Intensive Care and Emergency Medicine

Automated measurement of pressure injury through image processing

AIMS AND OBJECTIVES

To develop an image processing algorithm to automatically measure pressure injuries using electronic pressure injury images stored in nursing documentation.

BACKGROUND

Photographing pressure injuries and storing the images in the electronic health record is standard practice in many hospitals. However, the manual measurement of pressure injury is time-consuming, challenging and subject to intra/inter-reader variability with complexities of the pressure injury and the clinical environment.

DESIGN

A cross-sectional algorithm development study.

METHODS

A set of 32 pressure injury images were obtained from a western Pennsylvania hospital. First, we transformed the images from an RGB (i.e. red, green and blue) colour space to a YC_b C_r colour space to eliminate inferences from varying light conditions and skin colours. Second, a probability map, generated by a skin colour Gaussian model, guided the pressure injury segmentation process using the Support Vector Machine classifier. Third, after segmentation, the reference ruler - included in each of the images - enabled perspective transformation and determination of pressure injury size. Finally, two nurses independently measured those 32 pressure injury images, and intraclass correlation coefficient was calculated.

RESULTS

An image processing algorithm was developed to automatically measure the size of pressure injuries. Both inter- and intra-rater analysis achieved good level reliability.

CONCLUSIONS

Validation of the size measurement of the pressure injury (1) demonstrates that our image processing algorithm is a reliable approach to monitoring pressure injury progress through clinical pressure injury images and (2) offers new insight to pressure injury evaluation and documentation.

RELEVANCE TO CLINICAL PRACTICE

Once our algorithm is further developed, clinicians can be provided with an objective, reliable and efficient computational tool for segmentation and measurement of pressure injuries. With this, clinicians will be able to more effectively monitor the healing process of pressure injuries.

The relationship among pressure ulcer risk factors, incidence and nursing documentation in hospital-acquired pressure ulcer patients in intensive care units

AIMS AND OBJECTIVES

To explore the quality/comprehensiveness of nursing documentation of pressure ulcers and to investigate the relationship between the nursing documentation and the incidence of pressure ulcers in four intensive care units.

BACKGROUND

Pressure ulcer prevention requires consistent assessments and documentation to decrease pressure ulcer incidence. Currently, most research is focused on devices to prevent pressure ulcers. Studies have rarely considered the relationship among pressure ulcer risk factors, incidence and nursing documentation. Thus, a study to investigate this relationship is needed to fill this information gap.

DESIGN

A retrospective, comparative, descriptive, correlational study.

METHOD

A convenience sample of 196 intensive care units patients at the selected medical centre comprised the study sample. All medical records of patients admitted to intensive care units between the time periods of September 1, 2011 through September 30, 2012 were audited. Data used in the analysis included 98 pressure ulcer patients and 98 non-pressure ulcer patients. The quality and comprehensiveness of pressure ulcer documentation were measured by the modified European Pressure Ulcer Advisory Panel Pressure Ulcers Assessment Instrument and the Comprehensiveness in Nursing Documentation instrument.

RESULT

The correlations between quality/comprehensiveness of pressure ulcer documentation and incidence of pressure ulcers were not statistically significant. Patients with pressure ulcers had longer length of stay than patients without pressure ulcers stay. There were no statistically significant differences in quality/comprehensiveness scores of pressure ulcer documentation between dayshift and nightshift.

CONCLUSION

This study revealed a lack of quality/comprehensiveness in nursing documentation of pressure ulcers. This study demonstrates that staff nurses often perform poorly on documenting pressure ulcer appearance, staging and treatment. Moreover, nursing documentation of pressure ulcers does not provide a complete picture of patients' care needs that require nursing interventions.

RELEVANCE TO CLINICAL PRACTICE

The implication of this study involves pressure ulcer prevention and litigable risk of nursing documentation.

Albumin administration in the acutely ill: what is new and where next?

