Adherence to guidelines for the management of donors after brain death.

PURPOSE: Guideline adherence for the management of a donor after brain death (DBD) is largely unknown. This study aimed to perform an importance-performance analysis of prioritized key interventions (KIs) by linking guideline adherence rates to expert consensus ratings for the management of a DBD. MATERIALS AND METHODS: This observational, cross-sectional multicenter study was performed in 21 Belgian ICUs. A retrospective review of patient records of adult utilized DBDs between 2013 and 2016 used 67 KIs to describe adherence to guidelines. RESULTS: A total of 296 patients were included. Thirty-five of 67 KIs had a high level of adherence congruent to a high expert panel rating of importance. Nineteen of 67 KIs had a low level of adherence in spite of a high level of importance according to expert consensus. However, inadequate documentation proved an important issue, hampering true guideline adherence assessment. Adherence ranged between 3 and 100% for single KI items and on average, patients received 72% of the integrated expert panel recommended care set. CONCLUSIONS: Guideline adherence to an expert panel predefined care set in DBD donor management proved moderate leaving substantial room for improvement. An importance-performance analysis can be used to improve implementation and documentation of guidelines.

Development of key interventions and quality indicators for the management of an adult potential donor after brain death: a RAND modified Delphi approach.

BACKGROUND: A substantial degree of variability in practices exists amongst donor hospitals regarding the donor detection, determination of brain death, application of donor management techniques or achievement of donor management goals. A possible strategy to standardize the donation process and to optimize outcomes could lie in the implementation of a care pathway. The aim of the study was to identify and select a set of relevant key interventions and quality indicators in order to develop a specific care pathway for donation after brain death and to rigorously evaluate its impact. METHODS: A RAND modified three-round Delphi approach was used to build consensus within a single country about potential key interventions and quality indicators identified in existing guidelines, review articles, process flow diagrams and the results of the Organ Donation European Quality System (ODEQUS) project. Comments and additional key interventions and quality indicators, identified in the first round, were evaluated in the following rounds and a subsequent physical meeting. The study was conducted over a 4-month time period in 2016. RESULTS: A multidisciplinary panel of 18 Belgian experts with different relevant backgrounds completed the three Delphi rounds. Out of a total of 80 key interventions assessed throughout the Delphi process, 65 were considered to contribute to the quality of care for the management of a potential donor after brain death; 11 out of 12 quality indicators were validated for relevance and feasibility. Detection of all potential donors after brain death in the intensive care unit and documentation of cause of no donation were rated as the most important quality indicators. CONCLUSIONS: Using a RAND modified Delphi approach, consensus was reached for a set of 65 key interventions and 11 quality indicators for the management of a potential donor after brain death. This set is considered to be applicable in quality improvement programs for the care of potential donors after brain death, while taking into account each country's legislation and regulations regarding organ donation and transplantation.

Biomarkers in patients admitted to the emergency department after exposure to acrylonitrile in a major railway incident involving bulk chemical material.

BACKGROUND: A railway incident with victims of exposure to the cyanogenic substance acrylonitrile (ACN). AIMS: We retrospectively (i)built an inventory of the clinical characteristics of individuals admitted to surrounding emergency departments (ED's) and (ii)studied the correlation between N-2-cyanoethylvaline (CEV), a biomarker used in a population study for evaluating exposure to ACN, with lactate and thiocyanate (SCN), biomarkers determined during emergency care. RESULTS: 438 patients from 11 ED's were included and presented with known symptoms of ACN poisoning but also with concern about the risks. A comparison of CEV with lactate or SCN was possible in 108 and 73 patients respectively. CEV was very high in a critically ill patient with a high lactate. There was no correlation with CEV in the patients with normal or slightly elevated lactate concentrations. A correlation of CEV with SCN was only observed in smokers. LIMITATIONS: First there is a lack of data in some clinical files concerning the time and duration of exposure and the smoking-status. A second limitation is that blood samples for biomarkers were not taken systematically in all patients, which may have induced bias. A third limitation is that blood sampling was possibly done outside the correct time window related to the delayed toxicity of ACN. Finally the number of severely-intoxicated patients was low and ACN exposure may not have taken place e.g. in individuals consulting with psychological symptoms. These aspects may have contributed to the below detection limits' analyses of biomarkers. CONCLUSIONS: CEV was markedly elevated in a severely-intoxicated patient with high lactate, a sensitive marker for CN intoxication. We found no correlation of CEV with normal or slightly elevated lactate concentrations but clinicians should consider the possibility of subsequent rises due to the delay in ACN toxicity. CEV correlated with SCN in smokers, which may be explained by ACN in tobacco smoke and deserves further exploration. Further studies are necessary to evaluate the correlation between biomarkers in acute chemical exposures to ACN and these should be carried out prospectively using a preplanned template.

