negotiations with many department staff to establish prebooked timeslots in 1 day. The improvement project was tested and refined through Plan-Do-Study-Act cycles. The liver transplant assessment team used their established once-a-week meeting to learn what went well and to agree on revisions to the process for further testing. The process involved several adaptations, such as the removal and changing of individual time slots, reinforcement of early notification once patients had finished their tests and scheduling a separate outpatient appointment to provide time for junior doctor clerking and blood tests.The new day-case and outpatient coordinated liver transplant assessment process resulted in a reduction of inpatient hospital bed utilisation from an average of 257-20 inpatient bed days per annum. This reduction in inpatient bed utilisation was maintained for 3 years with a similar level of patient satisfaction. The cost avoidance was calculated at £381.96 per patient, which is a 63% reduction in cost. Assuming an average number of patients being assessed per annum of 110, this would result in an average cost avoidance of £42 016 per annum. The carbon footprint was calculated with an average reduction per patient from 618 kilograms of carbon dioxide equivalent (kgCO2e) to 179 kgCO2e.This project has highlighted how to change a complex inpatient assessment process to an alternative day-case and outpatient approach and could be considered useful learning for other inpatient assessment services, not just liver transplantation.

The organisation of nurse staffing in intensive care units: A qualitative study.

AIMS: To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates. BACKGROUND: Pre-pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence. METHODS: Focus groups with intensive care health care professionals (n = 52 participants) and individual interviews with critical care network leads and policy leads (n = 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis. FINDINGS: Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes. CONCLUSIONS: Whilst nurse:patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re-allocation during a shift took into account many other factors, such as patient and family nursing needs, staff well-being, intensive care layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies. IMPLICATIONS FOR NURSING MANAGEMENT: In order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket 'ratio' approach to nurse staffing, intended to apply uniformly across health services.

How COVID-19 has affected staffing models in intensive care: A qualitative study examining alternative staffing models (SEISMIC).

AIMS: To understand how COVID-19 affected nurse staffing in intensive care units (ICUs) in England, and to identify factors that influenced, and were influenced by, pandemic staffing models. DESIGN: Exploratory qualitative study. METHODS: Semi-structured, online interviews conducted July-September 2020 with regional critical care leaders including policy leads (n = 4) and directors/lead nurses (n = 10) across critical care networks in England. FINDINGS: The six themes emerging from the framework analysis illustrate how the pre-pandemic ICU culture influenced ICU staffing models during the pandemic. Changes in staffing impacted on the workforce and the care delivered, whilst it was necessary to learn from, and adjust to, a rapidly changing situation. Variation across and between networks necessitated variation in responses. The overwhelming outcome was that the pandemic has challenged the central tenets of ICU nurse staffing. CONCLUSIONS: Pandemic nurse staffing models resulted in changes to ICU skill-mix and staffing numbers. Factors such as the impact of nurse staffing on care practices and on the workforce need to be taken into account when developing and testing future nurse staffing models for ICU. The extent to which ICUs will return to former staffing models is not yet known but there seems to be an appetite for change. IMPACT: In common with many countries, nurse staffing in English ICUs was adapted to address surge requirements during the COVID-19 pandemic. Findings highlight the challenge COVID-19 presented to pre-pandemic ICU nurse staffing guidelines, the impact on patient and staff well-being and the potential legacy for future staffing models. Study findings have implications for ICU nurse managers, researchers and policy makers: nurse staffing models need to be adaptable to the local context of care and future research should investigate the impact of different models on patients, staff and health service outcomes.

Modifying Carbohydrate Supply to Fruit during Development Changes the Composition and Flavour of Actinidia chinensis var. chinensis 'Zesy002' Kiwifruit.

