Mortality Reduction After a Preincision Safety Check Before Cardiac Surgery: Is It the Aorta?

OBJECTIVES: The introduction and use of a preincision safety check were associated with lower mortality after mixed adult cardiac surgery; however, an explanatory mechanism is lacking. Stroke, one of the most severe complications after cardiac surgery, with high mortality, may be reduced by adapting the surgical handling of the ascending aorta. This study assessed the prevalence and predictors of this adaptation after a preincision safety check and the subsequent effect on outcome. DESIGN: A prospective, single-center, observational study comparing adaptation with no-adaptation. The primary outcome measure was 30-day mortality. Multivariate analyses were performed to determine independent predictors of adaptation. To study the effect of adaptation on outcome, a propensity score-matched cohort was constructed in a 1:3 intervention:control ratio. SETTING: At Isala Zwolle (NL), a large, nonacademic teaching hospital. PARTICIPANTS: All consecutive cardiac surgery procedures from 2012 until 2015, including 4,752 surgeries. INTERVENTIONS: The adaptation of surgical handling of the ascending aorta. MEASUREMENTS AND MAIN RESULTS: In 283 cardiac surgeries (5.9%), adaptation was indicated. The most important independent predictors for adaptation were extracardiac atherosclerosis, current smoking, and increasing age. In the propensity score-matched cohort consisting of 1,069 procedures, there were no significant differences in outcome. After correction for propensity score, the hazard ratio of adaptation for 30-day mortality was 1.8 (0.85-3.79). CONCLUSIONS: The adaptation of aortic surgical handling after a preincision safety check was necessary for 5.9% of cardiac surgeries, with extracardiac atherosclerosis as the strongest predictor. Outcome was not significantly different between patients with and without adaptation. Although promising, it remains unclear whether adaptation may fully explain mortality reduction after the use of a preincision safety check.

The Nursing Activities Score Per Nurse Ratio Is Associated With In-Hospital Mortality, Whereas the Patients Per Nurse Ratio Is Not.

OBJECTIVES: Studies have shown contradicting results on the association of nursing workload and mortality. Most of these studies expressed workload as patients per nurse ratios; however, this does not take into account that some patients require more nursing time than others. Nursing time can be quantified by tools like the Nursing Activities Score. We investigated the association of the Nursing Activities Score per nurse ratio, respectively, the patients per nurse ratio with in-hospital mortality in ICUs. DESIGN: Retrospective analysis of the National Intensive Care Evaluation database. SETTING: Fifteen Dutch ICUs. PATIENTS: All ICU patients admitted to and registered ICU nurses working at 15 Dutch ICUs between January 1, 2016, and January 1, 2018, were included. The association of mean or day 1 patients per nurse ratio and Nursing Activities Score per nurse ratio with in-hospital mortality was analyzed using logistic regression models. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nursing Activities Score per nurse ratio greater than 41 for both mean Nursing Activities Score per nurse ratio as well as Nursing Activities Score per nurse ratio on day 1 were associated with a higher in-hospital mortality (odds ratios, 1.19 and 1.17, respectively). After case-mix adjustment the association between a Nursing Activities Score per nurse ratio greater than 61 for both mean Nursing Activities Score per nurse ratio as well as Nursing Activities Score per nurse ratio on day 1 and in-hospital mortality remained significant (odds ratios, 1.29 and 1.26, respectively). Patients per nurse ratio was not associated with in-hospital mortality. CONCLUSIONS: A higher Nursing Activities Score per nurse ratio was associated with higher in-hospital mortality. In contrast, no association was found between patients per nurse ratios and in-hospital mortality in The Netherlands. Therefore, we conclude that it is more important to focus on the nursing workload that the patients generate rather than on the number of patients the nurse has to take care of in the ICU.

Quality improvement of Dutch ICUs from 2009 to 2021: A registry based observational study.

