Contextual Factors Influencing Intensive Care Patients' Discharge Processes: A Multicentre Prospective Observational Study.

AIMS: To compare contextual factors influencing discharge practices in three intensive care units (ICUs). DESIGN: A prospective observational study. METHODS: Data were collected using a discharge process report form (DPRF) between May and September 2023. Descriptive statistics were performed to analyse demographic and clinical data. One-way analysis of variance (ANOVA) was used to test the time interval differences among the three sites. RESULTS: Overall, 69 patients' discharge processes were observed. Among them, 41 (59%) experienced discharge delay, and 1 in 5 patients experienced after-hours discharge. There were statistically significant differences in mean hours in various time intervals during the discharge processes among the three sites. Patients in Hospital C waited the longest time (mean = 31.9 h) for the ward bed to be ready after the bed was requested and for being eventually discharged after ICU nurses to get them ready for discharge (mean = 26.7 h) compared to Hospital A and Hospital B. CONCLUSIONS: We found that discharge delay and after-hours discharge were common and there were significant differences in mean hours of various time intervals during the discharge processes occurred among the three sites. The influence of contextual factors in different hospitals/ICU needs to be considered to improve the ICU discharge process. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Researchers and clinicians should consider targeted context-specific interventions and strategies to optimise patient discharge process from ICUs. IMPACT: The study findings will inform the development of tailored interventions to reduce the discharge delay and after-hours discharge and, in turn, improve the quality and safety of patient care and health service efficiency. REPORTING METHOD: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. PATIENT OR PUBLIC CONTRIBUTION: Patients' discharge processes were observed, and consumer representatives were involved in the study design.

Optimal qualifications, staffing and scope of practice for first responder nurses in disaster.

AIMS AND OBJECTIVES: To explore: the selection criteria for first responder nurses during disaster; scope of practice for disaster relief nurses; appropriate nurse - medical practitioner ratio at the disaster site. BACKGROUND: Nurses are key members of disaster response medical teams. A scarcity of literature exists relating to nurses attending disasters, their qualifications, experience, scope of practice and appropriate staffing ratios. DESIGN: Qualitative and quantitative data were collected via survey using self-developed questionnaires. Participants were 95 medical workers, who participated in emergency rescue teams following the 2008 Wenchuan earthquake in China. A response rate of 93·7% achieved. METHOD: The questionnaire included questions relating to nurses: previous experience in disaster relief; scope of practice at the disaster site; optimal ratio of medical practitioners to nurses in disaster relief teams. RESULTS: Following a disaster, first responder nurses considered most suitable were those with at least three years clinical experience, particularly in the emergency department or having emergency rescue skills training. The scope of practice for disaster relief nurses was different to that of nurses working in a hospital. The majority of participants reported insufficient nurses during the relief effort, concluding the optimal ratio of medical practitioner to nurse should range between 1:1-1:2 depending on the task and situation. CONCLUSION: At the scene of disaster, the preferred first responder nurses were nurses: with emergency rescue training; experienced in the emergency department; with at least three years clinical experience. The scope of practice for first responder nurses needs to be extended. Appropriate nurse - medical practitioner ratios in responding medical teams is dependant on the specific medical requirements of the disaster. RELEVANCE TO CLINICAL PRACTICE: The recommendations made by this study provide a guide to ensure that nurses can contribute effectively as essential members of first responder emergency disaster relief teams.

"Holding back my own emotions": Evaluation of an online education module in pediatric end-of-life care.

Providing quality end-of-life care to a child who is dying in hospital can be stressful and challenging, and health professionals often feel ill-prepared and require additional support. End-of-Life Essentials offers online education modules for health professionals working in acute hospitals, including one on end-of-life care in pediatric settings. This study aimed to evaluate this module and explore learners' views on challenges faced when caring for a dying child and their family in a hospital setting. Learners comprised nurses, doctors, and allied health professionals. A quantitative pre-/post-evaluation analysis was conducted using learner data (n = 552) on knowledge and skills gained from engagement with the module, along with a qualitative thematic content analysis on learner responses (n = 395) to a post-evaluation free-text response question, between May 2019 and May 2020. Learners' post-evaluation ranks of perceived knowledge, skill, attitude, and confidence were significantly higher than pre-evaluation ranks (p < 0.001). Effect sizes were small to medium, ranging from 0.31 to 0.38 (95% confidence intervals from 0.23 to 0.45). Emerging themes from the qualitative data were dealing with emotions, and communicating effectively. This evaluation suggests that the Pediatrics module could be a useful online learning resource for health professionals. A planned longitudinal study will further investigate practice change.

