Epidemiology of early Rapid Response Team activation after Emergency Department admission

BACKGROUND

Rapid Response Team (RRT) calls can often occur within 24h of hospital admission to a general ward. We seek to determine whether it is possible to identify these patients before there is a significant clinical deterioration.

METHODS

Retrospective case-controlled study comparing patient characteristics, vital signs, and hospital outcomes in patients triggering RRT activation within 24h of ED admission (cases) with matched ED admissions not receiving a RRT call (controls).

RESULTS

Over 12 months, there were 154 early RRT calls. Compared with controls, cases had a higher heart rate (HR) at triage (92 vs. 84 beats/min; p=0.008); after 3h in the ED (91 vs. 80 beats/min; p=0.0007); and at ED discharge (91 vs. 81 beats/min; p=0.0005). Respiratory rate (RR) was also higher at triage (21.2 vs. 19.2 breaths/min; p=0.001). On multiple variable analysis, RR at triage and HR before ward transfer predicted early RRT activation: OR 1.07 [95% CI 1.02-1.12] for each 1 breath/min increase in RR; and 1.02 [95% CI 1.002-1.030] for each beat/minute increase in HR, respectively. Study patients required transfer to the intensive care in approximately 20% of cases and also had a greater mortality: (21% vs. 6%; OR 4.65 [95% CI 1.86-11.65]; p=0.0003) compared with controls.

CONCLUSIONS

Patients that trigger RRT calls within 24h of admission have a fourfold increase in risk of in-hospital mortality. Such patients may be identified by greater tachycardia and tachypnoea in the ED.

Mechanical ventilation and mobilization: comparison between genders

[Purpose] To investigate the impact of gender on mobilization and mechanical ventilation in hospitalized patients in an intensive care unit. [Subjects and Methods] A retrospective cross-sectional study was conducted of the medical records of 105 patients admitted to a general intensive care unit. The length of mechanical ventilation, length of intensive care unit stay, weaning, time to sitting out of bed, time to performing active exercises, and withdrawal of sedation exercises were evaluated in addition to the characteristics of individuals, reasons for admission and risk scores. [Results] Women had significantly lower values APACHE II scores, duration of mechanical ventilation, time to withdrawal of sedation and time to onset of active exercises. [Conclusion] Women have a better functional response when admitted to the intensive care unit, spending less time ventilated and performing active exercises earlier.

Mitigating nonurgent interruptions during high-severity intensive care unit tasks using a task-severity awareness tool: A quasi-controlled observational study

PURPOSE

In a previous study of interruptions to intensive care unit (ICU) nurses, we found that other personnel tend to regulate their interruptions based on nurses' tasks. However, nurses' tasks are not always immediately visible to an interrupter. This article evaluates a task-severity awareness tool (TAT) designed for nurses to inform others when they are performing high-severity tasks. When a nurse engages the tool within an ICU room, a "do not disturb please!" message is displayed outside the room.

METHODS

Task-severity awareness tool was installed in a cardiovascular ICU room at a Canadian hospital. Fifteen nurses assigned to the TAT room and 13 nurses assigned to 11 other rooms were observed, approximately 2 hours each, over a 3-week period. Data were collected in real time, using a tablet computer.

RESULTS

Interruption rate during high-severity tasks in the TAT room was significantly lower than in other rooms; interruptions with personal content were entirely mitigated during high-severity tasks. Furthermore, interruptions from nurses and medical doctors were also entirely mitigated during high-severity tasks but happened more frequently during non-high-severity tasks compared with rooms with no TAT.

CONCLUSIONS

Task-severity awareness tool proved to be effective in mitigating unnecessary interruptions to critical tasks. Future research should assess its long-term effectiveness.

Central line-associated blood stream infections in pediatric intensive care units: Longitudinal trends and compliance with bundle strategies

BACKGROUND

Knowing the temporal trend central line-associated bloodstream infection (CLABSI) rates among U.S. pediatric intensive care units (PICUs), the current extent of central line bundle compliance, and the impact of compliance on rates is necessary to understand what has been accomplished and can be improved in CLABSI prevention.