Recommendations for further improvement of the deceased organ donation process in Belgium.

Belgium has achieved high deceased organ donation rates but according to the medical record data in the Donor Action database, deceased potential donors are still missed along the pathway. Between 2010 and 2014, 12.9 ± 3.3% of the potential donors after brain death (DBD) and 24.6 ± 1.8% of the potential donors after circulatory (DCD) death were not identified. Conversion rates of 41.7 ± 2.1% for DBD and 7.9 ± 0.9% for DCD indicate room for further improvement. We identify and discuss different issues in the monitoring of donation activities, practices and outcomes; donor pool; legislation on deceased organ donation; registration; financial reimbursement; educational and training programs; donor detection and practice clinical guidance. The overall aim of this position paper, elaborated by a Belgian expert panel, is to provide recommendations for further improvement of the deceased organ donation process up to organ procurement in Belgium.

Care pathways for organ donation after brain death: guidance from available literature?

AIMS: A discussion of the literature concerning the impact of care pathways in the complex and by definition multidisciplinary process of organ donation following brain death. BACKGROUND: Enhancing the quality and safety of organs for transplantation has become a central concern for governmental and professional organizations. At the local hospital level, a donor coordinator can use a range of interventions to improve the donation and procurement process. Care pathways have been proven to represent an effective intervention in several settings for optimizing processes and outcomes. DESIGN: A discussion paper. DATA SOURCES: A systematic review of the Medline, CINAHL, EMBASE and The Cochrane Library databases was conducted for articles published until June 2015, using the keywords donation after brain death and care pathways. Each paper was reviewed to investigate the effects of existing care pathways for donation after brain death. An additional search for unpublished information was conducted. DISCUSSION: Although literature supports care pathways as an effective intervention in several settings, few studies have explored its use and effectiveness for complex care processes such as donation after brain death. IMPLICATIONS FOR NURSING: Nurses should be aware of their role in the donation process. Care pathways have the potential to support them, but their effectiveness has been insufficiently explored. CONCLUSION: Further research should focus on the development and standardization of the clinical content of a care pathway for donation after brain death and the identification of quality indicators. These should be used in a prospective effectiveness assessment of the proposed pathway.

The Value of E-Learning for the Prevention of Healthcare-Associated Infections.

BACKGROUND Healthcare workers (HCWs) lack familiarity with evidence-based guidelines for the prevention of healthcare-associated infections (HAIs). There is good evidence that effective educational interventions help to facilitate guideline implementation, so we investigated whether e-learning could enhance HCW knowledge of HAI prevention guidelines. METHODS We developed an electronic course (e-course) and tested its usability and content validity. An international sample of voluntary learners submitted to a pretest (T0) that determined their baseline knowledge of guidelines, and they subsequently studied the e-course. Immediately after studying the course, posttest 1 (T1) assessed the immediate learning effect. After 3 months, during which participants had no access to the course, a second posttest (T2) evaluated the residual learning effect. RESULTS A total of 3,587 HCWs representing 79 nationalities enrolled: 2,590 HCWs (72%) completed T0; 1,410 HCWs (39%) completed T1; and 1,011 HCWs (28%) completed T2. The median study time was 193 minutes (interquartile range [IQR], 96-306 minutes) The median scores were 52% (IQR, 44%-62%) for T0, 80% (IQR, 68%-88%) for T1, and 74% (IQR, 64%-84%) for T2. The immediate learning effect (T0 vs T1) was +24% (IQR, 12%-34%; P300 minutes yielded the greatest residual effect (24%). CONCLUSIONS Moderate time invested in e-learning yielded significant immediate and residual learning effects. Decision makers could consider promoting e-learning as a supporting tool in HAI prevention. Infect Control Hosp Epidemiol 2016;37:1052-1059.