Consumer acceptance of fruit is determined by size, flavour and ripeness. In this study we investigated how altering the carbohydrate supply to Actinidia chinensis var. chinensis 'Zesy002' kiwifruit altered the balance between growth and accumulation of metabolites. Canes were phloem girdled and fruit thinned to a leaf-to-fruit ratio (L:F) of either 2 (Low carbohydrate) or 6 (High carbohydrate) at either 38 (Early) or 86 (Late) days after anthesis (DAA) and compared with ungirdled control canes with a L:F of 3. Fruit growth, metabolite accumulation, cytokinin concentrations and maturation were monitored and the sensory attributes of ripe fruit were assessed. The final weight of Early-High and Late-High carbohydrate fruit was 38% and 16% greater compared with control fruit. High carbohydrate fruit had increased starch, soluble sugar and cytokinin concentrations and fruit began to mature earlier and those with a Low carbohydrate had decreased concentrations and matured later compared with control fruit. Control fruit were described by consumers as more acidic and under-ripe compared with those from Early-High carbohydrate canes, but as sweeter than those from Low carbohydrate canes. This study showed that carbohydrate supply can have a major impact on the growth, sugar accumulation and maturity of 'Zesy002' fruit sinks.

A gene expression atlas for kiwifruit (Actinidia chinensis) and network analysis of transcription factors.

BACKGROUND: Transcriptomic studies combined with a well annotated genome have laid the foundations for new understanding of molecular processes. Tools which visualise gene expression patterns have further added to these resources. The manual annotation of the Actinidia chinensis (kiwifruit) genome has resulted in a high quality set of 33,044 genes. Here we investigate gene expression patterns in diverse tissues, visualised in an Electronic Fluorescent Pictograph (eFP) browser, to study the relationship of transcription factor (TF) expression using network analysis. RESULTS: Sixty-one samples covering diverse tissues at different developmental time points were selected for RNA-seq analysis and an eFP browser was generated to visualise this dataset. 2839 TFs representing 57 different classes were identified and named. Network analysis of the TF expression patterns separated TFs into 14 different modules. Two modules consisting of 237 TFs were correlated with floral bud and flower development, a further two modules containing 160 TFs were associated with fruit development and maturation. A single module of 480 TFs was associated with ethylene-induced fruit ripening. Three "hub" genes correlated with flower and fruit development consisted of a HAF-like gene central to gynoecium development, an ERF and a DOF gene. Maturing and ripening hub genes included a KNOX gene that was associated with seed maturation, and a GRAS-like TF. CONCLUSIONS: This study provides an insight into the complexity of the transcriptional control of flower and fruit development, as well as providing a new resource to the plant community. The Actinidia eFP browser is provided in an accessible format that allows researchers to download and work internally.

A Data Driven Approach to Assess Complex Colour Profiles in Plant Tissues.

The ability to quantify the colour of fruit is extremely important for a number of applied fields including plant breeding, postharvest assessment, and consumer quality assessment. Fruit and other plant organs display highly complex colour patterning. This complexity makes it challenging to compare and contrast colours in an accurate and time efficient manner. Multiple methodologies exist that attempt to digitally quantify colour in complex images but these either require a priori knowledge to assign colours to a particular bin, or fit the colours present within segment of the colour space into a single colour value using a thresholding approach. A major drawback of these methodologies is that, through the process of averaging, they tend to synthetically generate values that may not exist within the context of the original image. As such, to date there are no published methodologies that assess colour patterning using a data driven approach. In this study we present a methodology to acquire and process digital images of biological samples that contain complex colour gradients. The CIE (Commission Internationale de l'Eclairage/International Commission on Illumination) ΔE2000 formula was used to determine the perceptually unique colours (PUC) within images of fruit containing complex colour gradients. This process, on average, resulted in a 98% reduction in colour values from the number of unique colours (UC) in the original image. This data driven procedure summarised the colour data values while maintaining a linear relationship with the normalised colour complexity contained in the total image. A weighted ΔE2000 distance metric was used to generate a distance matrix and facilitated clustering of summarised colour data. Clustering showed that our data driven methodology has the ability to group these complex images into their respective binomial families while maintaining the ability to detect subtle colour differences. This methodology was also able to differentiate closely related images. We provide a high quality set of complex biological images that span the visual spectrum that can be used in future colorimetric research to benchmark colourimetric method development.