METHODS

This is a longitudinal study of PICUs in National Healthcare Safety Network hospitals and a cross-sectional survey of directors and managers of infection prevention and control departments regarding PICU CLABSI prevention practices, including self-reported compliance with elements of central line bundles. Associations between 2011-2012 PICU CLABSI rates and infection prevention practices were examined.

RESULTS

Reported CLABSI rates decreased during the study period, from 5.8 per 1,000 line days in 2006 to 1.4 in 2011-2012 (P < .001). Although 73% of PICUs had policies for all central line prevention practices, only 35% of those with policies reported ≥95% compliance. PICUs with ≥95% compliance with central line infection prevention policies had lower reported CLABSI rates, but this association was statistically insignificant.

CONCLUSION

There was a nonsignificant trend in decreasing CLABSI rates as PICUs improved bundle policy compliance. Given that few PICUs reported full compliance with these policies, PICUs increasing their efforts to comply with these policies may help reduce CLABSI rates.

[Pain perception of nurses and pain expression of patients in critical care units]

PURPOSE

This study was done to identify pain perception (P-PER) by nurses and pain expression (P-EXP) by patients in critical care units (ICUs) and degree of agreement between nurses' P-PER and patients' P-EXP.

METHODS

Nurses' P-PER was measured with a self-administered questionnaire completed by 99 nurses working in ICUs during May, 2013. Patients' P-EXP was measured with the Critical Care Non-Verbal Pain Scale through observations of 31 ICU patients during nine nursing procedures (NPs) performed between May and July, 2013.

RESULTS

Nurses' P-PER was from 4.49 points for nasogastric tube (NGT) insertion to 0.83 for blood pressure (BP) measurement based on a 9-point scale, Patients' P-EXP was 4.48 points for NGT to 0.18 for BP measurement based on a 10-point scale. Eight NPs except oral care showed higher scores for nurses' P-PER than for patients' P-EXP. Position change (p=.019), subcutaneous injection (p<.001), blood sugar test (p<.001), and BP measurement (p<.001) showed significant differences between nurses' P-PER and patients' P-EXP.

CONCLUSION

Nasogastric tube (NGT) insertion was scored highest by both nurses and patients. Eight NPs except 'oral care' showed nurses' P-PER was higher or similar to patients' P-EXP, which indicates that nurses may overestimate procedural pain experienced by patients.

In vitro analysis of the effect of in-line 1.2 micron filters on two formulations of propofol (2,6-diisopropyl phenol)

Recent evidence has shown improved outcomes in pediatric intensive care units with the intensive use of intravenous in-line filtration. This has caused resurgence in interest in filter use but has raised questions in relation to emulsion-based formulations such as propofol. Our objective was to test two propofol products, Diprivan(®) and Fresofol(®), with the Pall Lipipor(®) TNA and Lipipor NLF intravenous in-line filters and to assay the content before and after filtration under typical infusion conditions. The propofol emulsions were delivered from a 50 mL syringe through an extension set and into either a Lipipor TNA (50 mL/h(-1)) or Lipipor NLF (20 mL/h(-1)) filter. Samples were taken at regular intervals and assayed using a high-performance liquid chromatography method before and after filtration. No evidence was found of a significant concentration change during passage of either product through either model of filter. Propofol from two products was found to pass through two different types of Pall 1.2 μm intravenous in-line filters. There was no significant change in concentration before and after filtration under typical conditions of administration. In conclusion, administration of these products through these models of in-line filter would be safe and effective.

Randomized study to compare nasojejunal with nasogastric nutrition in critically ill patients without prior evidence of altered gastric emptying

BACKGROUND AND AIMS

Studies comparing jejunal and gastric nutrition show inconsistent results regarding pneumonia. The aim of this study was to evaluate the incidence of pneumonia comparing gastric with jejunal nutrition. Secondarily, we evaluated 28(th) day Intensive Care Unit (ICU) mortality rate and other complications related to enteral feeding.

