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

Background: Evidence for implementation of evidence-based protocols (EBPs) in resource-constrained intensive care units (ICUs) is sparse.

Objectives: To evaluate a tailored best-practice multifaceted strategy for implementation of a validated physiotherapy EBP for the management of surgical ICU (SICU) patients. Also, to explore the physiotherapists' perceptions regarding the implementation process and factors affecting protocol adherence, guided by the Consolidated Framework for Implementation Research.

Methods: A type 2 hybrid implementation study design was applied, including all adult patients admitted over 16 months to two (control and experimental) SICUs in Western Cape Province, South Africa. The physiotherapists eligible to participate in the qualitative study (N=17) were those who participated in the implementation process and worked in the experimental SICU. The Therapeutic Index Scoring System-28 (TISS-28) and four process of care indicators (POCIs) were the primary and secondary outcomes, respectively, both analysed in Stata version 15. Thematic content analysis of textual data generated physiotherapists' perceptions of the implementation process.

Results: The intervention strategy did not result in protocol adherence, with no significant difference (p>0.05) in TISS-28 and POCI outcomes during and after implementation in the experimental unit and all phases of the control. Physiotherapists (71%; n=12/17) perceived that the process affected their thinking and clinical decision-making, but not the organisation of physiotherapy services, except for a more multidisciplinary approach to care in the experimental unit. Organisational factors (time constraints, workload/flow barriers) affected adherence, explaining the lack of practice change.

Conclusion: The importance of organisational change and support of the physiotherapy departments providing services to ICUs while also addressing the healthcare needs of a diverse group of hospitalised patients is highlighted.

Contribution of the study: The study provides insights for rehabilitation implementation in resource-constrained intensive care settings. It highlights the importance of taking the next step towards implementation in complex environments and a new approach to facilitating the uptake of evidence and ensuring sustainable change through addressing the structural and organisational aspects of physiotherapy service delivery and care, and the inclusion of a multidisciplinary team approach to the implementation of any discipline-specific evidence-based protocols in the intensive care setting.

Background: Traditionally, it was understood that children universally show greater ventilation of the non-dependent lung. Recent studies have questioned the understanding of ventilation distribution patterns in the paediatric population. There are no studies examining the effect of body position in mechanically ventilated infants/children.

Objectives: To determine the effect of body position on regional ventilation distribution in mechanically ventilated children.

Methods: Thoracic electrical impedance tomography (EIT) measurements were taken in left- and right-side lying, supine and prone positions in mechanically ventilated infants/children. Functional EIT images were produced, and regional relative tidal impedance (ΔZ) in the left, right, ventral and dorsal lung regions was calculated. The proportion of ventilation occurring in large lung regions and regional filling were also calculated.

Results: Seventeen children (n=8; 47% male) aged 6 months - 6 years are presented. Many of the children (n=8; 47%) consistently showed greater ventilation in the right lung in both side-lying positions, and in the dorsal lung region (n=6; 35%) in both the supine and prone positions. Regional filling was similar between lung regions in the different body positions.

Conclusion: Ventilation distribution in mechanically ventilated infants/children with mild lung disease is variable and similar to that of healthy spontaneously breathing infants/children.

Contribution of the study: Ventilation distribution in mechanically ventilated children with mild disease is not dissimilar to that in healthy infants and children. Positioning to optimise ventilation should be tailored to each child's responses. This study provides exploratory data describing ventilation distribution in mechanically ventilated infants and children. These data can be used to inform further research study design.

Background: The Measures of Process of Care for Service Providers (MPOC-SP(A)) tool, developed by the CanChild Centre for Childhood Disability Research in Canada, assesses service providers' perceptions of family-centred care (FCC) in adult rehabilitation. It consists of 27 items categorised into four domains: 'showing interpersonal sensitivity', 'providing general information', 'communicating specific information', and 'treating people respectfully'. Each domain encompasses a distinct aspect of family-centred care applicable in the intensive care unit (ICU). An earlier version of the tool was previously validated for use in neonatal ICUs. However, this tool has not been validated for use in adult ICUs.