Cuff pressure of endotracheal tubes after changes in body position in critically ill patients treated with mechanical ventilation.

BACKGROUND: In order to avoid microaspiration and tracheal injury, the target for endotracheal tube cuff pressure is 20 to 30 cm H2O. OBJECTIVE: To assess the effect of changes in body position on cuff pressure in adult patients. METHODS: Twelve orally intubated and sedated patients received neuromuscular blockers and were positioned in a neutral starting position (backrest, head-of-bed elevation 30º, head in neutral position) with cuff pressure at 25 cm H2O. Then, 16 changes in position were performed: anteflexion head, hyperextension head, left and right lateral flexion of head, left and right rotation of the head, semirecumbent position (head-of-bed elevation 45°), recumbent position (head-of-bed elevation 10°), horizontal backrest, Trendelenburg position (10°), and left and right lateral positioning over 30°, 45°, and 90°. Once a patient was correctly positioned, cuff pressure was recorded during an end-expiratory ventilatory hold. The pressure observed was compared with the cuff pressure at the starting position. Values outside the target range (20-30 cm H2O) were considered clinically relevant. RESULTS: A total of 192 measurements were performed (12 subjects × 16 positions). A significant deviation in cuff pressure occurred with all 16 changes (P < .05). No pressures were less than the lower limit (20 cm H2O). Pressures were greater than the upper limit (30 cm H2O) in 40.6% of the measurements. In each position, the upper target limit was exceeded at least once. Within-patient variability was substantial (P = .02). CONCLUSION: Simple changes in patients' positioning can result in potentially harmful cuff pressures.

A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients.

RATIONALE: The clinical relevance of Aspergillus-positive endotracheal aspirates in critically ill patients is difficult to assess. OBJECTIVES: We externally validate a clinical algorithm to discriminate Aspergillus colonization from putative invasive pulmonary aspergillosis in this patient group. METHODS: We performed a multicenter (n = 30) observational study including critically ill patients with one or more Aspergillus-positive endotracheal aspirate cultures (n = 524). The diagnostic accuracy of this algorithm was evaluated using 115 patients with histopathologic data, considered the gold standard. Subsequently, the diagnostic workout of the algorithm was compared on the total cohort (n = 524), with the categorization based on the diagnostic criteria of the European Organization for the Research and Treatment of Cancer/Mycoses Study Group. MEASUREMENTS AND MAIN RESULTS: Among 115 histopathology-controlled patients, 79 had proven aspergillosis. The algorithm judged 86 of 115 cases to have putative aspergillosis. This diagnosis was confirmed in 72 and rejected in 14 patients. The algorithm judged 29 patients to have Aspergillus colonization. This was confirmed in 22 and rejected in 7 patients. The algorithm had a specificity of 61% and a sensitivity of 92%. The positive and negative predictive values were 61 and 92%, respectively. In the total cohort (n = 524), 79 patients had proven invasive pulmonary aspergillosis (15.1%). According to the European Organization for the Research and Treatment of Cancer/Mycoses Study Group criteria, 32 patients had probable aspergillosis (6.1%) and 413 patients were not classifiable (78.8%). The algorithm judged 199 patients to have putative aspergillosis (38.0%) and 246 to have Aspergillus colonization (46.9%). CONCLUSIONS: The algorithm demonstrated favorable operating characteristics to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients.

Thrombocytopenia and outcome in critically ill patients with bloodstream infection.

OBJECTIVE: Thrombocytopenia is common in intensive care units (ICUs), and is associated with a poor prognosis. An acute decrease in total platelet count is frequently observed in severe sepsis, followed by a relative increase indicating organ-failure recovery. However, few data are available describing this effect and its relationship with outcomes in specific subgroups of ICU patients. METHODS: A retrospective, observational cohort study was conducted to investigate the incidence and prognosis of thrombocytopenia in a cohort of critically ill patients (n=155) with a microbiologically documented nosocomial bloodstream infection. RESULTS: Thrombocytopenia occurred more frequently in nonsurvivors. The ICU mortality rates increased according to severity of thrombocytopenia. Thrombocytopenia was independently associated with worse outcomes in ICU patients with nosocomial bloodstream infection. CONCLUSION: Determining trends in platelet counts is of additional prognostic value, compared with single measurements.