SUBJECTS

Age >18 years; need for enteral nutrition without contraindication for placement of an enteral tube, duration of ICU stay > than 48 h.

METHODS

Patients were randomly assigned to receive enteral feed via a gastric or jejunal tube. Jejunal tubes were inserted at bedside and placement was confirmed radiographically.

RESULTS

A total of 115 patients were enrolled, with 61 patients into the gastric tube group and 54 patients into the jejunal group tube. Baseline characteristics were similar. There was no difference in pneumonia or ICU mortality rates, ICU length of stay and ventilator days. Complications rates were similar.

CONCLUSIONS

We conclude that the enteral nutrition through a jejunal tube does not reduce the rate of pneumonia in comparison to a gastric tube. In addition, we did not observe differences in rates of gastrointestinal complications or ICU mortality. The routine placement of a jejunal tube in critically ill-patients cannot be recommended.

Characterization of patients exposed to multiple devices but free of hospital-acquired infection at intensive care unit discharge

Intensive care unit patients exposed to multiple devices but free of hospital-acquired infection (HAI) until discharge were identified through a surveillance network of HAIs in Lyon, France, between 2003 and 2011. Multiexposed patients were defined according to the tenth deciles of length of stay and exposures to invasive devices. Overall, 982 (5.0%) multiexposed patients were identified; 154 (15.7%) remained uninfected. Multiexposed infected patients differed from noninfected patients regarding length of exposures and mortality.

Use of bioelectrical impedance analysis for the assessment of nutritional status in critically ill patients

Malnutrition is common in the critically ill patients and known to cause a variety of negative clinical outcomes. However, various conventional methods for nutrition assessment have several limitations. We hypothesized that body composition data, as measured using bioelectrical impedance analysis (BIA), may have a significant role in evaluating nutritional status and predicting clinical outcomes in critically ill patients. We gathered clinical, biochemical, and BIA data from 66 critically ill patients admitted to an intensive care unit. Patients were divided into three nutritional status groups according to their serum albumin level and total lymphocyte counts. The BIA results, conventional indicators of nutrition status, and clinical outcomes were compared and analyzed retrospectively. Results showed that the BIA indices including phase angle (PhA), extracellular water (ECW), and ECW/total body water (TBW) were significantly associated with the severity of nutritional status. Particularly, PhA, an indicator of the health of the cell membrane, was higher in the well-nourished patient group, whereas the edema index (ECW/TBW) was higher in the severely malnourished patient group. PhA was positively associated with albumin and ECW/TBW was negatively associated with serum albumin, hemoglobin, and duration of mechanical ventilation. In non-survivors, PhA was significantly lower and both ECW/TBW and %TBW/fat free mass were higher than in survivors. In conclusion, several BIA indexes including PhA and ECW/TBW may be useful for nutritional assessment and represent significant prognostic factors in the care of critically ill patients.

Prevention of ventilator-associated pneumonia

Ventilator-associated pneumonia is the commonest, yet mostly preventable, infection in mechanically ventilated patients. Successful control of ventilator-associated pneumonia can save hospitalisation cost, and is possible by using a multidisciplinary clinical and administrative approach. The ventilator-associated pneumonia rate should be expressed as the number of ventilator-associated pneumonia days per 1000 ventilator days to take into account the device-utilisation duration for meaningful comparison. Various strategies address the issue, including general infection control measures, body positioning, intubation and mechanical ventilation, oral and gastro-intestinal tract, endotracheal tube, airway pressure, cuff pressure, selective digestive and/or oropharyngeal decontamination, and probiotic or early antibiotic treatment, as well as overall administration at a policy level. The rationale and controversy of these approaches are discussed in this article. The authors suggest that all units treating mechanically ventilated patients should have a ventilator-associated pneumonia prevention protocol in place, and ventilator-associated pneumonia should be seriously considered as a key performance indicator in local intensive care units.

"Not being able to talk was horrid": A descriptive, correlational study of communication during mechanical ventilation

OBJECTIVES

The purpose of this study was to describe the patient experience of communication during mechanical ventilation.