PURPOSE: To investigate the development in quality of ICU care over time using the Dutch National Intensive Care Evaluation (NICE) registry. MATERIALS AND METHODS: We included data from all ICU admissions in the Netherlands from those ICUs that submitted complete data between 2009 and 2021 to the NICE registry. We determined median and interquartile range for eight quality indicators. To evaluate changes over time on the indicators, we performed multilevel regression analyses, once without and once with the COVID-19 years 2020 and 2021 included. Additionally we explored between-ICU heterogeneity by calculating intraclass correlation coefficients (ICC). RESULTS: 705,822 ICU admissions from 55 (65%) ICUs were included in the analyses. ICU length of stay (LOS), duration of mechanical ventilation (MV), readmissions, in-hospital mortality, hypoglycemia, and pressure ulcers decreased significantly between 2009 and 2019 (OR <1). After including the COVID-19 pandemic years, the significant change in MV duration, ICU LOS, and pressure ulcers disappeared. We found an ICC ≤0.07 on the quality indicators for all years, except for pressure ulcers with an ICC of 0.27 for 2009 to 2021. CONCLUSIONS: Quality of Dutch ICU care based on seven indicators significantly improved from 2009 to 2019 and between-ICU heterogeneity is medium to small, except for pressure ulcers. The COVID-19 pandemic disturbed the trend in quality improvement, but unaltered the between-ICU heterogeneity.

Direct cost analysis of intensive care unit stay in four European countries: applying a standardized costing methodology.

OBJECTIVES: The objective of the present study was to measure and compare the direct costs of intensive care unit (ICU) days at seven ICU departments in Germany, Italy, the Netherlands, and the United Kingdom by means of a standardized costing methodology. METHODS: A retrospective cost analysis of ICU patients was performed from the hospital's perspective. The standardized costing methodology was developed on the basis of the availability of data at the seven ICU departments. It entailed the application of the bottom-up approach for "hotel and nutrition" and the top-down approach for "diagnostics," "consumables," and "labor." RESULTS: Direct costs per ICU day ranged from €1168 to €2025. Even though the distribution of costs varied by cost component, labor was the most important cost driver at all departments. The costs for "labor" amounted to €1629 at department G but were fairly similar at the other departments (€711 ± 115). CONCLUSIONS: Direct costs of ICU days vary widely between the seven departments. Our standardized costing methodology could serve as a valuable instrument to compare actual cost differences, such as those resulting from differences in patient case-mix.

Nurse Operation Workload (NOW), a new nursing workload model for intensive care units based on time measurements: An observational study.

BACKGROUND: Several instruments have been developed to measure nursing workload. The commonly used Nursing Activities Score (NAS) and Therapeutic Intervention Scoring System (TISS) are applied to all types of ICU patients. Former research showed that NAS explained 59 to 81% of actual nursing time, whereas the Therapeutic Intervention Scoring System (TISS) described only 43% of the actual nursing time. In both models the development was not based on time measurements. OBJECTIVES: The aim of this study was to develop a time-based model which can assess patient related nursing workload more accurately and to evaluate whether patient characteristics influence nursing time and therefore should be included in the model. DESIGN: Observational study design. SETTING: All 82 Dutch ICUs participate in the National Intensive Care Evaluation (NICE) quality registry. Fifteen of these ICUs are participating in the newly implemented voluntary nursing capacity module. Seven of these ICUs voluntarily participated in this study. PARTICIPANTS: The patient(s) that were under the responsibility of a chosen nurse were followed by the observer during the entire shift. METHODS: Time spent per nursing activity per patient was measured in different shifts in seven Dutch ICUs. Nursing activities were measured using an in-house developed web application. Three different models of varying complexity (1. nursing activities only; 2. nursing activities and case-mix correction; 3. complex model with case-mix correction per nursing activity) were developed to explain the total amount of nursing time per patient. The performance of the three models was assessed in 1000 bootstrap samples using the squared Pearson correlation coefficient (R2), Root Mean Squared Prediction Error (RMSPE), Mean Absolute Prediction Error (MAPE), and prediction bias. RESULTS: In total 287 unique patients have been observed in 371 shifts. Model one's Pearson's R was 0.89 (95%CI 0.86-0.92), model two with case-mix correction 0.90 (95%CI 0.88-0.93), and the third complex model 0.64 (95%CI 0.56-0.72) compared with the actual patient related nursing workload. CONCLUSION: The newly developed Nurse Operation Workload (NOW) model outperforms existing models in measuring nursing workload, while it includes a lower number of activities and therewith lowers the registration burden. Case-mix correction does not further improve the performance of this model. The patient related nursing workload measured by the NOW gives insight in the actual nursing time needed by patients and can therefore be used to evaluate the average workload per patient per nurse.