Phytohormone and Transcriptomic Analysis Reveals Endogenous Cytokinins Affect Kiwifruit Growth under Restricted Carbon Supply.

Following cell division, fruit growth is characterized by both expansion through increases in cell volume and biomass accumulation in cells. Fruit growth is limited by carbon starvation; however, the mechanism controlling fruit growth under restricted carbohydrate supply is poorly understood. In a previous study using red-fleshed kiwifruit, we showed that long-term carbon starvation had detrimental effects on carbohydrate, anthocyanin metabolism, and fruit growth. To elucidate the mechanisms underlying the reduction in fruit growth during kiwifruit development, we integrated phytohormone profiling with transcriptomic and developmental datasets for fruit under high or low carbohydrate supplies. Phytohormone profiling of the outer pericarp tissue of kiwifruit showed a 6-fold reduction in total cytokinin concentrations in carbon-starved fruit, whilst other hormones were less affected. Principal component analysis visualised that cytokinin composition was distinct between fruit at 16 weeks after mid bloom, based on their carbohydrate supply status. Cytokinin biosynthetic genes (IPT, CYP735A) were significantly downregulated under carbon starvation, in agreement with the metabolite data. Several genes that code for expansins, proteins involved in cell wall loosening, were also downregulated under carbon starvation. In contrast to other fleshy fruits, our results suggest that cytokinins not only promote cell division, but also drive fruit cell expansion and growth in kiwifruit.

Carbon starvation reduces carbohydrate and anthocyanin accumulation in red-fleshed fruit via trehalose 6-phosphate and MYB27.

Kiwifruit (Actinidia spp.) is a recently domesticated fruit crop with several novel-coloured cultivars being developed. Achieving uniform fruit flesh pigmentation in red genotypes is challenging. To investigate the cause of colour variation between fruits, we focused on a red-fleshed Actinidia chinensis var. chinensis genotype. It was hypothesized that carbohydrate supply could be responsible for this variation. Early in fruit development, we imposed high or low (carbon starvation) carbohydrate supplies treatments; carbohydrate import or redistribution was controlled by applying a girdle at the shoot base. Carbon starvation affected fruit development as well as anthocyanin and carbohydrate metabolite concentrations, including the signalling molecule trehalose 6-phosphate. RNA-Seq analysis showed down-regulation of both gene-encoding enzymes in the anthocyanin and carbohydrate biosynthetic pathways. The catalytic trehalose 6-phosphate synthase gene TPS1.1a was down-regulated, whereas putative regulatory TPS7 and TPS11 were strongly up-regulated. Unexpectedly, under carbon starvation MYB10, the anthocyanin pathway regulatory activator was slightly up-regulated, whereas MYB27 was also up-regulated and acts as a repressor. To link these two metabolic pathways, we propose a model where trehalose 6-phosphate and the active repressor MYB27 are involved in sensing the carbon starvation status. This signals the plant to save resources and reduce the production of anthocyanin in fruits.

Family satisfaction with critical care in the UK: a multicentre cohort study.

