The Southern African journal of critical care : the official journal of the Critical Care Society最新文献

Background: Machine learning (ML) refers to computational algorithms designed to learn from patterns in data to provide insights or predictions related to that data.

Objectives: Multiple studies report the development of predictive models for triage or identification of critically ill children. In this study, we validate machine learning models developed in South Africa for the identification of critically ill children presenting to a tertiary hospital.

Results: The validation sample comprised 267 patients. The event rate for the study outcome was 0.12. All models demonstrated good discrimination but weak calibration. Artificial neural network 1 (ANN1) had the highest area under the receiver operating characteristic curve (AUROC) with a value of 0.84. ANN2 had the highest area under the precision-recall curve (AUPRC) with a value of 0.65. Decision curve analysis demonstrated that all models were superior to standard strategies of treating all patients or treating no patients at a proposed threshold probability of 10%. Confidence intervals for model performance overlapped considerably. Post hoc model explanations demonstrated that models were logically coherent with clinical knowledge.

Conclusions: Internal validation of the predictive models correlated with model performance in the development study. The models were able to discriminate between critically ill children and non-critically ill children; however, the superiority of one model over the others could not be demonstrated in this study. Therefore, models such as these still require further refinement and external validation before implementation in clinical practice. Indeed, successful implementation of machine learning in practice within the South African setting will require the development of regulatory and infrastructural frameworks in conjunction with the adoption of alternative approaches to electronic data capture, such as the use of mobile devices.

Background: Barriers to early mobilisation in healthcare settings encompass various factors, including practical challenges, accountability and the crucial role of leadership.

Objectives: To gain consensus from multidisciplinary team members in South African (SA) and Zimbabwean public sector hospitals to formulate implementation strategies addressing identified barriers for early mobilisation.

Methods: An online two-round modified Delphi study including 23 experts from SA and Zimbabwe was undertaken. The implementation strategies were aligned with the Consolidated Framework for Implementation Research that outlines five areas impacting implementation.

Results: The expert panel included intensive care unit (ICU) clinicians, academics and managers, who participated in both Delphi rounds. The median years of ICU experience was 8.5 (range 5 - 17) years, with 16 (80.0%) having a general ICU background. The panel reached consensus on several strategies to standardise early mobilisation practices in ICUs, including defining specific early mobilisation activities, appointing champion leaders, ensuring timely management of fractures, promoting patient admission to specialised units, creating dedicated physiotherapy positions, and providing skills training for staff responsible for implementing early mobilisation activities in ICUs.

Conclusion: The strategies developed represent an important step toward implementation of early mobilisation in routine ICU patient care.

Contribution of the study: This study provides implementation strategies, aligned with the Consolidated Framework for Implementation Research, to overcome barriers to early patient mobilisation in public sector ICUs. These strategies emanate from consensus reached by a panel of experts and serve as the first step in guiding clinicians towards developing and implementing early mobilisation protocols for their units to promote better-quality patient care in daily clinical practice.

Background: Antimicrobial stewardship (AMS) has become integral to healthcare. In the case of antimicrobial medicines, nurses are responsible for preparing medication, and ensuring its correct and safe administration.

Objectives: To describe intensive care nurses' knowledge, attitudes and practices of intravenous antimicrobial infusion administration in the context of access to AMS teaching.

Methods: Convenience sampling was conducted of all 161 bedside nurses working in three general intensive care units. The nursing unit manager from each unit was requested to provide information detailing unit demographics and AMS activity within the unit (e.g. existence of AMS; nurse inclusion on the AMS team; frequency of AMS rounds; availability of AMS policies, protocols or guidelines; and training on the administration of intravenous antimicrobial medicines).