RESEARCH METHODOLOGY

This descriptive study is a secondary analysis of data collected to study the relationship between sedation and the MV patients' recall of the ICU. Interviews, conducted after extubation, included the Intensive Care Experience Questionnaire. Data were analysed with Spearman correlation coefficients (rs) and content analysis.

SETTING

Participants were recruited from a medical-surgical intensive care unit in the Midwest United States.

RESULTS

Participants (n = 31) with a mean age of 65 ± 11.9 were on the ventilator a median of 5 days. Inability to communicate needs was associated with helplessness (rs = .43). While perceived lack of information received was associated with not feeling in control (rs = 41) and helplessness (rs = 41). Ineffective communication impacted negatively on satisfaction with care. Participants expressed frustration with failed communication and a lack of information received. They believed receipt of information helped them cope and desired a better system of communication during mechanical ventilation.

CONCLUSION

Communication effectiveness impacts patients' sense of safety and well-being during mechanical ventilation. Greater emphasis needs to be placed on the development and integration of communication strategies into critical care nursing practice.

The effect of melody on the physiological responses of heel sticks pain in neonates

BACKGROUND

During health care in the neonatal intensive care unit (NICU), infants undergo extremely painful procedures, which may cause problems, if not controlled, such as changes in the pattern of respiratory rate, heart rate, and blood oxygen saturation. The present study aimed to find the effect of melody on the physiological responses of neonates' heel stick pain.

MATERIALS AND METHODS

This quasi-experimental study was conducted in Alzahra Hospital (Isfahan, Iran) for 5 months. Fifty infants were selected through convenient sampling method and were randomly assigned in equal numbers to two groups (n = 25). In the melody group (intervention), a selected melody was played for the infants at a distance of 1 m from them, with a sound intensity of 65 dB, from 3 minutes before, during, and after the heel stick procedure, respectively, and their physiological responses were observed with a monitoring system and recorded at the afore-mentioned time periods. Physiological responses were also recorded in the control group (no intervention) 3 min before, during, and after the heel stick procedure, respectively.

RESULTS

Means of respiratory and pulse rates in the melody and control groups showed a significant difference at different time points. But the mean blood oxygen saturation in the melody group showed no significant difference at different time points, although the difference was significant in the control group.

CONCLUSIONS

The results showed that melody could maintain more balance in some physiological responses of infants, such as the respiratory rate and pulse rate during the Guthrie test. Therefore, melody is recommended to be used to prevent the destructive effects of pain in infants during painful procedures.

Health care-acquired infections in neonatal intensive care units: risk factors and etiology

A 1-year prospective cohort study of health care-acquired infections was conducted at the neonatal intensive care unit of the University Clinical Centre Kragujevac, Serbia. The incidence rate of neonates with health care-acquired infections was 18.6%, and the incidence rate of the infections themselves was 19.4%. The incidence density of the health care-acquired infections was 9.1 per 1,000 patient days. The independent risk factors for health care-acquired infections were birth weight, length of hospitalization, duration of mechanical ventilation, and Apgar score. More than half of all isolated microorganisms were Klebsiella-Enterobacter (39.3%) and Escherichia coli (25.0%).

Tramadol overdose and apnea in hospitalized children, a review of 20 cases

We aimed to determine the clinical manifestations of tramadol intoxication in children and to find its potential poor prognostic factors. In a retrospective study, from 1363 cases of admitted pediatric poisoning, all tramadol-exposed hospitalized patients younger than 12 years were included in the study. They were hospitalized between March 2010 and April 2012 to the only referral hospital for pediatric poisoned patients in Tehran, Iran. Data including age, weight, gender, ingested dose (determined by history), pupil size, seizure, apnea, treatment interventions, and laboratory results was collected using chart review of the hospitalized intoxicated children. Twenty children with a mean age of 3.7 ± 2.9 years were identified amongst children during this 26-month period of whom, 14 (70%) had a decreased level of consciousness, 3 (15%) experienced apnea, and four (20%) had nausea and vomiting. Witnessed seizure did not occur in any of these patients. All patients were referred to hospital within 10.5 h of the exposure. The mean ingested dose was 9.6 ± 5.5 mg/kg. There was no significant relation between apnea and the estimated toxic dose. Apnea was more common in children who had presented with respiratory acidosis (Relative risk = 3.8, 95% CI = 1.6, 8.7, P = 0.043). All patients survived. Patients with apnea were managed conservatively by naloxone and recovered without need for intubation. Respiratory depression might occur at doses just above the therapeutic dose. We recommend an observation time of 12 h for all asymptomatic children who have ingested any dose greater than the therapeutic one.

