When not to start antibiotics: avoiding antibiotic overuse in the intensive care unit.

BACKGROUND: Most intensive care unit (ICU) patients receive broad-spectrum antibiotics. While lifesaving in some, in others these treatments may be unnecessary and place patients at risk of antibiotic-associated harms. OBJECTIVES: To review the literature exploring how we diagnose infection in patients in the ICU and address the safety and utility of a 'watchful waiting' approach to antibiotic initiation with selected patients in the ICU. SOURCES: A semi-structured search of PubMed and Cochrane Library databases for articles published in English during the past 15 years was conducted. CONTENT: Distinguishing infection from non-infectious mimics in ICU patients is uniquely challenging. At present, we do not have access to a rapid point-of-care test that reliably differentiates between individuals who need antibiotics and those who do not. A small number of studies have attempted to compare early aggressive versus conservative antimicrobial strategies in the ICU. However, this body of literature is small and not robust enough to guide practice. IMPLICATIONS: This issue will not likely be resolved until there are diagnostic tests that rapidly and reliably identify the presence or absence of infection in the ICU population. In the meantime, prospective trials that identify clinical situations wherein it is safe to delay or withhold antibiotic initiation in the ICU until the presence of an infection is proven are warranted.

Emergency nurses' knowledge and understanding of their role in recognising and responding to patients with sepsis: A qualitative study.

AIM: Sepsis is a significant and time-sensitive clinical concern for patients who present to Emergency Departments (EDs). Existing guidelines do not define nurses' roles in managing sepsis. This study explored ED nurses' experiences and perceptions around recognising and responding to patients with sepsis, and their awareness of sepsis screening and prognostic tools. The knowledge and insights gained from this study may be used to inform local and international ED policies, and enrich nursing educational packages that may be used to improve quality of patient care and patient outcomes. METHODS: Qualitative design incorporating semi-structured interviews with 14 ED nurses was undertaken. Thematic and consensus-based content analyses were used to explore transcripts. FINDINGS: Six key themes were identified; (1) contribution of the organisation, (2) appreciation of knowledge, (3) appreciation of clinical urgency, (4) appreciation of importance of staff supervision, (5) awareness of the importance of staff experience, and (6) awareness of the need to seek advice. CONCLUSION: ED nurses' identified deficits in their capacity to recognise and respond to patients with sepsis, despite their vital role within the multidisciplinary team that cares for patients with sepsis. The knowledge and insights gained from this study can be used to inform ED policies, to enrich context-specific educational packages that aim to improve quality of patient care and outcomes and identify areas for further research. Development and implementation of a nurse-inclusive sepsis pathway may address many deficits identified in this study.

Cost awareness among healthcare professionals at a South African hospital: A cross-sectional survey.

BACKGROUND: Financial cost is a recognised cause of lack of access to adequate healthcare in South Africa (SA). Data describing the SA healthcare professional (HCP)'s awareness of costs are scant. Their increased awareness of healthcare costs may improve efficacy and reduce wasteful expenditure. OBJECTIVE: To assess SA HCP's knowledge of healthcare costs, identify factors that influence cost awareness, and to determine if surveyed HCPs received training related to cost management during their studies or at any stage during their practice. METHODS: This cross-sectional survey was conducted by means of a standardised questionnaire. HCPs working at a major tertiary academic hospital were asked to answer an anonymous standardised questionnaire aimed at determining their awareness of the costs of commonly requested hospital items and tests. Cost accuracy was determined by assessing the log deviation of the estimated cost from true cost, with values >0 and <0 representing overestimates and underestimates, respectively. Cost estimations were considered correct if the absolute value of the log deviation was <0.2. Participants' attitudes towards the potential impact of the availability of cost information on their practice were assessed. RESULTS: The overall cost estimation of accuracy was low (mean 0.60; standard deviation 1.99) and differed widely between items. Cheaper items were more likely to be overestimated and expensive items to be underestimated. The majority of participants indicated that cost awareness education was not part of their training or practice (84.5%) and that they would like cost information to be made readily available (92.2%). Eighty-four percent of participants were of the opinion that cost information would not negatively affect patient care. CONCLUSION: The use of percentage deviation from true cost as a method of assessing cost awareness creates a bias towards overestimation, which is more relevant for cheap items, as larger overestimates are more common for these items. We propose the use of log deviation of the estimated cost from the true cost as a method of assessing cost estimation accuracy. HCPs have a limited understanding of the costs of disposables, tests and drugs commonly used in their practice and would prefer that cost information be made readily available to them. Attention should be paid to improving cost awareness among HCPs working at SA hospitals.