Preventing unrecognized deterioration & improving outcomes of critically ill patients using the National Early Warning Score 2 in a high dependency unit in Bangladesh: A quality improvement project

This Quality Improvement Project (QIP) aimed to assess the acceptability and utility of the National Early Warning Score 2 (NEWS2) in a Bangladeshi level-2 care setting. All nurses and physicians were trained on NEWS2 scores and a proper response before starting the QIP. Utilization of NEWS2 and patient outcome were documented and analyzed. Acceptability was acknowledged by increase in utilization, and utility by reduction in unrecognized deterioration of patients. The modified NEWS2 was well adopted and utilized by the nursing staff. There was a statistically significant reduction in unrecognized deterioration leading to cardiac arrest and the need for transfer to the Intensive Care Unit after implementation of NEWS2. With adequate training, motivation and appropriate modification, NEWS2 can become a well-accepted, widely adopted and realistic bedside monitoring tool in resource-limited settings like Bangladesh.

Indian Society of Critical Care Medicine Experts Committee Consensus Statement on ICU Planning and Designing, 2020

BACKGROUND

Indian Society of Critical Care Medicine (ISCCM) guidelines on Planning and Designing Intensive care (ICU) were first developed in 2001 and later updated in 2007. These guidelines were adopted in India, many developing Nations and major Institutions including NABH. Various international professional bodies in critical care have their own position papers and guidelines on planning and designing of ICUs; being the professional body of intensivists in India ISCCM therefore addresses the subject in contemporary context relevant to our clinical practice, its variability according to specialty and subspecialty, quality, resource limitation, size and location of the institution. Aim: To have a consensus document reflecting the philosophy of ISCCM to deliver safe & quality Critical Care in India, taking into consideration the requirement of regulatory agencies (national & international) and need of people at large, including promotion of training, education and skill upgradation. It also aiming to promote leadership and development and managerial skill among the critical care team. Material and Methods: Extensive review of literature including search of databases in English language, resources of regulatory bodies, guidelines and recommendations of international critical care societies. National Survey of ISCCM members and experts to understand their viewpoints on respective issues. Visiting of different types and levels of ICUs by team members to understand prevailing practices, aspiration and Challenges. Several face to face meetings of the expert committee members in big and small groups with extensive discussions, presentations, brain storming and development of initial consensus draft. Discussion on draft through video conferencing, phone calls, Emails circulations, one to one discussion Result: Based upon extensive review, survey and input of experts' ICUs were categorized in to three levels suitable in Indian setting. Level III ICUs further divided into sub category A and B. Recommendations were grouped in to structure, equipment and services of ICU with consideration of variation in level of ICU of different category of hospitals. Conclusion: This paper summarizes consensus statement of various aspect of ICU planning and design. Defined mandatory and desirable standards of all level of ICUs and made recommendations regarding structure and layout of ICUs. Definition of intensive care and intensivist, planning for strength of ICU and requirement of manpower were also described.

HOW TO CITE THIS ARTICLE

Rungta N, Zirpe KG, Dixit SB, Mehta Y, Chaudhry D, Govil D, et al. Indian Society of Critical Care Medicine Experts Committee Consensus Statement on ICU Planning and Designing, 2020. Indian J Crit Care Med 2020;24(Suppl 1):S43-S60.

Clinical Profile of Obstetric Patients Getting Admitted to ICU in a Tertiary Care Center Having HDU Facility: A Retrospective Analysis

Background

The critically ill obstetric patient represents a challenge that usually requires a multidisciplinary approach. Lack of awareness and the absence of regular antenatal care make the critically ill patients to be referred late and sometimes in moribund conditions. The objective of the present study is to determine the incidence, predictors and outcome of obstetric ICU admissions.

Methods

This retrospective study was conducted over a period of 2 year from July 2015 to June 2017 in Department of Obstetrics and Gynecology at Institute of Medical Sciences, BHU, Varanasi, India.

Results

Out of a total of 4986 deliveries, 756 patients underwent HDU admission, while 92 obstetric patients were admitted to ICU during this study period. Maximum number of patients (73.91%) were in the age-group of 20-35 years, 64.13% of patients constitute lower socioeconomic status group, 68.47% of patients reside in rural area and there was inadequacy in receiving antenatal care in case of 60.86% of patients. Maximum number of patients were admitted for a period of 4-7 days. Blood transfusion (64.1%), the use of inotropic drugs (45.6%), central line placement (44.5%) and mechanical ventilation (26.08%) were the major interventions performed in ICU. Obstetric hemorrhage was found to be the most frequent clinical diagnosis leading to ICU admission (31.5%) followed by hypertensive disorders (25%).

Conclusion

In addition to timely referral, health education and training of health professionals may improve clinical outcome and better obstetric practice, especially in countries like India. Obstetric ICU dedicated for the management of only obstetric patients should be constructed in order to compensate for heavy burden critically ill women.