OBJECTIVE: To assess family satisfaction with intensive care units (ICUs) in the UK using the Family Satisfaction in the Intensive Care Unit 24-item (FS-ICU-24) questionnaire, and to investigate how characteristics of patients and their family members impact on family satisfaction. DESIGN: Prospective cohort study nested within a national clinical audit database. SETTING: Stratified, random sample of 20 adult general ICUs participating in the Intensive Care National Audit & Research Centre Case Mix Programme. PARTICIPANTS: Family members of patients staying at least 24 hours in ICU were recruited between May 2013 and June 2014. INTERVENTIONS: Consenting family members were sent a postal questionnaire 3 weeks after the patient died or was discharged from ICU. Up to four family members were recruited per patient. MAIN OUTCOME MEASURES: Family satisfaction was measured using the FS-ICU-24 questionnaire. MAIN RESULTS: A total of 12 346 family members of 6380 patients were recruited and 7173 (58%) family members of 4615 patients returned a completed questionnaire. Overall and domain-specific family satisfaction scores were high (mean overall family satisfaction 80, satisfaction with care 83, satisfaction with information 76 and satisfaction with decision-making 73 out of 100) but varied significantly across adult general ICUs studied and by whether the patient survived ICU. For family members of ICU survivors, characteristics of both the family member (age, ethnicity, relationship to patient (next-of-kin and/or lived with patient) and visit frequency) and the patient (acute severity of illness and receipt of invasive mechanical ventilation) were significant determinants of family satisfaction, whereas, for family members of ICU non-survivors, only patient characteristics (age, acute severity of illness and duration of stay) were significant. CONCLUSIONS: Overall family satisfaction in UK adult general ICUs was high but varied significantly. Adjustment for differences in family member/patient characteristics is important to avoid falsely identifying ICUs as statistical outliers. TRIAL REGISTRATION NUMBER: ISRCTN47363549.

Histone modification and activation by SOC1-like and drought stress-related transcription factors may regulate AcSVP2 expression during kiwifruit winter dormancy.

The SHORT VEGETATIVE PHASE (SVP)-like and DORMANCY ASSOCIATED MADS-BOX (DAM) genes have been shown to regulate winter dormancy in woody perennials. In kiwifruit, AcSVP2 affects the duration of dormancy in cultivars that require high chill for dormancy release. In this study, we used a low-chill kiwifruit Actinidia chinensis 'Hort16A' to further study the function and regulation of AcSVP2. Overexpression of AcSVP2 in transgenic A. chinensis delayed budbreak in spring. A reduction in the active trimethylation histone marks of the histone H3K4 and acetylation of histone H3 contributed to the reduction of AcSVP2 expression towards dormancy release, while the inactive histone marks of trimethylation of the histone H3K27 and H3K9 in AcSVP2 locus did not show significant enrichment at the end of winter dormancy. Analysis of expression in shoot buds showed that AcSVP2 transcript was elevated in dormant buds during winter months and declined prior to budbreak, which was coordinated with expression of some of kiwifruit SUPPRESSOR OF OVEREXPRESSION OF CONSTANS1 (SOC1)-like genes. Screening of 101 transcription factors in an assay with a 2.3 kb promoter region of AcSVP2 found that kiwifruit SOC1-like genes are able to activate the AcSVP2 promoter. We further identified additional transcription factors associated with drought/osmotic stress and dormancy which may regulate AcSVP2 expression.

Nursing workloads and activity in critical care: A review of the evidence.

OBJECTIVES: To review current methods for informing nurse workforce decisions in critical care. Many clinical outcomes are worse if staffing is inadequate. Workforce planning is usually according to guidelines developed from the opinions of expert groups. Objective systems for planning and distributing staff have been developed but their value is unclear. DESIGN: A rapid review methodology was employed. REVIEW METHODS: The search included research studies, guidelines and surveys within and outside United Kingdom since 1995. FINDINGS: Thirty-two studies met eligibility criteria. Studies originated worldwide, with considerable work undertaken in the United Kingdom and Brazil. Two were large multicentre studies. Tools examined fell into three groups: those focused on the condition and needs of the patient, those focused on the number and time for nursing activities and those that also took account of psycho-social factors. Many tools were not used beyond their country of origin. CONCLUSION: There is limited experience of using tools to determine nurse staffing. No one tool is likely to suit every application. More information is needed to clarify the practicalities of using the tools.

Exogenous cytokinin application to Actinidia chinensis var. deliciosa 'Hayward' fruit promotes fruit expansion through water uptake.

