Journal of the Intensive Care Society最新文献

Background: Patients presenting with suspected sepsis to secondary care often require fluid resuscitation to correct hypovolaemia and/or septic shock. Existing evidence signals, but does not demonstrate, a benefit for regimes including albumin over balanced crystalloid alone. However, interventions may be started too late, missing a critical resuscitation window.

Methods: ABC Sepsis is a currently recruiting randomised controlled feasibility trial comparing 5% human albumin solution (HAS) with balanced crystalloid for fluid resuscitation in patients with suspected sepsis. This multicentre trial is recruiting adult patients within 12 hours of presentation to secondary care with suspected community acquired sepsis, with a National Early Warning Score ≥5, who require intravenous fluid resuscitation. Participants are randomised to 5% HAS or balanced crystalloid as the sole resuscitation fluid for the first 6 hours.

Objectives: Primary objectives are feasibility of recruitment to the study and 30-day mortality between groups. Secondary objectives include in-hospital and 90-day mortality, adherence to trial protocol, quality of life measurement and secondary care costs.

Discussion: This trial aims to determine the feasibility of conducting a trial to address the current uncertainty around optimal fluid resuscitation of patients with suspected sepsis. Understanding the feasibility of delivering a definitive study will be dependent on how the study team are able to negotiate clinician choice, Emergency Department pressures and participant acceptability, as well as whether any clinical signal of benefit is detected.

Introduction: National guidelines suggest recommended staffing levels for therapies. The aim of this study was to capture information on existing staffing levels, roles and responsibilities and service structures.

Methods: An observational study using online surveys distributed to 245 critical care units across the United Kingdom (UK). Surveys consisted of a generic and five profession specific surveys.

Results: Eight hundred sixty-two responses were received from 197 critical care units across the UK. Of those that responded, over 96% of units had input from dietetics, physiotherapy and SLT. Whereas only 59.1% and 48.1% had an OT or psychology service respectively. Units with ring fenced services had improved therapist to patient ratios.

Discussion: There is significant variation in access to therapists for patients admitted to critical care in the UK, with many services not having services for core therapies such as psychology and OT. Where services do exist, they fall below the recommended guidance.

Background: Delayed gastric emptying (DGE) is a major cause of undernutrition that can be overcome using nasointestinal (NI) feeding, but tube placement often fails. We analyse which techniques enable successful NI tube placement.

Methods: Efficacy of tube technique was determined at each of six anatomical points: Nose, nasopharynx-oesophagus, stomach-upper and -lower, duodenum part-1 and intestine.

Results: In 913 first NI tube placements, significant associations with tube advancement were found in the pharynx (head tilt, jaw thrust, laryngoscopy), stomach_upper (air insufflation, 10 cm or 20-30 cm flexible tube tip ± reverse Seldinger manoeuvre), stomach_lower (air insufflation, possibly flexible tip and wire stiffener) and duodenum part-1 and beyond part-2 (flexible tip and combinations of micro-advance, slack removal, wire stiffener or prokinetic drugs).

Conclusion: This is the first study to show what techniques are associated with tube advancement and the alimentary tract level they are specific to.

Purpose: Prolonged bed rest and immobility in the intensive care units (ICU) increase the risk of ICU-acquired weakness (ICUAW) and other complications. Mobilisation has been shown to improve patient outcomes but may be limited by the perceived barriers of healthcare professionals to mobilisation. The Patient Mobilisation Attitudes and Beliefs Survey for the ICU (PMABS-ICU) was adapted to assess perceived barriers to mobility in the Singapore context (PMABS-ICU-SG).

Methods: The 26-item PMABS-ICU-SG was disseminated to doctors, nurses, physiotherapists, and respiratory therapists working in ICU of various hospitals across Singapore. Overall and subscale (knowledge, attitude, and behaviour) scores were obtained and compared with the clinical roles, years of work experience, and type of ICU of the survey respondents.

Results: A total of 86 responses were received. Of these, 37.2% (32/86) were physiotherapists, 27.9% (24/86) were respiratory therapists, 24.4% (21/86) were nurses and 10.5% (9/86) were doctors. Physiotherapists had significantly lower mean barrier scores in overall and all subscales compared to nurses (p < 0.001), respiratory therapists (p < 0.001), and doctors (p = 0.001). A poor correlation (r = 0.079, p < 0.05) was found between years of experience and the overall barrier score. There was no statistically significant difference in the overall barriers score between types of ICU (χ2(2) = 4.720, p = 0.317).

Conclusion: In Singapore, physiotherapists had significantly lower perceived barriers to mobilisation compared to the other three professions. Years of experience and type of ICU had no significance in relation to barriers to mobilisation.

Aim: In the United Kingdom (UK), 600 deaths per annum are attributable to drowning. Despite this there is scarce critical care data on drowning patients globally. We describe drowning cases admitted to critical care units with a focus on functional outcomes.

Materials and methods: Medical records for critical care admissions following a drowning event were retrospectively reviewed across six hospitals in Southwest England for cases presenting in the period between 2009 and 2020. Data was collected according to the Utstein international consensus guidelines on drowning.