Albumin solutions have been used worldwide for the treatment of critically ill patients since they became commercially available in the 1940s. However, their use has become the subject of criticism and debate in more recent years. Importantly, all fluid solutions have potential benefits and drawbacks. Large multicenter randomized studies have provided valuable data regarding the safety of albumin solutions, and have begun to clarify which groups of patients are most likely to benefit from their use. However, many questions remain related to where exactly albumin fits within our fluid choices. Here, we briefly summarize some of the physiology and history of albumin use in intensive care before offering some evidence-based guidance for albumin use in critically ill patients.

Preferred content and usefulness of a photodiary as described by ICU-patients--a mixed method analysis

Many ICU-patients have memory-gaps which may affect their recovery. A tool in the recovery can be an ICU-diary to explain and clarify thoughts and events from the ICU-period. There are different standards for the content in the ICU-diary. The aim of this study was to identify the preferred content and usefulness of an ICU-diary as described by ICU-patients.

METHOD

A descriptive, exploratory cohort design with a mixed method approach. The patients answered a questionnaire (n=115) and participated in an interview (n=15) six months after the ICU-stay. Data analysis was carried out in three stages; the questionnaire was analysed by descriptive statistics and categorised by content (four open-ended questions) and the interviews were analysed by manifest content analysis.

RESULTS

The patients were explained that detailed information about daily activities and medical facts had to be included to understand and give a sense of coherence of what had happened. The content in the ICU-diary had to be chronological in order to follow the process in which photos were an important part. The patients re-read the ICU-diary during the recovery which helped them to fill in the memory gaps and used it as a tool for communication.

CONCLUSION

To construct a coherent story, it was essential that the ICU-diary was complete and were amplified by photos, all appearing in a chronological order. The results of this study could form a basis for further developments of standards and guidelines for ICU-diaries.

Enhancing Braden pressure ulcer risk assessment in acutely ill adult veterans

This study sought to determine if a parsimonious pressure ulcer (PU) predictive model could be identified specific to acute care to enhance the current PU risk assessment tool (Braden Scale) utilized within veteran facilities. Factors investigated include: diagnosis of gangrene, anemia, diabetes, malnutrition, osteomyelitis, pneumonia/pneumonitis, septicemia, candidiasis, bacterial skin infection, device/implant/graft complications, urinary tract infection, paralysis, senility, respiratory failure, acute renal failure, cerebrovascular accident, or congestive heart failure during hospitalization; patient's age, race, smoking status, history of previous PU, surgery, hours in surgery; length of hospitalization, and intensive care unit days. Retrospective chart review and logistic regression analyses were used to examine Braden scores and other risk factors in 213 acutely ill veterans in North Florida with (n = 100) and without (n = 113) incident PU from January-July 2008. Findings indicate four medical factors (malnutrition, pneumonia/pneumonitis, candidiasis, and surgery) have stronger predictive value (sensitivity 83%, specificity 72%, area under receiver operating characteristic [ROC] curve 0.82) for predicting PUs in acutely ill veterans than Braden Scale total scores alone (sensitivity 65%, specificity 70%, area under ROC curve 0.70). In addition, accounting for four medical factors plus two Braden subscores (activity and friction) demonstrates better overall model performance (sensitivity 80%, specificity 76%, area under ROC curve 0.88).

Critical care trial design and interpretation: a primer

OBJECTIVE

Better understanding of the pathophysiology of critical illness has led to an increase in clinical trials designed to improve the clinical care and outcomes of patients with life-threatening illness. Knowledge of basic principles of clinical trial design and interpretation will assist the clinician in better applying the results of these studies into clinical practice.

DATA SOURCES

We review selected clinical trials to highlight important design features that will improve understanding of the results of critical care clinical trials designed to improve clinical care of the critically ill.

RESULTS

Trial design features such as patient selection, bias, sample size calculation, selection of subjects and controls, and primary outcome measure may influence the results of a critical care clinical trial designed to test a therapy targeting improved clinical care. In conjunction with trial design knowledge, understanding the size of the anticipated treatment effect, the importance of any clinical end point achieved, and whether patients in the trial are representative of typical patients with the illness will assist the reader in determining whether the results should be applied to specific patients or usual clinical practice.