Workload scoring systems in the Intensive Care and their ability to quantify the need for nursing time: A systematic literature review.

INTRODUCTION: The Intensive Care Unit is a resource intense service with a high nursing workload per patient resulting in a low ratio of patients per nurse. This review aims to identify existing scoring systems for measuring nursing workload on the Intensive Care and assess their validity and reliability to quantify the needed nursing time. METHODS: We conducted a systematic review of the literature indexed before 01/Mar/2018 in the bibliographic databases MEDLINE, Embase, and Cinahl. Full-text articles were selected and data on systems measuring nursing workload on the Intensive Care and translation of this workload into the amount of nursing time needed was extracted. RESULTS: We included 71 articles identifying 34 different scoring systems of which 27 were included for further analysis as these described a translation of workload into nursing time needed. Almost all systems were developed with nurses. The validity of most scoring systems was evaluated by comparing them with another system (59%) or by using time measurements (26%). The most common way to translate workload-scores into nursing time needed was by categorizing the Nurse:Patient-ratios. Validation of the Nurse:Patient-ratios was mostly evaluated by comparing the results with other systems or with the actual planning and not with objective time measurements. CONCLUSION: Despite the large attention given to nursing workload systems for Intensive Care, only a few systems objectively evaluated the validity and reliability of measuring nursing workload with moderate results. The Nursing Activity Score system performed best. Poor methodology for the translation of workload scores into Nurse:Patient-ratio weakens the value of nursing workload scoring systems in daily Intensive Care practice.

Implementation of a specific safety check is associated with lower postoperative mortality in cardiac surgery.

INTRODUCTION: In cardiac surgery, a preincision safety checklist may decrease complications and improve survival. Until now, it has not been demonstrated whether the implementation of such a checklist indeed reduces mortality. OBJECTIVE: Introduction of a preincision safety checklist on mortality was studied in a large adult cardiac surgery population. METHODS: This prospective, multicenter cohort study included 5937 consecutive adult patients, undergoing cardiac surgery, between January 2015 and December 2015, in 7 Dutch non-academic cardiac centers. The Isala Safety Check (ISC) is a short checklist addressing specific cardiac surgery safety items, in combination with a concise postinduction transesophageal echocardiography, which was gradually over time introduced in the 7 hospitals during 2015. We compared 120-day mortality and major complications between patients undergoing surgery with or without the use of the ISC. Propensity matching and Cox regression analyses were performed to adjust for potential confounders. RESULTS: The ISC was applied in 2718 patients (46%). Comorbidity and age were comparable in both groups. In the ISC group, 120-day mortality was significantly lower (1.7% vs 3.0%; P < .01). Both after propensity matching (hazard ratio, 0.44; 95% confidence interval, 0.22-0.87) and Cox regression analysis (hazard ratio, 0.56; 95% confidence interval, 0.35-0.90), the use of the ISC was still associated with reduced 120-day mortality. Deep sternal wound infection, surgical re-exploration, and stroke were not significantly different between both groups. CONCLUSIONS: Application of a short preincision safety checklist in a mixed population of adult cardiac surgery patients is associated with significantly reduced 120-day mortality.

Development of a nursing intervention to prepare frail older patients for cardiac surgery (the PREDOCS programme), following phase one of the guidelines of the Medical Research Council.