Exogenous application of a cytokinin-like compound forchlorfenuron (CPPU) can promote fruit growth, although often at the expense of dry matter (DM), an important indicator of fruit quality. Actinidia chinensis var. deliciosa 'Hayward' fruit are very responsive to CPPU treatments, but the mechanism underlying the significant fruit weight increase and associated decrease in DM is unclear. In this study, we hypothesised that CPPU-enhanced growth increases fruit carbohydrate demand, but limited carbohydrate supply resulted in decreased fruit DM. During fruit development, CPPU effects on physical parameters, metabolites, osmotic pressure and transcriptional changes were assessed under conditions of both standard and a high carbohydrate supply. We showed that CPPU increased fruit fresh weight but the dramatic DM decrease was not carbohydrate limited. Enhanced glucose and fructose concentrations contributed to an increase in soluble carbohydrate osmotic pressure, which was correlated with increased water accumulation in CPPU-treated fruit and up-regulation of water channel aquaporin gene PIP2.4 at 49 days after anthesis. Transcipt analysis suggested that the molecular mechanism contributing to increased glucose and fructose concentrations was altered by carbohydrate supply. At standard carbohydrate supply, the early glucose increase in CPPU fruit was associated with reduced starch synthesis and increased starch degradation. When carbohydrate supply was high, the early glucose increase in CPPU fruit was associated with a general decrease in starch synthesis but up-regulation of vacuolar invertase and fructokinase genes. We conclude that CPPU affected fruit expansion by increasing the osmotically-driven water uptake and its effect was not carbohydrate supply-limited.

Reducing the incidence of pressure ulcers in critical care units: a 4-year quality improvement.

QUALITY PROBLEM: Critical care patients often have several risk factors for pressure ulceration and implementing prevention interventions have been shown to decrease risk. INITIAL ASSESSMENT: We identified a high incidence of pressure ulcers in the four adult critical care units in our organization. Therefore, avoiding pressure ulceration was an important quality priority. CHOICE OF SOLUTION: We undertook a quality improvement programme aimed at reducing the incidence of pressure ulceration using an evidence-based bundle approach. IMPLEMENTATION: A bundle of technical and non-technical interventions were implemented supported by clinical leadership on each unit. Important components were evidence appraisals; changes to mattresses; focussed risk assessment alongside mandating patients at very high risk to be repositioned two hourly; and staff training to increase awareness of how to prevent pressure ulcers. EVALUATION: Pressure ulcer numbers, incidence and categories were collected continuously and monitored monthly by unit staff. Pressure ulcer rates reduced significantly from 8.08/100 patient admissions to 2.97/100 patient admissions, an overall relative rate reduction of 63% over 4 years. The greatest reduction was seen in the most severe category of pressure ulceration. The average estimated cost saving was £2.6 million (range £2.1-£3.1). LESSONS LEARNED: A quality improvement programme including technical and non-technical interventions, data feedback to staff and clinical leadership was associated with a sustained reduction in the incidence of pressure ulceration in the critically ill. Strategies used in this programme may be transferable to other critical care units to bring more widespread patient benefit.

Falls in critical care: a local review to identify incidence and risk.

BACKGROUND: Patient falls are the most common adverse event in hospitals, resulting in devastating physical, psychological and financial consequences. Therefore the emphasis on falls assessment and prevention is a key priority. Within hospitals those reported at greatest risk of falls are older patients with little known about the factors within critical care. At a local level, a practice development project was identified to review risk factors contributing to falls in critical care. AIMS: To identify the incidence of falls within adult critical care and the risk factors most likely to contribute to a fall. METHODS: Reported falls incidents were reviewed retrospectively using a local incident reporting system, over a 2-year period from four critical care units. FINDINGS: Forty-two incidents were reviewed indicating a low rate of injury and low rate of occurrence (0·99 falls/1000 bed days). The median age of fallers was 58 years and the most common risk factor for falls was confusion or agitation, followed by patients attempting to mobilize against advice. DISCUSSION: Critically ill patients were less likely to fall and were more likely to be younger than patients falling on an acute care ward. Neuroscience/trauma critically ill patients were more likely to fall than general critically ill patients; this was expected to be because of the increased presence of confusion or agitation in this group. The local system used to report falls produced difficulties in identifying risk factors in a consistent way. Although limitations exist, this review has enabled the development of more suitable local critical care falls risk factor assessment and interventions to minimize the risk of falling. CONCLUSIONS: Fall rates, related injuries and circumstances of falls vary considerably among acute care and critical care specialities. Future work should concentrate on better falls reporting systems and further research should include validating risk factors for critical care falls.

