Bedside nurse-patient interactions do not reliably detect delirium: an observational study.

UNLABELLED: Delirium is an acute, reversible and fluctuating central nervous system dysfunction with an organic cause, and is associated with substantial morbidity and mortality. Many recent studies have shown that delirium is highly prevalent in the Intensive Care Unit (ICU) population. Despite its seriousness; delirium in the ICU is under recognized by bedside nurses. OBJECTIVE: To determine if routine bedside nurse-patient interactions enable the detection of delirium. METHOD: We performed a single center observational study, in a 12 bed general Intensive Care Unit. Bedside nurses were asked to assess patients for delirium during routine patient care throughout their shift. This assessment was then compared to an independent assessment using the Confusion Assessment Method - ICU (CAM-ICU) performed by a nurse trained in this delirium detection tool. RESULTS: We analysed the results of 35 matched assessments performed on 35 patients. The presence of delirium was identified by the bedside nurse in 27% of CAM-ICU delirium positive assessments, whereas the absence of delirium was identified by the bedside nurse in 92% of CAM-ICU delirium negative assessments. CONCLUSION: There was a significant discrepancy between the ICU bedside nurses' assessment of delirium and the independent formal delirium assessment utilizing the CAM-ICU. We concluded that routine bedside nursing patient interaction do not reliably detect delirium in a critically ill patient.

Implementation of a pharmacist-initiated pharmaceutical handover for oncology and haematology patients being transferred to critical care units.

GOALS OF WORK: An information gap with respect to specific therapies was identified when patients were transferred from the oncology and haematology unit (OHU) to the critical care units. The goal was to implement and evaluate the effectiveness of a pharmacist-initiated pharmaceutical handover (PIPH) for patients being transferred from the OHU to the critical care units at a major teaching hospital. PATIENTS AND METHODS: A PIPH process for the specific therapies of mouthcare, chemotherapy regimen, growth factors and antibiotics was developed. The PIPH was delivered in written format or combined written and verbal format. The impact of the PIPH was by assessment of recorded clinical pharmacist interventions. Data were analysed to evaluate any difference in the number of interventions relating to and the time to administration of the specific therapies. MAIN RESULTS: Data were available for 30 patient transfers in the pre-implementation group, with 22 transfers available in the post-implementation period. The number of interventions relating to the specific therapies was significantly reduced in the post-implementation group (144 vs 26; p < 0.0001). A significantly greater proportion of the specific therapies were administered on time in the post-implementation group (57% vs 96%; p < 0.0001). CONCLUSIONS: Clinical pharmacists in the specialty area of oncology and haematology can improve the continuum of care when their patients are transferred to other units. By providing an accurate handover about specific therapies, there is an overall improvement in the prescribing and timely administration of these therapies.

Epidemiology of sepsis in cancer patients in Victoria, Australia: a population-based study using linked data.

OBJECTIVE: To determine the clinical characteristics, outcomes and longitudinal trends of sepsis occurring in cancer patients. METHOD: Retrospective study using statewide Victorian Cancer Registry data linked to various administrative datasets. RESULTS: Among 215,763 incident cancer patients, incidence of sepsis within one year of cancer diagnosis was estimated at 6.4%. The incidence of sepsis was higher in men, younger patients, patients diagnosed with haematological malignancies and those with de novo metastatic disease. Of the 13,316 patients with a first admission with sepsis, 55% had one or more organ failures, 29% required care within an intensive care unit and 13% required mechanical ventilation. Treatments associated with the highest sepsis incidence were stem cell/bone marrow transplant (33%), major surgery (4.4%), chemotherapy (1.1%) and radical radiotherapy (0.6%). The incidence of sepsis with organ failure increased between 2008 and 2015, while 90-day mortality decreased. CONCLUSIONS: Sepsis in patients with cancer has high mortality and occurs most frequently in the first year after cancer diagnosis. Implications for public health: The number of cancer patients diagnosed with sepsis is expected to increase, causing a substantial burden on patients and the healthcare system.

Evaluation of practice change in Tanzanian health professionals 12 months after participation in an Infection Prevention and Management Course.