Results: Intensive care nursing management reported cessation of AMS programmes in all three units during COVID-19, with minimal activity in one intensive care unit even before the onset of the pandemic. Responses from bedside nurses emphasised the unavailability of in-service AMS teaching in the units (46.4%). Questions on antibiotic groups scored poorly (55.7%). Respondents (63.8%) indicated that the hospital intravenous antibiotic policy was useful but 21.7% reported that they had never seen this policy in their unit. Opportunities for training on intravenous administration of antimicrobial medications were provided on induction to the hospital (14.5%), or in-service (30.4%) by the clinical facilitators (34.8%), or by doctors (24.6%). Fifty-one percent of respondents reported administering antibiotics through a dedicated antibiotic infusion line. Forty-five percent of respondents used a non-dedicated line, and 56.5% of respondents flushed the line between doses.

Conclusion: Results suggest inadequate training. This, coupled with the evident poor access to policies and protocols, may adversely affect nurse knowledge of principles to prevent antimicrobial resistance.

Contribution of the study: This study highlights that a lack of antimicrobial stewardship guidance to bedside nurses persists; that nurses do not always have access to in-service training and policies, protocols, and guidelines; and that flushing the IV administration line following the administration of an intermittent antimicrobial infusion, should be viewed as best practice to ensure the complete delivery of the dose.

Background: Paediatric traumatic brain injury (TBI) is a public health problem with high morbidity and mortality.

Objectives: To highlight risk factors and describe associated morbidity and mortality of children admitted with TBI to the Paediatric Intensive Care Unit (PICU) at Red Cross War Memorial Children's Hospital, Cape Town.

Methods: We retrospectively documented the hospitalisation of all children with TBI admitted into our PICU between 2015 and 2019.

Results: Of 320 children identified, 314 were enrolled: 267 (85%) had severe TBI (Glasgow Coma Scale (GCS) ≤8), 36 (11.5%) moderate TBI (GCS 9 - 12) and 11 (3.5%) mild TBI (GCS ≥13). Median age was 6.5 (interquartile range (IQR) 3.5 - 8.9) years; 194 (61.8%) were male. Motor vehicle collisions accounted for 75% (235) of injuries. Two hundred and seventy-nine (88.9%) children were invasively ventilated for a median of 4.5 (IQR 1 - 8) days; 13.9% (38/273) had a failed extubation and 10.8% (30/277) required tracheostomies. One hundred and sixty-three children (52.2%, n=312) had intracranial pressure monitoring. Almost a third (81/257) required vasopressor support. Approximately 40% (113/286) developed trauma-related seizures; 15.4% (44/286) required a thiopentone infusion and 6% (17/280) a decompressive craniectomy. Common complications were as follows: 12.2% developed post-extubation stridor (34/279), 10.5% a hemiparesis (33/314) and 6.4% diabetes insipidus (19/298). Median PICU stay was 4 (IQR 1 - 10) days, and hospitalisation 11 (IQR 5 - 21) days. Ninety-three (29.6%) children were transferred for further rehabilitation; 38 (12.1%) died.

Conclusion: Children admitted to our PICU with TBI had considerable morbidity and mortality, but this is a marked improvement since the 1990s. Enhanced primary preventive strategies, especially for motor vehicle collisions, are imperative to prevent TBI in children.

Contribution of the study: Paediatric traumatic brain injury (TBI) is associated with considerable morbidity and mortality. Through our profile of children with TBI admitted to PICU, we hope to contribute to future guidance and interventions to improve the quality of care in this subset of patients.

Background: Ventilator-associated pneumonia (VAP) is a common nosocomial infection in critically ill patients in intensive care units (ICUs) worldwide. Despite the huge healthcare economic burden and the significant negative morbidity and mortality impact of VAP, its incidence and outcomes in the trauma ICU (TICU) population were poorly documented in South Africa (SA).

Objectives: To determine the incidence of VAP in a level I trauma centre at Inkosi Albert Luthuli Central Hospital in Durban, SA, compared with international benchmarks. Determining mortality rates, the average length and cost of ICU stay, ventilator days and antibiotic consumption was a secondary objective.