Advanced imaging use in intensive care units has decreased, resulting in lower charges without negative effects on patient outcomes

PURPOSE

There has been both greater recognition and scrutiny of the increased use of advanced imaging. Our aim was to determine whether there has been a change over time in the use of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US) modalities in the intensive care units (ICUs).

MATERIALS AND METHODS

A retrospective review of 75657 admissions to 20 ICUs was conducted. Results were analyzed with multivariate linear, negative binomial, and Poisson regressions. Primary outcomes were rates of use of CT, MRI, and US per 1000 ICU admissions every 6 months. Secondary outcomes were changes in radiology use associated with impacts on mortality, hospital length of stay (LOS), ICU LOS, and hospital charges.

RESULTS

The rate of imaging use decreased by 13.5% between 2007 and 2011 (incidence rate ratio [IRR], 0.982; P < .001). Most of this decrease was by CTs (21.0%; IRR, 0.973; P < .001). Use of MRI decreased by 6.0% (IRR, 0.991; P = .04), whereas US increased by 18.9% (IRR, 1.012; P < .001). The charges associated with imaging decreased by $74 per ICU admission, which would save an estimated $1.2 million in charges during 2011. Decreased imaging was not associated with changes in mortality, hospital, and ICU LOS.

CONCLUSION

Advanced imaging use decreased for 5 years in the ICUs, resulting in decreased charges without negative effects on patient outcomes.

External validation of the Intensive Care National Audit & Research Centre (ICNARC) risk prediction model in critical care units in Scotland

BACKGROUND

Risk prediction models are used in critical care for risk stratification, summarising and communicating risk, supporting clinical decision-making and benchmarking performance. However, they require validation before they can be used with confidence, ideally using independently collected data from a different source to that used to develop the model. The aim of this study was to validate the Intensive Care National Audit & Research Centre (ICNARC) model using independently collected data from critical care units in Scotland.

METHODS

Data were extracted from the Scottish Intensive Care Society Audit Group (SICSAG) database for the years 2007 to 2009. Recoding and mapping of variables was performed, as required, to apply the ICNARC model (2009 recalibration) to the SICSAG data using standard computer algorithms. The performance of the ICNARC model was assessed for discrimination, calibration and overall fit and compared with that of the Acute Physiology And Chronic Health Evaluation (APACHE) II model.

RESULTS

There were 29,626 admissions to 24 adult, general critical care units in Scotland between 1 January 2007 and 31 December 2009. After exclusions, 23,269 admissions were included in the analysis. The ICNARC model outperformed APACHE II on measures of discrimination (c index 0.848 versus 0.806), calibration (Hosmer-Lemeshow chi-squared statistic 18.8 versus 214) and overall fit (Brier's score 0.140 versus 0.157; Shapiro's R 0.652 versus 0.621). Model performance was consistent across the three years studied.

CONCLUSIONS

The ICNARC model performed well when validated in an external population to that in which it was developed, using independently collected data.

Healthcare-associated bloodstream infections in critically ill patients: descriptive cross-sectional database study evaluating concordance with clinical site isolates

Background

Healthcare-associated bloodstream infections are related to both increased antibiotic use and risk of adverse outcomes. An in-depth understanding of their epidemiology is essential to reduce occurrence and to improve outcomes by targeted prevention strategies. The objectives of the study were to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates.