Effects of probiotics on serum levels of Th1/Th2 cytokine and clinical outcomes in severe traumatic brain-injured patients: a prospective randomized pilot study.

INTRODUCTION: Traumatic brain injury (TBI) is associated with a profound immunological dysfunction manifested by a severe shift from T-helper type 1 (Th1) to T-helper type 2 (Th2) response. This predisposes patients to infections, sepsis, and adverse outcomes. Probiotic bacteria have been shown to balance the Th1/Th2 cytokines in allergic murine models and patients. For the present study, we hypothesized that the enteral administration of probiotics would adjust the Th1/Th2 imbalance and improve clinical outcomes in TBI patients. METHODS: We designed a prospective, randomized, single-blind study. Patients with severe TBI and Glasgow Coma Scale scores between 5 and 8 were included, resulting in 26 patients in the control group and 26 patients in the probiotic group. All patients received enteral nutrition via a nasogastric tube within 24 to 48 hours following admission. In addition, the probiotic group received 109 bacteria of viable probiotics per day for 21 days. The associated serum levels of Th1/Th2 cytokines, Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores, nosocomial infections, length of ICU stay, and 28-day mortality rate were studied. RESULTS: The patients responded to viable probiotics, and showed a significantly higher increase in serum IL-12p70 and IFNγ levels while also experiencing a dramatic decrease in IL-4 and IL-10 concentrations. APACHE II and SOFA scores were not significantly affected by probiotic treatment. Patients in the probiotic group experienced a decreased incidence of nosocomial infections towards the end of the study. Shorter ICU stays were also observed among patients treated with probiotic therapy. However, the 28-day mortality rate was unaffected. CONCLUSIONS: The present study showed that daily prophylactic administration of probiotics could attenuate the deviated Th1/Th2 response induced by severe TBI, and could result in a decreased nosocomial infection rate, especially in the late period. TRIAL REGISTRATION: ChiCTR-TRC-10000835.

A survey of the practice of nurses' skills in Wenchuan earthquake disaster sites: implications for disaster training.

AIMS: To determine nursing skills most relevant for nurses participating in disaster response medical teams; make recommendations to enhance training of nurses who will be first responders to a disaster site; to improve the capacity of nurses to prepare and respond to severe natural disasters. BACKGROUND: Worldwide, nurses play a key role in disaster response teams at disaster sites. They are often not prepared for the challenges of dealing with mass casualties; little research exists into what basic nursing skills are required by nurses who are first responders to a disaster situation. This study assessed the most relevant disaster nursing skills of first responder nurses at the 2008 Wenchuan earthquake disaster site. METHOD: Data were collected in China in 2008 using a self-designed questionnaire, with 24 participants who had been part of the medical teams that were dispatched to the disaster sites. FINDINGS: The top three skills essential for nurses were: intravenous insertion; observation and monitoring; mass casualty triage. The three most frequently used skills were: debridement and dressing; observation and monitoring; intravenous insertion. The three skills performed most proficiently were: intravenous insertion; observation and monitoring; urethral catheterization. The top three ranking skills most important for training were: mass casualty transportation; emergency management; haemostasis, bandaging, fixation, manual handling. CONCLUSION: The core nursing skills for disaster response training are: mass casualty transportation; emergency management; haemostasis, bandaging, fixation, manual handling; observation and monitoring; mass casualty triage; controlling specific infection; psychological crisis intervention; cardiopulmonary resuscitation; debridement and dressing; central venous catheter insertion; patient care recording.

Enteral nutrition in patients with severe traumatic brain injury: reasons for intolerance and medical management.

Approximately, 50% of patients with severe traumatic brain injury (TBI) exhibit intolerance to enteral nutrition (EN). This intolerance hampers the survival and rehabilitation of this subpopulation to a great extent, and poses various difficulties for clinicians due to its complex underlying mechanisms. This review discusses the possible reasons for intolerance to EN following severe TBI, current trends in medical management, as well as other related issues that are experienced by many clinicians.

What is a compassionate response in the emergency department? Learner evaluation of an End-of-Life Essentials online education module.