Small volume plasma exchange for Guillain-Barré syndrome in resource poor settings: a safety and feasibility study

Background

In Bangladesh, most patients with Guillain-Barré syndrome (GBS) cannot afford standard treatment with intravenous immunoglobulin (IVIG) or a standard plasma exchange (PE) course, which partly explains the high rate of mortality and residual disability associated with GBS in this country. Small volume plasma exchange (SVPE) is an affordable and potentially effective alternative form of plasma exchange. SVPE is the repeated removal of small volumes of supernatant plasma over several days via sedimentation of patient whole blood. The aim of this study is to define the clinical feasibility and safety of SVPE in patients with GBS in resource poor settings.

Methods

A total of 20 adult patients with GBS will be enrolled for SVPE at a single center in Bangladesh. Six daily sessions of whole blood sedimentation and plasma removal will be performed in all patients with GBS with a target to remove an overall volume of at least 8 liters (L) of plasma over a total of 8 days. Serious adverse events (SAE) are defined as the number of patients developing severe sepsis associated with the central venous catheter or deep venous thrombosis in the limb where the catheter is placed for SVPE. Based upon a predictive success rate of 75%, the SVPE procedure will be considered safe if less than 5 of 20 SVPE-treated GBS patients have a SAE. The procedure will be considered feasible if 8 L of plasma can be removed in at least 15 of 20 patients with GBS who receive SVPE. In addition, detailed clinical and neurological outcome assessments will be performed until discharge of the patient from the hospital and up to 4 weeks after study entry.

Discussion

This is the first clinical study to evaluate the feasibility and safety of SVPE as a potential alternative low-cost treatment for the patients with GBS in resource poor settings.

Trial registration

Clinicaltrials.gov NCT02780570

Electronic supplementary material

The online version of this article (10.1186/s40814-017-0185-0) contains supplementary material, which is available to authorized users.

Daily 2% chlorhexidine gluconate bath wash in a tertiary adult intensive care and high dependency units to reduce risk of hospital acquired multi resistant organisms: a best practice implementation project

BACKGROUND

There is growing evidence that the incidence of hospital acquired multi resistant organisms are increasing worldwide. Intensive care patients are particularly prone to hospital-acquired infections. In an effort to combat increasing nosocomial infections rates within the intensive care/high dependency unit setting, Canberra Hospital has implemented a daily 2% chlorhexidine gluconate bath wash in combination as part of a best practice policy to reduce hospital acquired multi resistant organism rates of colonization. This project focused on auditing the extent to which the protocol was implemented and on promoting its implementation.

OBJECTIVES

The primary aim of this evidence implementation project was to promote best practice in the use of 2% chlorhexidine gluconate body cleansing in the Canberra Hospital intensive care unit and high dependency unit settings. A secondary aim was to improve intensive care/high dependency unit patient outcomes and resource utilization.

METHODS

The project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tools for promoting change in 2% chlorhexidine gluconate wash health practice. A baseline audit was conducted followed by a three-prong education approach strategy targeted at clinicians and finalized using a follow-up audit.

RESULTS

There was an improvement in best practice for all criteria monitored in the follow-up audit compared to the initial audit. The most significant improvement was education and allergy assessment with 90% and 46% improvements respectively. Wipe application compliance improved by 28% to 55%, suggesting a need for continual education. Minor decreases in compliance were also noted in allergy documentation and application technique by 2% and 7% respectively.

CONCLUSIONS

The project was successful in increasing knowledge surrounding 2% chlorhexidine gluconate wash administration and has provided a future direction for sustaining evidence-based practice change. Further audits will need to be carried out in order to maintain the practice change and support sustained implementation of the best practice protocol.

Patient characteristics and severity of human rhinovirus infections in children

BACKGROUND

It is increasingly recognized that human rhinoviruses (HRV) can be associated with severe infections. However, conflicting results have been reported on the relative prevalence and severity of the three HRV species.

OBJECTIVES

The relative prevalence and clinical characteristics of HRV-A, B and C, in children attending a South London teaching hospital were investigated retrospectively.

STUDY DESIGN

Children aged<16 years with episodes of respiratory tract infections and detectable entero/rhinovirus RNA in respiratory samples between November 2009 and December 2010 were investigated. Retrospective case review was performed and patients' characteristics recorded.

RESULTS

Entero/rhinoviruses were the commonest viral pathogens (498/2316; 21.5%). Amongst 204 infection episodes associated with entero/rhinovirus, 167 were typed HRV, HRV-C was the most prevalent (99/167, 59.3%) followed by HRV-A (60/167; 35.9%) and HRV-B (8/167, 4.8%). The severity spectrum of HRV-A and HRV-C infections were similar and affected all parts of the respiratory tract. Co-pathogens were observed in 54 (26.5%) episodes. Severity was increased in patients with non-viral co-pathogens and those with an underlying respiratory condition. Univariate and multiple regression analyses of potential prognostic variables including age, co-pathogens and underlying respiratory illnesses showed that mono-infection with HRV-C, as compared with other HRV species, was associated with more severe disease in young children<3 years.

CONCLUSIONS

HRV-C was the most prevalent species and on its own was associated with severe disease in children<3 years. The association between infection with HRV species and clinical presentation is complex and affected by many confounding factors.