BACKGROUND: Hospital-acquired infection (HAI) is a problem confronting developing countries. Education programmes have been shown to be effective in increasing awareness and changing practice in health professionals. METHODS: Practice change in health professionals who completed an Infection Prevention and Management Course in Tanzania was explored via focus group 12 months after completion of the course. FINDINGS: Positive changes in infection control practice were found, along with barriers to more widespread change. CONCLUSIONS: Providing tailored and continuing education programs to hospital staff, including managers, is recommended.

Educational innovation for infection control in Tanzania: bridging the policy to practice gap.

The incidence of hospital acquired infection in developing countries is between two to 20 times higher than in developed countries and is attributable to multiple causes. Evidence-based international policies and guidelines developed to improve infection prevention and control are often not used in practice in these countries. To combat this challenge, this article presents an innovative educational framework used to bridge the gap between policy written by global health agencies and the realities of practice in Tanzania.

Anticholinergic syndrome following an unintentional overdose of scopolamine.

Scopolamine hydrobromide (hyoscine) is an antimuscarinic drug which is primarily used in the prophylaxis and treatment of motion sickness and as a premedication to dry bronchial and salivary secretions. In acute overdosage, the main clinical problem is central nervous system (CNS) depression. In Australia, tablets containing scopolamine hydrobromide 0.3 mg are available over the counter in packs of ten. The recommended dose for adults is one to two tablets as a single dose, repeated four to six hours later, if required. The maximum dose stated on the pack is four tablets over a 24-hour period with a caution regarding drowsiness and blurred vision. We describe a patient who presented with symptoms of anticholinergic syndrome secondary to an unintentional overdose of scopolamine. Whilst at work, the patient noticed that he had forgotten his prescribed medication, domperidone, at home; a friend gave him some travel sickness medication which contained scopolamine for relief of nausea. On a previous occasion, he had experienced a similar, less severe reaction with another anticholinergic agent, loperamide. This report highlights the need to consider nonprescription products, ie, over the counter medications, herbal/nutritional supplements as causes of anticholinergic syndrome when a patient presents with symptoms suggestive of this diagnosis.

Induced hypothermia after out-of-hospital cardiac arrest: one hospital's experience.

OBJECTIVE: Induced mild hypothermia has been shown to reduce in-hospital mortality and to improve neurological outcome in patients who remain comatose after out-ofhospital cardiac arrest (OHCA). We conducted a retrospective audit to assess whether induced hypothermia had been successfully incorporated into routine care at our hospital, and whether this improved patient outcomes. DESIGN AND SETTING: Retrospective audit of patients admitted to a Level III intensive care unit, Melbourne, Victoria, between 2001 and 2007. Patients treated with therapeutic hypothermia (introduced in 2004) were compared with those who did not receive this therapy. PARTICIPANTS: Patients admitted to the ICU comatose after OHCA with a presumed cardiac cause. INTERVENTIONS: Induction of mild hypothermia by rapid infusion of cold intravenous fluids. MAIN OUTCOME MEASURES: Hospital survival and neurological outcome at hospital discharge; time taken for core temperature to reach the target range (33 degrees +/-0.5 degrees C) and time temperature was maintained, determined from patient ICU records. RESULTS: 123 patients were admitted comatose after OHCA with a presumed cardiac cause: 75 were admitted after induced hypothermia was introduced into routine care and received this treatment; and 48 admitted earlier did not receive the treatment. For patients with the initial rhythm of ventricular fibrillation (VF) or unstable ventricular tachycardia (uVT), treatment with induced hypothermia was associated with a higher hospital survival rate (P=0.03; odds ratio [OR], 2.51; 95% CI, 1.06-5.95) and better neurological outcome (P=0.02; OR, 2.85; 95% CI, 1.19-6.86). In 90% of patients treated with induced hypothermia, core temperature reached the target range within 6 hours of hospital presentation; mean duration of in-hospital cooling was 25.5 hours (SD, 2.9 hours). CONCLUSIONS: We found that induced hypothermia can be incorporated into routine care of patients admitted to an ICU after OHCA. For patients with an initial rhythm of VF or uVT, this seems to have significantly improved hospital survival and neurological outcome. We also found that rapid infusion of cold intravenous fluids was effective for inducing hypothermia.