Nurses' knowledge of evidence-based guidelines for the prevention of surgical site infection.

BACKGROUND: Prevention of surgical site infection (SSI) is an important responsibility for nurses. Knowledge of the related evidence-based recommendations is necessary to provide high-quality nursing care. AIM: Development of an evaluation tool and subsequent evaluation of intensive care unit (ICU) nurses' knowledge of the SSI prevention guideline to identify their specific educational needs, as part of a needs analysis preceding the development of an e-learning module on infection prevention. METHODS: We developed a multiple-choice knowledge test concerning evidence-based SSI prevention. After expert assessment of its face and content validity, the test was used in a survey among 809 ICU nurses. Demographics included were gender, ICU experience, number of ICU beds, and whether respondents had obtained a specialized ICU qualification. Based on the test results, an item analysis was performed. RESULTS: Face and content validity were achieved for 9 out of 10 items of the questionnaire. From the survey, we collected 650 questionnaires (response rate 80.3%). The item analysis revealed overall good results with values for item difficulty ranging from 0.1 to 0.5 for eight questions, while one question had a value of 0.02; discriminative values ranging from 0.27 to 0.53 and values for the quality of the response alternatives between 0.1 and 0.7. Overall, these results demonstrate the questionnaire's reliability. The nurses' mean score on the knowledge test was 29%. Males were shown to have better scores. CONCLUSIONS: Opportunities exist to improve ICU nurses' knowledge about SSI prevention recommendations. Current guidelines should support their ongoing training and education.

Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middle-aged, old, and very old patients.

BACKGROUND: We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients. METHODS: In a single-center, historical cohort study (1992-2006), we compared middle-aged (45-64 years; n = 524), old(65-74 years; n = 326), and very old ICU patients (> 75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay. RESULTS: Although the total number of ICU admissions (patients aged > or = 45 years) decreased by approximately 10%, the number of very old patients increased by 33% between the periods 1992-1996 and 2002-2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992-1996) to 13.5% (1997-2001) and 17.4% (2002-2006) (p <0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4 per thousand in middle-aged, 5.5 per thousand in old, and 4.6 per thousand in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0 -1.5) and significant for very old age (hazard ratio,1.8; 95% confidence interval, 1.4 -2.4). CONCLUSION: Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.

Centers for Disease Control and Prevention guidelines for preventing central venous catheter-related infection: results of a knowledge test among 3405 European intensive care nurses.

OBJECTIVE: To determine European intensive care unit (ICU) nurses' knowledge of guidelines for preventing central venous catheter-related infection from the Centers for Disease Control and Prevention. DESIGN: Multicountry survey (October 2006-March 2007). SETTING: Twenty-two European countries. PARTICIPANTS: ICU nurses. MEASUREMENTS AND MAIN RESULTS: Using a validated multiple-choice test, knowledge of ten recommendations for central venous catheter-related infection prevention was evaluated (one point per question) and assessed in relation to participants' gender, ICU experience, number of ICU beds, and acquisition of a specialized ICU qualification. We collected 3405 questionnaires (70.9% response rate); mean test score was 44.4%. Fifty-six percent knew that central venous catheters should be replaced on indication only, and 74% knew this also concerns replacement over a guidewire. Replacing pressure transducers and tubing every 4 days, and using coated devices in patients requiring a central venous catheter >5 days in settings with high infection rates only were recognized as recommended by 53% and 31%, respectively. Central venous catheters dressings in general are known to be changed on indication and at least once weekly by 43%, and 26% recognized that both polyurethane and gauze dressings are recommended. Only 14% checked 2% aqueous chlorhexidine as the recommended disinfection solution; 30% knew antibiotic ointments are not recommended because they trigger resistance. Replacing administration sets within 24 hrs after administering lipid emulsions was recognized as recommended by 90%, but only 26% knew sets should be replaced every 96 hrs when administering neither lipid emulsions nor blood products. Professional seniority and number of ICU beds showed to be independently associated with better test scores. CONCLUSIONS: Opportunities exist to optimize knowledge of central venous catheter-related infection prevention among European ICU nurses. We recommend including central venous catheter-related infection prevention guidelines in educational curricula and continuing refresher education programs.