OBJECTIVE: To evaluate the End-of-Life Essentials education module 'Emergency Department End-of-Life Care' and explore learners' views on what constitutes a compassionate response in the ED. METHODS: The present study used a multi-methods approach. Learners comprised a mix of nurses, doctors and allied health professionals. A quantitative pre-post evaluation analysis of learners' (n = 959) knowledge, skills, attitude and confidence was conducted, along with a qualitative thematic content analysis on learner responses (n = 538) to the post-evaluation question, 'What is a compassionate response for you in the emergency department?' Data were extracted for a 12-month period, 6 May 2019 to 6 May 2020. RESULTS: Learners' post-evaluation ranks of knowledge, skill, attitude and confidence were significantly higher than the pre-evaluation ranks (P < 0.001). Emerging themes from the qualitative data were organised into three overarching categories: communication skills (e.g. listening and use of names), care discussion and provision (e.g. provide information and discuss care plans) and humanising healthcare (e.g. emotional support and empathy, taking the time, and offering kindness and comfort). CONCLUSION: The 'Emergency Department End-of-Life Care' module had a significant positive impact on learners in relation to perceived knowledge, skill, attitude and confidence. This evaluation suggests that the End-of-Life Essentials ED module could be a useful online learning resource for health professionals.

End-of-Life Care in Acute Hospitals: Practice Change Reported by Health Professionals Following Online Education.

Providing quality care for those dying in hospital is challenging for health professionals who receive little training in this. "End of Life Essentials" (EOLE) was developed to address gaps in health professionals' knowledge, skills and confidence in end-of-life care via the provision of online learning modules and practice resources. This study aimed to determine whether respondents could describe clinical practice change as a result of module completion. Deidentified data were collected between October and November 2018 from learners registered for the online learning modules. Both quantitative and qualitative data were extracted and analysed. The survey design and conduct were reviewed, and ethical approval was obtained. Although the response rate was very low, results from n = 122 learners show improvements in knowledge, skills, awareness and confidence as a result of the undertaking of the learning modules. Two thirds self-reported practice changes (71%, n = 59) following the education, with "communication" cited most commonly (n = 19). The findings suggest that the EOLE education modules can help to improve end-of-life care by increasing health professionals' awareness of good practice as well as their knowledge, skills and confidence. Online learning has also been reinforced as an appropriate forum for end-of-life education. Following education, implementing what has been learned occurs more easily at a personal level rather than at a team and organisational level. Barriers to and enablers of clinical practice change in hospital are described, including the fact that the organisation may not be responsive to changes or have the relevant resources to support change.

Da-Cheng-Qi Decoction () Combined with Lactobacillus Acidophilus Improves Gastrointestinal Function of Traumatic Brain-Injured Model Mice.

OBJECTIVE: To investigate the effects of Da-Cheng-Qi Decoction (DCQD, ) combined with Lactobacillus acidophilus (LA) on the recovery of gastrointestinal (GI) function in traumatic brain-injured (TBI) mice. METHODS: A total of 150 male C57BL/6 mice were randomly divided into sham-injury, normal saline (NS), DCQD (0.4 mL/day), LA (⩾1 × 1010 cfu/day LA), DCQD+LA (LA administration at the same dosage after 4 h of feeding DCQD), and ½ DCQD+LA groups (LA administration at the same dosage after 4 h of feeding ½ DCQD dose) by a random number table, 5-8 mice in each group. The sever TBI model was constructed according to Feeney's enhanced gravitational forces of free falling. On days 1, 3, and 7 post-TBI, plasma diamine oxidase (DAO) and D-lactic acid levels were assessed by enzyme-linked immunosorbent assay (ELISA). Occludin expression in the intestinal epithelium was assessed by Western blot analysis. Transmission electron microscopy (TEM) was used to observe the morphological changes in the network structure of interstitial cells of Cajal (ICC) and change of enteric nervous system-ICC-smooth muscle cell (ENS-ICC-SMC). Immunofluorescence staining was used to detect changes in the network structure of the ICC. RESULTS: Compared with the NS group, occludin expression in the DCQD+LA group significantly increased on Day 1, 3, and 7 post-TBI (P<0.05 or P<0.01). The concentration of DAO significantly decreased in the LA, DCQD, and DCQD+LA groups on Day 3 and 7, whilst the D-lactate concentrations in the LA and ½ DCQD+LA groups decreased on Day 1 and 3 post-injury (P<0.05 or P<0.01). The NS group experienced a great damage on the ENS-ICC-SMC network morphology and ICC network structure, and all treatment groups had some improvements, among which the DCQD+LA group presented relatively intact network morphology. CONCLUSIONS: DCQD combined with LA treatment could effectively repair the intestinal mucosal barrier and improve GI motility in mice after TBI. The combination of DCQD and LA was more effective than their respective monotherapies.