CONCLUSIONS

Better understanding of important aspects of trial design and interpretation, such as whether patients enrolled in both intervention arms were comparable and whether the primary outcome of the trial is clinically important, will assist the bedside clinician in determining whether to apply the findings from the clinical study into clinical practice.

Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients

BACKGROUND

: Damage control with external fixation (DC-EF) of femoral shaft fractures in polytrauma patients is becoming standard treatment in many trauma centers. However, skeletal traction (ST) has long been used in the temporization of fractures. The purpose of this study was to compare the major physiologic clinical outcomes of provisional ST with DC-EF of femoral shaft fractures in severely injured patients.

METHODS

: We retrospectively reviewed 205 patients sustaining blunt trauma, a femoral shaft fracture, and an Injury Severity Score > or =17 from 2001 to 2007 at a level I trauma center. Patients underwent definitive fixation in the first 24 hours with intramedullary nailing (IMN) (N = 126), initial DC-EF with delayed definitive treatment (N = 19), or initial ST with delayed definitive treatment (N = 60). Incidences of adult respiratory distress syndrome, multiple organ failure, sepsis, pneumonia, pulmonary embolism, and deep vein thrombosis were evaluated. Length of stay (LOS), intensive care unit LOS, days of mechanical ventilation, and mortality were also compared.

RESULTS

: There were no significant differences between ST and DC-EF groups in age, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score on arrival, mean time to definitive fixation (4.1 days versus 5.0 days, respectively), or Abbreviated Injury Scale for chest. However, the ST group had a higher Abbreviated Injury Scale-head (2.5 versus 1.0, p = 0.0026). There were no significant differences in subsequent rates of adult respiratory distress syndrome, multiple organ failure, pulmonary embolism, deep vein thrombosis, pneumonia, mechanical ventilation days, intensive care unit LOS, and death. However, the ST group had a lower rate of sepsis (8.3% versus 31.6%, p = 0.0194) and a shorter LOS (26.5 days versus 36.2 days, p = 0.0237) than the EF group.

CONCLUSION

: DC-EF of femur fractures in severely injured patients offers no significant advantage in clinical outcomes compared with ST. Unless initially subjected to general anesthesia for life saving procedures, the use of ST as a temporization method remains a practical option.

What limits for acute care in the elderly?

PURPOSE OF REVIEW

This review aims to address the important question of the increasing life expectancy and the aging population in the healthcare system today. We try to give some elements that will help the reflection about the ethical stakes balancing the necessity of care in the increasing number of elderly patients and the limited resources available, in the special context of acute care.

RECENT FINDINGS

There is growing evidence that the chronological age itself is not a reliable marker of bad prognosis or of mortality. The new concept of frailty may better correlate with the aging process of the elderly. The frailty index is an integrative approach considering the multiple factors impacting on the aging individual. Applied in the practical arena, it might become a useful tool for clinicians.

SUMMARY

Aging implies many biological modifications at molecular, cellular, organic levels as well as of the behavior. Some aspects of these processes and their consequences on health are described. The frailty concept is detailed, and its potential interest explained. We conclude that the measurement of aging phenomenon, including the frailty index, may help us to better assess the true health and the required therapeutics of elderly patients.

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.

Closed-loop ventilation: an emerging standard of care?

The rational for using closed loop ventilation is becoming strong and stronger. Studies are now available supporting the hypothesis that patient outcome is improved by using closed loop ventilation. In the highly sophisticated ICU world driven by the triumvirate of cost-efficiency, quality, and safety, closed loop ventilation will become definitely unavoidable. The challenge is how to make that change effortless, "friendly" and as fast as possible. Introducing novel graphical user interfaces and providing data displays that are pertinent, integrative and dynamic will reduce cognitive resources of the clinician and have the potential to make ventilation safer. They may be the key to adopt closed loop ventilation in everyday practice.