A critical care network pressure ulcer prevention quality improvement project.

BACKGROUND: Pressure ulcer prevention is an important safety issue, often underrated and an extremely painful event harming patients. Critically ill patients are one of the highest risk groups in hospital. The impact of pressure ulcers are wide ranging, and they can result in increased critical care and the hospital length of stay, significant interference with functional recovery and rehabilitation and increase cost. AIMS: This quality improvement project had four aims: (1) to establish a critical care network pressure ulcer prevention group; (2) to establish baseline pressure ulcer prevention practices; (3) to measure, compare and monitor pressure ulcers prevalence; (4) to develop network pressure ulcer prevention standards. METHODS: The approach used to improve quality included strong critical care nursing leadership to develop a cross-organisational pressure ulcer prevention group and a benchmarking exercise of current practices across a well-established critical care Network in the North of England. The National Safety Thermometer tool was used to measure pressure ulcer prevalence in 23 critical care units, and best available evidence, local consensus and another Critical Care Networks' bundle of interventions were used to develop a local pressure ulcer prevention standards document. RESULTS: The aims of the quality improvement project were achieved. This project was driven by successful leadership and had an agreed common goal. The National Safety Thermometer tool was an innovative approach to measure and compare pressure ulcer prevalence rates at a regional level. A limitation was the exclusion of moisture lesions. CONCLUSION: The project showed excellent engagement and collaborate working in the quest to prevent pressure ulcers from many critical care nurses with the North of England Critical Care Network. RELEVANCE TO CLINICAL PRACTICE: A concise set of Network standards was developed for use in conjunction with local guidelines to enhance pressure ulcer prevention.

The hybrid non-ethylene and ethylene ripening response in kiwifruit (Actinidia chinensis) is associated with differential regulation of MADS-box transcription factors.

BACKGROUND: Ripening in tomato is predominantly controlled by ethylene, whilst in fruit such as grape, it is predominantly controlled by other hormones. The ripening response of many kiwifruit (Actinidia) species is atypical. The majority of ripening-associated fruit starch hydrolysis, colour change and softening occurs in the apparent absence of ethylene production (Phase 1 ripening) whilst Phase 2 ripening requires autocatalytic ethylene production and is associated with further softening and an increase in aroma volatiles. RESULTS: To dissect the ripening response in the yellow-fleshed kiwifruit A. chinensis ('Hort16A'), a two dimensional developmental stage X ethylene response time study was undertaken. As fruit progressed through maturation and Phase 1 ripening, fruit were treated with different concentrations of propylene and ethylene. At the start of Phase 1 ripening, treated fruit responded to ethylene, and were capable of producing endogenous ethylene. As the fruit progressed through Phase 1 ripening, the fruit became less responsive to ethylene and endogeneous ethylene production was partially repressed. Towards the end of Phase 1 ripening the fruit were again able to produce high levels of ethylene. Progression through Phase 1 ripening coincided with a developmental increase in the expression of the ethylene-unresponsive MADS-box FRUITFUL-like gene (FUL1). The ability to respond to ethylene however coincided with a change in expression of another MADS-box gene SEPALLATA4/RIPENING INHIBITOR-like (SEP4/RIN). The promoter of SEP4/RIN was shown to be transactivated by EIN3-like transcription factors, but unlike tomato, not by SEP4/RIN itself. Transient over-expression of SEP4/RIN in kiwifruit caused an increase in ethylene production. CONCLUSIONS: These results suggest that the non-ethylene/ethylene ripening response observed in kiwifruit is a hybrid of both the tomato and grape ripening progression, with Phase 1 being akin to the RIN/ethylene inhibitory response observed in grape and Phase 2 akin to the RIN-associated autocatalytic ethylene response observed in tomato.