Methods

We conducted a descriptive cross-sectional study in critically ill adults admitted to a tertiary semi-closed intensive care unit in England to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates. All nosocomial positive blood cultures over a 4-year study period were identified. Pathogens detected and concordances with clinical site are reported as proportions.

Results

Contaminant pathogens accounted for half of the isolates. The most common non-contaminant pathogens cultured were Pseudomonas spp. (8.0%), Enterococcus spp. (7.3%) and Escherichia coli (5.6%). Central venous catheter-linked bloodstream infections represent only 6.0% of the positive blood cultures. Excluding contaminants and central venous line infections, in only 39.5% of the bloodstream infections could a concordant clinical site source be identified, the respiratory and urinary tracts being the most common.

Conclusions

Clinical practice should focus on a) improving blood culture techniques to reduce detection of contaminant pathogens and b) ensuring paired clinical site cultures are performed alongside all blood cultures to better understand the epidemiology and potential implications of primary and secondary discordant health-care associated bloodstream infections.

[Risk factors for deliberate self-extubation]

PURPOSE

This study was conducted to analyze intubation survival rates according to characteristics and to identify the risk factors affecting deliberate self-extubation.

METHODS

Data were collected from patients' electronic medical reports from one hospital in B city. Participants were 450 patients with endotracheal intubation being treated in intensive care units. The collected data were analyzed using Kaplan-Meier estimation, Log rank test, and Cox's proportional hazards model.

RESULTS

Over 15 months thirty-two (7.1%) of the 450 intubation patients intentionally extubated themselves. The patients who had experienced high level of consciousness, agitation. use of sedative, application of restraints, and day and night shift had significantly lower intubation survival rates. Risk factors for deliberate self-extubation were age (60 years and over), unit (neurological intensive care), level of consciousness (higher), agitation, application of restraints, shift (night), and nurse-to-patient ratio (one nurse caring for two or more patients).

CONCLUSION

Appropriate use of sedative drugs, effective treatment to reduce agitation, sufficient nurse-to-patient ratio, and no restraints for patients should be the focus to diminish the number of deliberate self-extubations.

Adult cardiac critical care at the King Abdulaziz Cardiac Center

Adult Cardiac Critical Cardiac Care division at the King Abdulaziz Cardiac Center – Riyadh, Saudi Arabia, was created in 2011 to address the critical care needs of cardiac surgery and adult cardiology patients that were beyond the scope of their specialties. The division offers its services in two semi-closed intensive care units consisting of 17 beds of Level 3 care. The concept and rationale behind this relatively new subspecialty and its organization in our center are presented in this brief report.

Adults with childhood-onset chronic conditions admitted to US pediatric and adult intensive care units

PURPOSE

The purpose of the study is to compare demographics, intensive care unit (ICU) admission characteristics, and ICU outcomes among adults with childhood-onset chronic conditions (COCCs) admitted to US pediatric and adult ICUs.

MATERIALS AND METHODS

Retrospective cross-sectional analyses of 6088 adults aged 19 to 40 years admitted in 2008 to 70 pediatric ICUs that participated in the Virtual Pediatric Intensive Care Unit Performance Systems and 50 adult ICUs that participated in Project IMPACT.

RESULTS

Childhood-onset chronic conditions were present in 53% of young adults admitted to pediatric units, compared with 9% of those in adult units. The most common COCC in both groups were congenital cardiac abnormalities, cerebral palsy, and chromosomal abnormalities. Adults with COCC admitted to pediatric units were significantly more likely to be younger, have lower functional status, and be nontrauma patients than those in adult units. The median ICU length of stay was 2 days, and the intensive care unit mortality rate was 5% for all COCC patients with no statistical difference between pediatric or adult units.

CONCLUSIONS

There are marked differences in characteristics between young adults with COCC admitted to pediatric ICUs and adult ICUs. Barriers to accommodating these young adults may be reasons why many such adults have not transitioned from pediatric to adult critical care.