Methods: This retrospective chart review of the trauma registry at the centre examined the incidence of VAP and secondary outcomes over the period January 2017 - December 2019. A data pro forma was used with VAP diagnoses as per the 2015 Centers for Disease Control and Prevention definitions. The comparator was international literature-based benchmark VAP rates in TICUs.

Results: The study included 395 patients, of whom 143 (36.2%) were diagnosed with VAP. The VAP rate was calculated to be 35.6 per 1 000 ventilator days. Thirty-one patients with VAP (21.7%) died in the ICU, a similar figure to that for the non-VAP group (22.6%). There were no statistically significant differences in age, sex, mechanism of injury or Injury Severity Score between the VAP and non-VAP groups (p>0.05). There were statistically significant differences between the two groups in number of days on mechanical ventilation, ICU length of stay and ICU cost. The VAP group had a median of 12 ventilation days v. 5 days for the non-VAP group (p<0.001), and spent a median of 7 days longer in the ICU (p<0.001). The median cost of ICU stay for VAP patients was almost double that for non-VAP patients (p<0.001).

Conclusion: VAP rates in this local TICU were similar to international rates. Trauma patients, especially those with traumatic brain injury, are at higher risk of VAP than general ICU patients, so strict adherence to evidence-based VAP prevention bundles is necessary among TICU staff.

Contribution of the study: This study is the first to assess ventilator-associated pneumonia rates in a South African trauma-specific intensive care unit compared with national and international benchmarks, and sets the standard for local morbidity and mortality norms.

Background: Nurses working in intensive care units (ICUs) must incorporate new knowledge and evidence-based practice (EBP) into their daily routines to enhance patient outcomes. However, this integration often falls short in ICU settings. Weekly clinical audits reveal incidents where ICU nurses neglect evidence-based interventions, impacting patient outcomes and ICU stays.

Objectives: To explore the factors influencing the translation of knowledge into ICU practice.

Methods: We conducted exploratory, qualitative research to investigate ICU nurses' perspectives on knowledge translation into ICU practices. The study employed purposive sampling to select ICU nurses. We used paired interviews and group discussions to gather insights from ICU nurses regarding the factors influencing the translation of knowledge into ICU practices. Data analysis was performed using Boomer and McCormack's nine steps of creative hermeneutic data analysis.

Results: One main theme, 'We are just surviving' emerged, encompassing two sub-themes: management and workplace culture. Under management, participants described barriers, such as resource scarcity, behaviour, outdated evidence-informed protocols and workload. Under workplace culture, participants mentioned negative attitudes and a lack of teamwork, contributing to poor-quality care.

Conclusion: In ICUs, nurses are expected to integrate new knowledge and scientific evidence into their daily practice, yet they face challenges in doing so. Interventions should be implemented to address management and workplace culture.

Contribution of the study: This study raised awareness for the intensive care nurse practicioner to intergrate new knowledge and scientific evidence into clinical practice. This study highlighted the importance of teamwork and collaboration between nurses and doctors to ensure knowledge translation and quality care of the critical ill/injured patients. This study confirmed that support from management is vital to address challenges such as workload, staff shortage, inadequate equipment and outdated protocols as these aspects impact negatively on intensive care nurses ability to transfer knowledge into clinical practice.

Background: Melioidosis cases are increasing in Southeast Asia, posing a significant challenge owing to the rising number of diabetic and immune compromised patients. Pneumonia is the most common presentation of melioidosis, while cutaneous melioidosis is rare.

Objectives: We report a case of primary cutaneous melioidosis (PCM) that eventually required intensive care unit (ICU) management.

Methods: We describe the case of a 33-year-old male with uncontrolled diabetes mellitus who initially presented with a skin lesion, which was followed by gradual multiorgan involvement diagnosed as melioidosis based on culture-positive results from blood and synovial fluid, and needed ICU admission.

Results: He was successfully treated with intravenous antibiotics and invasive mechanical ventilation after ICU admission.