Objectives: To validate the content validity index of the MPOC-SP(A) tool for healthcare professionals working in adult ICUs in South Africa.

Methods: Following approval from the Human Research Ethics Committee, a multidisciplinary group of experienced ICU healthcare professionals was invited to review the MPOC-SP(A) tool, rating each item's relevance on a four-point scale to avoid neutrality. The content validity index (CVI) was calculated for each item (I-CVI) and domain (S-CVI/Ave) using Microsoft Excel. An I-CVI of 0.83 and S-CVI/Ave of 0.9 were deemed acceptable. Items with a CVI below 0.83 were discarded.

Results: The scale-level CVI (S-CVI/Ave) for every domain was 0.9 and above, which is acceptable. Two items in domain A and one item in domain B were deleted owing to low I-CVI values. Two items were revised to improve the item's clarity. Thus, a 24-item MPOC-SP(A) tool applicable to adult ICUs was generated following the content validity analysis.

Conclusion: The content experts' assessment of the instrument's items is essential to ensure its validity. This study has finalised the content validation process of the MPOC-SP(A) tool for use in the adult ICU. The refined tool is now ready for the next phase of validation focusing on construct and internal consistency.

Contribution of the study: This study contributes to the field of research by providing robust evidence for the content validity of the MPOC-SP(A) tool in adult ICU settings, supporting its relevance, clarity, and comprehensiveness for measuring family-centred care practices. It also offers a framework for future validation studies in similar resource-limited healthcare contexts.

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: COVID-19 infection has a variable clinical presentation, with a small subgroup of patients developing severe disease, requiring intensive care with mechanical ventilation, with an increased mortality rate. South Africa (SA) has experienced multiple waves of this pandemic, spanning the pre-vaccine and vaccine periods. The method and initiation of treatment is a debated topic, changing according to evolving research and the literature. The present study investigated the use of high-dose intravenous immunoglobulin (IVIg) as a salvage therapy after initial medical treatment failure.

Objectives: To compare disease progression among critically ill COVID-19 pneumonia patients receiving IVIg therapy with that in patients receiving standard of care (SoC), in respect of inflammation, organ dysfunction and oxygenation.

Methods: This was a single-centre, retrospective study of patients admitted to the intensive care unit (ICU) at Chris Hani Baragwanath Academic Hospital, Johannesburg, SA, during the pre-vaccine COVID-19 pandemic. Demographics, inflammatory markers (C-reactive protein (CRP)), organ function (Sequential Organ Failure Assessment (SOFA) score), oxygenation (ratio of partial pressure of oxygen in arterial blood to fraction of inspiratory oxygen (P/F ratio)), overall mortality and complications (nosocomial infections and thromboembolism) were recorded and compared.

Results: We included 113 eligible patients in the study. The IVIg cohort had a significantly lower initial P/F ratio than the SoC cohort (p=0.01), but the change in P/F ratio was similar (p=0.54). Initial CRP and changes in CRP were similar in the two groups (p=0.38 and p=0.75, respectively), as were initial SOFA score and changes in SOFA score (p=0.18 and p=0.08, respectively) and vasopressor dose on day 0 and day 5 (p=0.97 and p=0.93, respectively). Duration of mechanical ventilation did not differ significantly between the IVIg group and the SoC group (p=0.13). There were no significant differences in measured complications between the two groups. On univariate analysis, the relative risk of death was 1.6 times higher (95% confidence interval (CI) 1.1 - 2.3) in the IVIg group; however, a logistical regression model demonstrated that only a higher P/F ratio (odds ratio (OR) 0.991; 95% CI 0.983 - 0.997) and higher mean airway pressure (OR 1.283; 95% CI 1.026 - 1.604) were significantly associated with ICU mortality.

Conclusion: Use of IVIg in our study was directed at an older population, with significantly worse oxygenation. We found no evidence of adverse effects of immunoglobulin therapy; however, we found no benefit either. Only the P/F ratio and mean airway pressure independently predicted ICU mortality.

Contribution of the study: During the COVID-19 pandemic, treatment protocols changed in response to the evolving literature. Hospitals

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.