Increased plasma selenium is associated with better outcomes in children with systemic inflammation

OBJECTIVE

The aim of this study was to assess the effects of changes in plasma selenium on the outcome of critically ill children.

METHODS

Plasma selenium was prospectively measured in 99 children with acute systemic inflammation. The exposure variables were selenium level on admission and on day 5 of stay in the intensive care unit (ICU) and the difference in selenium concentrations between day 5 post-admission and the ICU admission (delta selenium). Selenium was given only as part of enteral diets. Age, malnutrition, red cell glutathione peroxidase-1 activity, serum C-reactive protein, Pediatric Index of Mortality 2, and Pediatric Logistic Organ Dysfunction scores were analyzed as covariates. The outcome variables were ventilator-free days, ICU-free days, and 28-d mortality.

RESULTS

Plasma selenium concentrations increased from admission (median 23.4 μg/L, interquartile range 12.0-30.8) to day 5 (median 25.1 μg/L, interquartile range 16.0-39.0; P = 0.018). After adjustment for confounding factors, a delta selenium increase of 10 μg/L was associated with reductions in ventilator days (1.3 d; 95% confidence interval [CI], 0.2-2.3; P = 0.017) and ICU days (1.4 d; 95% CI, 0.5-2.3; P < 0.01). Delta selenium >0 was associated with decreased 28-d mortality on a univariate model (odds ratio, 0.67; 95% CI, 0.46-0.97; P = 0.036). The mean daily selenium intake (6.82 μg; range 0-48.66 μg) was correlated with the increase in selenium concentrations on day 5.

CONCLUSIONS

An increase in plasma selenium is independently associated with shorter times of ventilation and ICU stay in children with systemic inflammation. These findings raise the hypothesis that selenium supplementation could be beneficial in children with critical illnesses.

Vancomycin-resistant Enterococcus colonization in the intensive care unit: clinical outcomes and attributable costs of hospitalization

BACKGROUND

The clinical and economic impact of vancomycin-resistant Enterococcus (VRE) colonization remains unclear. Little data are available on factors affecting hospitalization length of stay (LOS) and costs. This study aimed to estimate mortality, LOS, and hospitalization costs for VRE colonized patients compared with a matched hospital population.

METHODS

We performed a retrospective propensity score matched cohort study comparing the outcomes of patients with VRE colonization with those of uncolonized subjects matched at the time they were admitted to the intensive care unit (ICU). Between January 2008 and December 2010, we obtained rectal swab cultures within 24 hours of ICU admission to detect VRE colonization.

RESULTS

During the study period, 567 (7.2%) of the 7,703 patients were colonized with VRE. There were 199 VRE colonized patients compared with 199 uncolonized patients using the propensity score. VRE colonized patients when compared with uncolonized patients were likely to have a higher case fatality rate (24.6% vs 17.1%; OR, 2.35). Longer total admission days were observed in the VRE colonized patients (28.7 vs 21.4 days; multiplicative effect, 1.25; P = .004). VRE colonization is found to be a significant factor associated with increased ICU cost in the multivariable regression model ($6,065 vs $5,298; multiplicative effect, 1.22; P = .029). Multivariable analysis identified the factors affecting ICU cost as follows: VRE colonization (odds ratio [OR], 1.20; P = .038), ICU length of stay (OR, 1.93; P < .001), ICU type (OR, 1.51; P = .001), valvular heart disease (OR, 2.38; P = .27), hospitalization within 12 months (OR, 1.21; P = .037), and use of invasive devices (OR, 1.28; P = .017).

CONCLUSION

Compared with a matched hospital population, VRE colonization was associated with increased mortality, LOS, and costs. Strict infection control programs, including preemptive isolation for a high-risk group, should be helpful.

Mortality prediction by acute kidney injury biomarkers in comparison with serum creatinine

OBJECTIVES

To investigate the performance of acute kidney injury (AKI) biomarkers for mortality prediction.