Evaluation of an End-of-Life Essentials Online Education Module on Chronic Complex Illness End-of-Life Care.

Chronic complex illness/multimorbidity is a leading cause of death worldwide. Many people with chronic complex illnesses die in hospital, with the overall quality of end-of-life care requiring substantial improvement, necessitating an increase in the knowledge of the health professionals caring for them. End-of-Life-Essentials (EOLE) offers online education modules for health professionals working in acute hospitals, including one on chronic complex illness. A quantitative pre-post-evaluation analysis was undertaken on data from learners (n = 1489), who completed a questionnaire related to knowledge gained from module completion between December 2018 and November 2019. A qualitative post-evaluation analysis was also conducted using data on learner responses to a question posed between May and November 2019. Results showed a significant positive impact on learners' knowledge, skill, attitude, and confidence in providing end-of-life care to patients living with chronic complex illness. The majority (82.9%, n = 900) intended to change their practice after module completion. A total of n = 559 qualitative comments were analysed thematically, with three major themes emerging: Patient centred care and care planning, Discussion of prognosis, and Valued communication skills. This evaluation has demonstrated that healthcare professionals could benefit from this education to improve quality of care of the dying.

Zero Health Worker Infection: Experiences From the China Ebola Treatment Unit During the Ebola Epidemic in Liberia.

In November 2014, a total of 164 health care workers were dispatched by the Chinese government as the first medical assistance team to Liberia. The tasks of this team were to establish a China Ebola treatment unit (ETU), to commence the initial admission and treatment of suspected and confirmed Ebola patients, and to provide public health and infection control training for relevant local personnel. Overall, during the 2-month stay of this first medical assistance team in Liberia, 112 Ebola-suspected patients presented to the ETU, 65 patients were admitted, including 5 confirmed cases, and 3 confirmed cases were cured. Furthermore, 1520 local people were trained, including health care workers, military health care workers, staff members employed by the ETU, and community residents. Most importantly, as the first Chinese medical assistance team deployed to Liberia fighting the Ebola virus on the frontline, not a single member of this team or the hired local staff were infected by Ebola virus. This highly successful outcome was due to the meticulous infection control initiatives developed by the team, thereby making a significant contribution to China's ETU "zero infection" of health workers in Liberia. The major infection control initiatives conducted in the China ETU that contributed to achieving "zero infection" of all health workers in the ETU are introduced in this report. (Disaster Med Public Health Preparedness. 2017;11:262-266).

[Heterogeneity changes in secretion ability of monocyte/macrophage and its significance after trauma hemorrhage in rat].

OBJECTIVE: To investigate the relationship between the heterogeneity in secretion ability of monocyte (Mo)/macrophage and the immune dysfunction after severe trauma. METHODS: Twenty-four healthy Wistar rats were randomly divided into normal control group and trauma hemorrhage 1, 4 and 7 days groups. The contents of interleukin-6 (IL-6) and IL-10 secretion of Mo/macrophage from different anatomical regions were determined by radioimmunoassay. RESULTS: (1)In normal rats, the ability to secrete IL-6 and IL-10 was different among alveolar macrophages (AM), peritoneal macrophages (PM) and Mo. PM showed the highest ability to secrete IL-10 while Mo had the highest ability to secrete IL-6. (2)After trauma hemorrhage, the secretion of IL-6 and IL-10 by AM were increased dramatically. On the contrary, the secretion of IL-6 by PM was declined from the 1st day to the 4th day, then increased even over that of the normal control group on the 7th day. However, the secretion of IL-10 by PM was significantly elevated on the 1st day after trauma hemorrhage, peaking on the 4th day, and only slight lowering was found on the 7th day. The secretion of IL-6 by Mo was declined gradually all the time, reaching the lowest point on the 7th day. On the contrary, the secretion of IL-10 by Mo was increasing, reaching its peak on the 7th day. CONCLUSION: The heterogeneity of secretion ability of Mo/macrophage obtained from different anatomical regions is present under normal condition, and is more obvious following a severe injury. This change may play an important role in the immune dysfunction and the development of complications after trauma.