Part 2: pressure ulcer assessment: implementation and revision of CALCULATE.

INTRODUCTION: Critically ill patients are a vulnerable group at very high risk of developing pressure ulcers, and the incidence varies within critical care. METHODS: A number of strategies were used to implement the pressure ulcer assessment tool CALCULATE across four adult critical care units. Strategies included, nursing leadership, the provision of definitions for each risk factor, information laid out on posters at each patient's bedside, changes to pre-printed nursing documentation and a 30-min focused training package. Two local audits were conducted to measure the number and types of risk factors occurring in patients with pressure ulcers, and to assess the frequency of assessments and gain feedback on the usability of the tool in practice. FINDINGS: Critical care acquired pressure ulcer incidence was 3.4%. The two most commonly occurring risk factors were impaired circulation (82%) and mechanical ventilation (75%). Patients had a mean score of 4, and 65% had 4 or more reported risk factors. Feedback on the usability of the tool was mainly positive. DISCUSSION: The tool CALCULATE was relatively straightforward to implement and was likely to be due to the design and the various change strategies used to implement the new approach. The seven point tool was revised to an eight point score based on nurses' clinical feedback. CONCLUSIONS: Research is required to further enhance and develop pressure ulcer assessment. Meanwhile CALCULATE offers an easy to use and appropriate tool to assist in the identification of patients at an elevated risk of pressure ulcer damage. IMPLICATIONS FOR PRACTICE: Careful choice of change management strategies are needed when implementing a new assessment tool. CALCULATE should be considered for use in critical care for pressure ulcer assessment, but used alongside nurses' clinical judgement and observations of skin.

Part 1: Pressure ulcer assessment - the development of Critical Care Pressure Ulcer Assessment Tool made Easy (CALCULATE).

INTRODUCTION: Critically ill patients are at high risk of developing pressure ulcers resulting in serious untoward patient and health care system outcomes. Pressure ulcer prevention is therefore an important patient safety priority and establishing a structured approach to pressure ulcer risk assessment to identify patients at risk is a critical first step. METHODS: The literature was searched using three electronic databases from 2000 to 2011 to identify papers reporting on pressure ulcer risk factors and assessment in adult critical care. The review and appraisal of papers were conducted by two critical care nurses. Papers underwent detailed review if they met inclusion criteria where they identified pressure ulcer assessment scores, scales or risk factors and related to adult critical care patients FINDINGS: Seven papers were reviewed. No single assessment tool was sufficiently validated for critically ill patients and seven key critical care risk factors were identified. These risk factors were: mechanical ventilation, impaired circulation, dialysis, long surgery, low protein and too unstable to turn. TOOL DEVELOPMENT: The tool Critical Care Pressure Ulcer Assessment Tool made Easy (CALCULATE) was developed utilizing the risk factors from the literature and expert critical care nursing consensus decision-making. DISCUSSION: In the absence of current consensus, valid assessment scales and limited evidence for the most appropriate pressure ulcer assessment for critically ill patients, this assessment tool offers an easy, appropriate alternative for critically ill patients than existing tools primarily validated for acute care wards. CONCLUSIONS: 'CALCULATE' offers an important contribution towards the advancement and development of critical care pressure ulcer risk assessment. Future research is needed to further enhance and inform pressure ulcer risk assessment of the critically ill patients. IMPLICATIONS FOR PRACTICE: The identification of critical care risk factors may be an indicative method of assessing pressure ulcer risk in the critically ill patients.