MATERIALS AND METHODS

Cutoff values of urinary L-type fatty acid-binding protein (L-FABP) and N-acetyl-β-d-glucosaminidase (NAG) for AKI diagnosis in ICU were determined in the derivation cohort. The performance of these AKI biomarkers for mortality prediction was evaluated in the validation cohort with stratification of serum-creatinine based AKI diagnosis.

RESULTS

Mortality in the AKI patients diagnosed by serum creatinine was increased remarkably when urinary L-FABP and NAG were positive.

CONCLUSIONS

These AKI biomarkers can specifically detect high-risk patients among creatinine-base diagnosed AKI.

Neuromuscular electrical stimulation in mechanically ventilated patients: a randomized, sham-controlled pilot trial with blinded outcome assessment

PURPOSE

The purpose of the study is to compare neuromuscular electrical stimulation (NMES) vs sham on leg strength at hospital discharge in mechanically ventilated patients.

MATERIALS AND METHODS

We conducted a randomized pilot study of NMES vs sham applied to 3 bilateral lower extremity muscle groups for 60 minutes daily in the intensive care unit (ICU). Between June 2008 and March 2013, we enrolled adults who were receiving mechanical ventilation within the first week of ICU stay and who could transfer independently from bed to chair before hospital admission. The primary outcome was lower extremity muscle strength at hospital discharge using Medical Research Council score (maximum, 30). Secondary outcomes at hospital discharge included walking distance and change in lower extremity strength from ICU awakening. Clinicaltrials.gov: NCT00709124.

RESULTS

We stopped enrollment early after 36 patients due to slow patient accrual and the end of research funding. For NMES vs sham, mean (SD) lower extremity strength was 28 (2) vs 27 (3), P = .072. Among secondary outcomes, NMES vs sham patients had a greater mean (SD) walking distance (514 [389] vs 251 [210] ft, P = .050) and increase in muscle strength (5.7 [5.1] vs 1.8 [2.7], P = .019).

CONCLUSIONS

In this pilot randomized trial, NMES did not significantly improve leg strength at hospital discharge. Significant improvements in secondary outcomes require investigation in future research.

Demographic and occupational predictors of stress and fatigue in French intensive-care registered nurses and nurses' aides: a cross-sectional study

BACKGROUND

Healthcare workers (HCWs) working in intensive-care units (ICUs) are exposed to high physical and mental demands potentially affecting their health or having repercussions on patient care. Although several studies have explored the links between some aspects of working conditions in hospitals and HCW health, the complex dynamics at play are not fully understood.

OBJECTIVES

This study aimed to explore the impact of a wide array of demographic, employment and organizational factors related to fatigue and stress of French ICU HCWs.

DESIGN AND SETTING

A cross-sectional study was conducted in ICUs of Paris-area hospitals between January 18, 2013 and April 2, 2013. All types of adult ICUs were included (medical, surgical and polyvalent).

PARTICIPANTS

Included in the study were HCWs with patient contact (doctors, residents, registered nurses, nurse's aides and physical therapists). Participation was proposed to all eligible HCWs present during on-site visits. Temporary staff not typically assigned to the given ICU was excluded.

METHODS

Data were collected using an individual questionnaire administered in interviews during day and night shifts (N=682). Stress and fatigue outcomes included the 10-item Perceived Stress Scale (PSS10), the Nottingham Health Profile sleep and energy level rubrics and the current fatigue state at the interview. Multivariate analysis was restricted to nurse and nurse's aide data (n=536).

RESULTS

Doctors and residents reported fewer sleep difficulties but were more likely to report a tired current state. Female gender was associated with higher stress levels and greater fatigue for all outcomes, while greater social support of supervisor or colleagues decreased stress and fatigue. At the organizational level, longer shifts (12 h vs. 8 h) were associated with tired current state and greater sleep difficulties. Personnel on rotating shifts had lower stress and a better current state, while those on night shifts had greater sleep and energy level difficulties.

CONCLUSIONS

Even when controlling for demographic factors, employment and organizational elements remained significantly associated with stress and fatigue outcomes. To improve HCW health it is important to consider simultaneously factors at the individual and organizational level.