Association between TLR4 and PTEN Involved in LPS-TLR4 Signaling Response.

In this study, we explored the potential mechanisms of how PTEN regulating LPS induced TLR4 signaling pathway. The initial findings from ELISA demonstrate that PTEN influences TNF-α secretion by its lipid phosphatase activity. Subsequently, western blot, immunoprecipitation assay, and immunofluorescence were performed to explore the activation process of PTEN by stimulation with LPS. As early as 20 minutes after LPS stimulation, reduced phosphorylation of PTEN was found obviously. Accordingly, the whole cell-scattered PTEN translocated towards the cell membrane 20 minutes after stimulating with LPS. Moreover, the weak physical association between PTEN and TLR4 in resting RAW264.7 cells increased gradually after the stimulation of LPS. Furthermore, our study showed PTEN decreased LPS-induced Akt activity and upregulated NF-κB-dependent gene transcription, identifying indirectly that the PTEN could regulate the activation of NF-κB by its downstream Akt kinase. In summary, our study illustrates the potential signal transduction process of PTEN while stimulated by LPS: by increasing the association of TLR4, PTEN recruits to its phosphoinositide substrate PI(3,4,5)P3 located on the cell membrane and exerts its dephosphorylated function and subsequently depresses the activity of downstream molecule Akt and results in activation of NF-κB, followed by the secretion of inflammatory mediators TNF-α.

Identification of synthetic peptides that inhibit lipopolysaccharide (LPS) binding to myeloid differentiation protein-2 (MD-2).

Many studies have suggested that the synergic effect of myeloid differential protein-2 (MD-2) on bacterial lipopolysaccharide (LPS) stimulation of toll-like receptor 4 (TLR4) may be a critical step during the LPS-TLR4 response signaling pathway. We performed a bioinformatic analysis on the MD-2 protein and identified the amino acid sequence NH2-FSKGKYKCV-COOH (K128-132) as a possible key sequence involved in the binding between MD-2 and LPS. We then screened a random phage display peptide library using this sequence as bait in order to identify antagonistic peptides. After 3 rounds of selection, 3 positive clones were identified. All 3 peptides were shown to inhibit, in a dose-dependent manner the production of tumor necrosis factor-α and interleukin-6 in human U937 and THP-1 cell lines as well as human peripheral blood monocytes stimulated by LPS. Only 2 of the 3 peptides were able to bind MD-2 directly as shown by sulfo-SBED biotin label transfer experiments. BALB/C mice were used to estimate the protection of these peptides from LPS challenge, and 2 of the 3 peptides (Lys-Thr-Val-Pro-Asp-Asn-His and Ile-Gly-Lys-Phe-Leu-Tyr-Arg) reduced mortality of the challenged mice from 100% to 53.8%. This study has demonstrated that interfering with the binding between MD-2 and LPS might be a potential therapeutic strategy for treating LPS-induced sepsis, and in doing so has identified 2 potential peptide candidates.

Increased gut absorptive capacity in rats with severe head injury after feeding with probiotics.

OBJECTIVE: The absorptive capacity of the gut is decreased after severe head injury (SHI), and this may be related to poor recovery. Probiotics may be a promising approach to improving gut absorption. The aim of this study was to investigate the effect of probiotics on gut absorptive capacity (GAC) after SHI. METHODS: A rat model in which SHI was induced by air percussion was used. One hundred fourteen Sprague-Dawley rats were randomized into three groups: SHI followed by standard enteral nutrition (group A); SHI followed by standard enteral nutrition plus probiotics (group B); and standard chow diet ad libitum (group C, sham-operated). The enteral diets were infused for 14 d after SHI. RESULTS: SHI induced weight loss and decreased the serum concentration of D-xylose and the apparent protein digestibility. Probiotics significantly improved GAC after SHI. Apparent protein digestibility and the concentration of D-xylose were lower in group A than in B or C after 14 d. The rats receiving probiotics showed less weight loss than group A. SHI induced intestinal flora dysfunction and a decrease in villus height and surface area. Digestive enzyme activities and gut motion were also depressed significantly, and these changes were closely related to the decrease in GAC. Probiotics increased villus height and surface area; Escherichia coli counts decreased significantly, and anaerobic counts increased. CONCLUSION: Probiotics improve the GAC after SHI, perhaps because of enhanced villus surface area, and correction of intestinal flora dysfunction.