Conclusion: Cutaneous melioidosis can lead to ICU admission and, if untreated, has a high fatality rate. Faster diagnostic methods like VITEK 2 Compact and MALDI TOF substantially reduce delays in initiating required treatment.

Contribution of the study: Our study emphasize on the need of considering Meliodosis as a possible differential diagnosis, as in lower middle income countries (LMIC) where it can be a frequent cause of multiorgan involvement due to tropical environment and diagnostic resource limitations.

Background: Growing evidence is describing the long-term morbidity experienced by critical illness survivors, a major contributing factor being impaired physical function. Consensus is yet to be reached on which physical function measures should be included in this population. This review aimed to describe physical functioning measurement instruments used in longitudinal studies of critical illness survivors, based on the International Classification of Function (ICF).

Methods: An electronic database search of EbscoHost, Web of Science and Scopus was conducted from inception to November 2023. Two reviewers independently applied the inclusion and exclusion criteria to titles, abstracts and full text-studies. Extracted data included year of publication; country; participant age; follow-up timeframes and physical measurement instruments used. Instruments were classified according to ICF domains.

Results: Eighty studies published between 1995 and November 2023 were included. Forty-four different outcome measures were identified. Most studies (68) included multiple followed-up points and were completed within a year, and few studies (12) follow-up beyond a year. Based on the ICF, 11 (25%) instruments measured impairments and 33 (75%) activity limitations. Muscle power functions were the most frequently measured impairment (65%), utilising manual muscle testing (37.3%). The six-minute walk test (6MWT) was the most frequently used instrument in the activity/participation domain (31.6%). Only one instrument addressed all five the physical activity/participation domains, while the majority focused on mobility domain.

Conclusion: Multiple tools are used to report on physical deficits experienced by ICU survivors, either measuring impairments or activity/ participation limitations. Most studies report on physical function within the first year of survival. The heterogeneity and inconsistency over time of instruments used prevents synthesis of data to determine intervention efficacy. The validity, predictive value and sensitivity of the reported measures within ICU survivors needs to be established, only then can intervention studies be designed to measure effectiveness.

Contribution of the study: This scoping review contributes to the existing literature and development of standardised core outcome measure sets (COMS) for critical illness research by providing a comprehensive and systematic mapping of physical function measurement instruments utilised in longitudinal studies of critical illness survivors. By categorising these instruments according to the International Classification of Functioning, Disability and Health (ICF) framework, the review offers a novel perspective on the current state of outcome measurement in this field.

Background: Caring in a critical care environment may be conceptualised differently compared with other nursing disciplines because of the patient's critical condition and the specialised staffing categories and skills. However, critical care nurses who prioritise caring can meaningfully connect with critically ill patient and their families, resulting in positive healthcare outcomes.

Objectives: To assess critical care nurses' orientations to caring for critically ill patient and their families.

Methods: A quantitative, descriptive, cross-sectional study was conducted with 139 purposively sampled critical care nurses working in a tertiary referral hospital in KwaZulu-Natal, South Africa. Data were collected using the Caring Assessment for Caregivers questionnaire, and analysis included descriptive and comparative statistics.

Results: The overall mean score of critical care nurses' orientations to caring was 116.01 (range of 25 - 125). Of the five subscales (dimensions), the dimension of 'Maintaining belief' had the highest mean score of 24.25 and the dimension of 'Being with' had the lowest mean score of 22.70 (range 5 - 25).

Conclusion: While critical care nurses reported high overall orientations to caring, lower mean scores on the subscale 'Being with' suggest that there are areas for critical care nurses to grow in their role as carers. Further research using qualitative approaches may shed valuable insights into how the critical care environment impacts the caring orientations of critical care nurses.

Contribution of the study: The study aims to highlight the orientations of critical care nurses to different areas of caring. In so doing management can provide specific support to nurses to strengthen their caring abilities.