BACKGROUND: In older patients undergoing elective cardiac surgery, the timely identification and preparation of patients at risk for frequent postoperative hospital complications provide opportunities to reduce the risk of these complications. AIMS: We developed an evidence-based, multi-component nursing intervention (Prevention of Decline in Older Cardiac Surgery Patients; the PREDOCS programme) for application in the preadmission period to improve patients' physical and psychosocial condition to reduce their risk of postoperative complications. This paper describes in detail the process used to design and develop this multi-component intervention. METHODS: In a team of researchers, experts, cardiac surgeons, registered cardiac surgery nurses, and patients, the revised guidelines for developing and evaluating complex interventions of the Medical Research Council (MRC) were followed, including identifying existing evidence, identifying and developing theory and modelling the process and outcomes. Additionally, the criteria for reporting the development of complex interventions in healthcare (CReDECI) were followed. RESULTS: The intervention is administered during a consultation by the nurse two to four weeks before the surgery procedure. The consultation includes three parts: a general part for all patients, a second part in which patients with an increased risk are identified, and a third part in which selected patients are informed about how to prepare themselves for the hospital admission to reduce their risk. CONCLUSIONS: Following the MRC guidelines, an extended, stepwise, multi-method procedure was used to develop the multi-component nursing intervention to prepare older patients for cardiac surgery, creating transparency in the assumed working mechanisms. Additionally, a detailed description of the intervention is provided.

Prevention of ICU delirium and delirium-related outcome with haloperidol: a study protocol for a multicenter randomized controlled trial.

BACKGROUND: Delirium is a frequent disorder in intensive care unit (ICU) patients with serious consequences. Therefore, preventive treatment for delirium may be beneficial. Worldwide, haloperidol is the first choice for pharmacological treatment of delirious patients. In daily clinical practice, a lower dose is sometimes used as prophylaxis. Some studies have shown the beneficial effects of prophylactic haloperidol on delirium incidence as well as on mortality, but evidence for effectiveness in ICU patients is limited. The primary objective of our study is to determine the effect of haloperidol prophylaxis on 28-day survival. Secondary objectives include the incidence of delirium and delirium-related outcome and the side effects of haloperidol prophylaxis. METHODS: This will be a multicenter three-armed randomized, double-blind, placebo-controlled, prophylactic intervention study in critically ill patients. We will include consecutive non-neurological ICU patients, aged ≥ 18 years with an expected ICU length of stay >1 day. To be able to demonstrate a 15% increase in 28-day survival time with a power of 80% and alpha of 0.05 in both intervention groups, a total of 2,145 patients will be randomized; 715 in each group. The anticipated mortality rate in the placebo group is 12%. The intervention groups will receive prophylactic treatment with intravenous haloperidol 1 mg/q8h or 2 mg/q8h, and patients in the control group will receive placebo (sodium chloride 0.9%), both for a maximum period of 28-days. In patients who develop delirium, study medication will be stopped and patients will subsequently receive open label treatment with a higher (therapeutic) dose of haloperidol. We will use descriptive summary statistics as well as Cox proportional hazard regression analyses, adjusted for covariates. DISCUSSION: This will be the first large-scale multicenter randomized controlled prevention study with haloperidol in ICU patients with a high risk of delirium, adequately powered to demonstrate an effect on 28-day survival. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01785290.EudraCT number: 2012-004012-66.

A microcosting study of intensive care unit stay in the Netherlands.

The primary objective of this study was to estimate the actual daily costs of intensive care unit stay using a microcosting methodology. As a secondary objective, the degree of association between daily intensive care unit costs and some patient characteristics was examined. This multicenter, retrospective cost analysis was conducted in the medical-surgical adult intensive care units of 1 university and 2 general hospitals in the Netherlands for 2006, from a hospital perspective. A total of 576 adult patients were included, consuming a total of 2868 nursing days. The mean total costs per intensive care unit day were 1911, with labour (33%) and indirect costs (33%) as the most important cost drivers. An ordinary least squares analysis including age, Nine Equivalent of Nursing Manpower Use score/Therapeutic Intervention Scoring System score, mechanical ventilation, blood products, and renal replacement therapy was able to predict 50% of the daily intensive care unit costs.