Design and organization of an equine intensive care unit

Identifying Built Environment Risk Factors to Provider Workflow and Patient Safety Using Simulation-Based Evaluation of a Pediatric ICU Room

OBJECTIVE

This study aimed to identify latent conditions in a pediatric intensive care unit (PICU) by analyzing characteristics of flow disruptions (FD) during a simulation of a three-phased scenario.

BACKGROUND

The built environment of healthcare facilities contributes to FD that can lead to clinical errors and patient harm. In the facility design process, there is an opportunity to identify built environment features that cause FD and pose safety risks. Simulation-based evaluation of proposed designs may help in identifying and mitigating safety concerns before construction and occupancy.

METHODOLOGY

During design development for a new 400-bed children's hospital, a series of simulations were conducted using physical mock-ups in a large warehouse. A three-phased scenario, (1) admission and intubation, (2) cardiac arrest, and (3) bedside surgery involving a cannulation to extracorporeal membrane oxygenation, was conducted in a PICU room mock-up. Each scenario was video recorded from four angles. The videos were systematically coded to identify FD.

RESULTS

Analysis identified FDs in three ICU zones: respiratory therapists (RT) zone, nurse zone, and head of the patient. Challenges in these zones were related to spatial constraints in the RT zone and head of the bed, equipment positioning in the RT zone and nurse zone, and impeded visibility related to the location of the boom monitor in the nurse zone.

CONCLUSION

Simulation-based evaluation of prototypes of patient care spaces can help identify characteristics of minor and major FD related to the built environment and can provide valuable information to inform the iterative design process.

Diagnostic value of plasma and peritoneal fluid procalcitonin concentrations in horses with strangulating intestinal lesions

OBJECTIVE

To assess the diagnostic value of plasma and peritoneal fluid procalcitonin concentrations for identification of horses with strangulating intestinal lesions.

ANIMALS

65 horses with signs of colic of intestinal origin and 10 healthy (control) horses.

PROCEDURES

For each horse, plasma and peritoneal fluid samples were obtained for a CBC and determination of total protein, procalcitonin, and lactate concentrations. Signalment and clinicopathologic findings were compared among control horses and horses with strangulating and nonstrangulating intestinal lesions.

RESULTS

Mean ± SD plasma (274.9 ± 150.8 pg/mL) and peritoneal fluid (277 ± 50.6 pg/mL) procalcitonin concentrations for horses with colic were significantly greater than the mean ± SD plasma (175.5 ± 46.0 pg/mL) and peritoneal fluid (218.8 ± 48.7 pg/mL) procalcitonin concentrations for control horses. Mean procalcitonin concentration in peritoneal fluid, but not plasma, differed significantly between horses with strangulating lesions and those with nonstrangulating lesions. A peritoneal fluid procalcitonin concentration ≥ 281.7 pg/mL had a sensitivity of 81%, specificity of 69%, positive predictive value of 56.7%, and negative predictive value of 87.9% for detection of strangulating lesions.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that peritoneal fluid procalcitonin concentration, when evaluated in conjunction with other clinicopathologic results, might be a sensitive indicator of intestinal ischemia and facilitate early identification of horses that require surgery to address a strangulating lesion.

Use of serial measurements of peritoneal fluid lactate concentration to identify strangulating intestinal lesions in referred horses with signs of colic

OBJECTIVE

To determine the value of serial measurements of peritoneal fluid lactate concentration (PFL) for detecting strangulating intestinal lesions (SLs) in referred horses with signs of colic.

DESIGN

Retrospective cohort study.

ANIMALS

94 horses with signs of colic.

PROCEDURES

Medical records of horses evaluated between September 2006 and February 2010 because of signs of colic were reviewed. All included horses had ≥ 2 peritoneal fluid samples collected, including one at admission and another within 1 to 6 hours after admission. Of the 94 horses, 26 were assigned to the SL group on the basis of findings at surgery or necropsy and 68 were assigned to the nonstrangulating intestinal lesion group because their signs of colic resolved with medical management. Peritoneal fluid lactate concentration was measured by use of a handheld lactate monitor. Data were analyzed by use of univariable and multivariable logistic regression analysis.

RESULTS

PFL at admission > 4 mmol/L, an increase in PFL over time, and especially an increase in PFL over time in horses with a PFL < 4 mmol/L at admission (OR, 62; sensitivity, 95%; specificity, 77%) were significant predictors of horses with an SL.

CONCLUSIONS AND CLINICAL RELEVANCE

Serially determined PFL was a strong predictor for differentiating horses with SLs from horses with nonstrangulating intestinal lesions. Given the high OR, sensitivity, and specificity of these tests, serially determined PFL may have potential as a screening test for identifying horses with SLs. Further evaluation of the clinical value of PFL for predicting SLs in a prospective, multicenter study is warranted.

The intensive care unit work environment: current challenges and recommendations for the future

The need for critical care services has grown substantially in the last decade in most of the G8 nations. This increasing demand has accentuated an already existing shortage of trained critical care professionals. Recent studies argue that difficulty in recruiting an appropriate workforce relates to a shortage of graduating professionals and unhealthy work environments in which critical care professionals must work.

Objective

This narrative review summarizes existing literature and experiences about the key work environment challenges reported within the critical care context and suggests best practices—implemented in hospitals or suggested by professional associations—which can be an initial step in enhancing patient care and professional recruitment and retention in our intensive care units, with particular emphasis on the recruitment and retention of an appropriately trained and satisfied workforce. The experiences are categorized for the physical, emotional, and professional environments. A case study is appended to enhance understanding of the magnitude and some of the proposed remedies of these experiences.

Characterization of equine intestinal fatty acid binding protein and its use in managing horses with colic

OBJECTIVE

To determine the nucleotide sequence of the equine intestinal fatty acid binding protein (I-FABP) gene, its expression in various regions of the gastrointestinal tract, and the use of measuring I-FABP in horses with colic. Animals-86 horses with colic.

PROCEDURE

The mRNA sequence for the I-FABP gene was obtained by use of a rapid amplification of complementary DNA ends technique. Comparative I-FABP gene expression was quantitated by use of a real-time reverse transcription-polymerase chain reaction assay. Amounts of I-FABP in abdominal fluid and plasma were measured by use of an ELISA kit. Association between I-FABP concentrations and clinical variables was performed by nonparametric analysis, and associations of these variables with intestinal ischemia were determined by the Spearman correlation test.

RESULTS

The nucleotide sequence had 87% identity with human I-FABP The I-FABP gene was highly expressed in the small intestinal mucosa but had low expression in the colon. High concentrations of I-FABP in abdominal fluid correlated with an increase in protein concentrations in peritoneal fluid and nonsurvival, whereas plasma I-FABP concentrations correlated with the necessity for abdominal surgery. Clinical variables associated with intestinal ischemia included the color and protein content of abdominal fluid and serum creatine kinase activity.

CONCLUSIONS AND CLINICAL RELEVANCE

Determination of I-FABP concentrations in abdominal fluid and plasma may be useful for predicting survival and the need for abdominal surgical intervention in horses with colic. Furthermore, serum creatine kinase activity and color and protein concentrations of abdominal fluid may be useful in the diagnosis of intestinal ischemia.