Results: Forty-nine patients were included, 36 males and 13 females, including seven children. Median submersion duration was 2.5 min 20 cases were in cardiac arrest when rescued. At discharge 22 patients had preserved functional status, 10 patients had a reduced functional status. 17 patients died in hospital.

Conclusion: Admission to critical care following drowning is uncommon and associated with high rates of mortality and poor functional outcomes. We find that 31% of those who survived a drowning event subsequently required an increased level of assistance with their activities of daily living.

Intensive Care Unit staff deal with potentially traumatic cases throughout their careers. We designed and implemented a 'Team Immediate Meet' (TIM) tool, a communication aid designed to facilitate a two-minute 'hot debrief' after a critical event, provide the team with information about the normal reaction to such an event and signpost staff to strategies to help support their colleagues (and themselves). We describe our TIM tool awareness campaign, quality improvement project and subsequent feedback from staff who reported that the tool would be useful for navigating the aftermath of potentially traumatic events and could be transferable to other ICUs.

Background: This study aims to identify any effect of frailty in altering the risk of death or poor outcome already associated with receipt of organ support on ICU. It also aims to assess the performance of mortality prediction models in frail patients.

Methods: All admissions to a single ICU over 1-year were prospectively allocated a Clinical Frailty Score (CFS). Logistic regression analysis was used to investigate the effect of frailty on death or poor outcome (death/discharge to a medical facility). Logistic regression analysis, area under the Receiver Operator Curve (AUROC) and Brier scores were used to investigate the ability of two mortality prediction models, ICNARC and APACHE II, to predict mortality in frail patients.

Results: Of 849 patients, 700 (82%) patients were not frail, and 149 (18%) were frail. Frailty was associated with a stepwise increase in the odds of death or poor outcome (OR for each point rise of CFS = 1.23 ([1.03-1.47]; p = .024) and 1.32 ([1.17-1.48]; p = <.001) respectively). Renal support conferred the greatest odds of death and poor outcome, followed by respiratory support, then cardiovascular support (which increased the odds of death but not poor outcome). Frailty did not modify the odds already associated with organ support. The mortality prediction models were not modified by frailty (AUROC p = .220 and .437 respectively). Inclusion of frailty into both models improved their accuracy.

Conclusions: Frailty was associated with increased odds of death and poor outcome, but did not modify the risk already associated with organ support. Inclusion of frailty improved mortality prediction models.

Background: The Covid-19 pandemic has highlighted weaknesses in the National Health Service critical care provision including both capacity and infrastructure. Traditionally, healthcare workspaces have failed to fully incorporate Human-Centred Design principles resulting in environments that negatively affect the efficacy of task completion, patient safety and staff wellbeing. In the summer of 2020, we received funds for the urgent construction of a Covid-19 secure critical care facility. The aim of this project was to design a pandemic resilient facility centred around both staff and patient requirements and safety, within the available footprint.

Methods: We developed a simulation exercise, underpinned by Human-Centred Design principles, to evaluate intensive care designs through Build Mapping, Tasks Analysis and Qualitative data. Build Mapping involved taping out sections of the design and mocking up with equipment. Task Analysis and qualitative data were collected following task completion.

Results: 56 participants completed the build simulation exercise generating 141 design suggestions (69 task related, 56 patient and relative related, 16 staff related). Suggestions translated to 18 multilevel design improvements; five significant structural changes (Macro level) including wall moves and lift size change. Minor improvements were made at a Meso and Micro design level. Critical care design drivers identified included functional drivers (visibility, Covid-19 secure environment, workflow, and task efficiency) and behavioural drivers (learning and development, light, humanising intensive care and design consistency).

Conclusion: Success of clinical tasks, infection control, patient safety and staff/patient wellbeing are highly dependent on clinical environments. Primarily, we have improved clinical design by focusing on user requirements. Secondly, we developed a replicable approach to exploring healthcare build plans revealing significant design changes, that may have only been identified once built.

Background: Delirium is a common complication in patients treated in the intensive care unit (ICU). Family members can help alleviate patient anxiety and may be able to aid in the management of delirium. This study aimed to explore the perceptions of former ICU patients and their families together, regarding the involvement of family in delirium management.

Method: Nine audio-recorded, semi-structured interviews took place with former ICU patients together with a family member. Participants were interviewed after their intensive care follow-up clinic appointment in an East Midlands hospital in England. Interviews were transcribed, coded and analysed using thematic analysis.

Results: Three themes were identified: 'understanding about delirium'; 'influencers of delirium management: family and healthcare professionals' and 'family-based delirium care'. Participants expressed that family have a valuable role to play in the management of delirium in the ICU. However, education and guidance is needed to support the family in how delirium can be managed and the current treatment options available. It is important for ICU staff to gain an understanding of the patient's life and personality to personalise delirium management to the needs of the patient and their family.

Conclusion: This study found that family presence and knowledge about the patient may be beneficial to delirium management in the ICU. Further research should investigate the effectiveness of the strategies and interventions to understand their influence on delirium management in ICU patients.