Adult Intensive Care Settings Research Articles

Prevalence of enterobacteria producing carbapenemases and BLSE in the adult resuscitation environment at Hassan ii hospital in Fes

Enterobacteriaceae producing carbapenemases (EPCs) and extended-spectrum betalactamases (E-BLSEs) are an emerging threat. The aim of this study is to specify the epidemiological profile of E-BLSEs and EPCs, determine their prevalence in patients hospitalized in the adult intensive care unit of the CHU Hassan II hospital center, and describe their current antibiotic resistance profile for better patient management based on local data. Our study is retrospective, carried out at the microbiology laboratory of CHU HASSAN II in Fez over a one-year period from January 1, 2022 to December 31, 2022, and concerns all E-BLSE and EPC strains isolated from all urine, pus, blood cultures and respiratory samples taken from adult intensive care units at CHU Hassan II in Fez. Of the 1,792 bacteriological samples processed during this period, 352 were positive for Gram-negative bacilli (GNB), including 71 BMR, giving an overall prevalence of 20.17%. During our study, we retained 71 BMR, including carbapenemase-producing enterobacteria with 30.98% of cases (22 strains) and 49 strains of E-BLSE B (64.01%). The overall prevalence of EPCs among enterobacteria was 6.25%. The blaOX-48 gene predominated at (45.45%), followed by bla-NDM a (31.81%).and finally the two genes with a (22.72%). The overall prevalence of E-BLSE was 14%. Among these E-BLSE, Escherichia coli constituted the majority (59.18%) of isolates, followed by Klebsiella pneumoniae with a rate of (32.65%). Then Enterobacter cloacae with a rate of (8.16%). All EPC enterobacteria isolated showed resistance to quinolones. However, the sensitivity of our strains to amikacin was 98%, while colistin showed a sensitivity rate of 100%. This study has shown that the prevalence of EBLSE and EPC in the adult intensive care setting is significant. We need to continue our efforts in early detection of these BMRs in hospitals to control their spread both in the hospital environment and in the community.

Frailty in the prediction of delirium in the intensive care unit: A secondary analysis of the Deli study.

Delirium is an acute disorder of attention and cognition with an incidence of up to 70% in the adult intensive care setting. Due to the association with significantly increased morbidity and mortality, it is important to identify who is at the greatest risk of an acute episode of delirium while being cared for in the intensive care. The objective of this study was to determine the ability of the cumulative deficit frailty index and clinical frailty scale to predict an acute episode of delirium among adults admitted to the intensive care. This study is a secondary analysis of the Deli intervention study, a hybrid stepped-wedge cluster randomized controlled trial to assess the effectiveness of a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adult intensive care units in the south-west of Sydney, Australia. Important predictors of delirium were identified using a bootstrap approach and the absolute risks, based on the cumulative deficit frailty index and the clinical frailty scale are presented. During the 10-mth data collection period (May 2019 and February 2020) 2566 patients were included in the study. Both the cumulative deficit frailty index and the clinical frailty scale on admission, plus age, sex, and APACHE III (AP III) score were able to discriminate between patients who did and did not experience an acute episode of delirium while in the intensive care, with AUC of 0.701 and 0.703 (moderate discriminatory ability), respectively. The addition of a frailty index to a prediction model based on age, sex, and APACHE III score, resulted in net reclassified of risk. Nomograms to individualize the absolute risk of delirium using these predictors are also presented. We have been able to show that both the cumulative deficits frailty index and clinical frailty scale predict an acute episode of delirium among adults admitted to intensive care.

Facilitators and barriers to evidence-based practice in central venous access device insertion and management in an intensive care unit: A qualitative study

IntroductionResearch evidence and clinical practice guidelines exist on preventing central line-associated bloodstream infections. However, there is limited knowledge about the barriers and facilitators to evidence-based central venous access device care. AimThe aim of this study was to investigate the facilitators and barriers to evidence-based central venous access device care in the adult intensive care setting. MethodThis exploratory qualitative study involved focus groups and interviews with registered nurses and physicians involved in central venous access device insertion and management in a tertiary Australian intensive care unit. Purposive sampling was used to recruit staff (n = 26) with varying years of clinical experience and clinical positions. Six focus groups and three individual interviews were conducted. Interviews were audio recorded, transcribed verbatim and analysed using content analysis. ResultsThree overarching categories emerged: work structures to support optimal performance; processes to optimise quality of care, and factors influencing staff members’ behaviour. Perceived facilitators to optimal central venous access device care included explicit language use in procedure documents, work-system integrated strategies, research evidence dissemination, audit, and feedback. However, there was a lack of consistency in practices such as audit, feedback, and patient participation. ConclusionTo bring about effective improvement in central venous access device care, future interventions should be tailored to address identified barriers, including integrating audit and feedback into clinicians’ work processes. Additionally, future research is needed to explore the role of patients and their families in central venous access device care. Implications for clinical practiceWhen developing practice policies or procedure manuals, it is important to use explicit language to ensure clear communication of evidence-based recommendations to clinicians. Strategies integrated into work processes can enhance adherence to evidence-based practice. Large departments with limited educators should explore innovative methods like online education to ensure optimal central venous access device care.

Barriers and enablers for safe medication administration in adult and neonatal intensive care units mapped to the behaviour change wheel.

Intensive care settings have high rates of medication administration errors. Medications are often administered by nurses and midwives using a specified process (the '5 rights'). Understanding where medication errors occur, the contributing factors and how best practice is delivered may assist in developing interventions to improve medication safety. To identify medication administration errors and context specific barriers and enablers for best practice in an adult and a neonatal intensive care unit. Secondary aims were to identify intervention functions (through the Behaviour Change Wheel). A dual methods exploratory descriptive study was conducted (May to June 2021) in a mixed 56-bedded adult intensive care unit and a 6-bedded neonatal intensive care unit in Sydney, Australia. Incident monitoring data were examined. Direct semi-covert observational medication administration audits using the 5 rights (n = 39) were conducted. Brief interviews with patients, parents and nurses were conducted. Data were mapped to the Behaviour Change Wheel. No medication administration incidents were recorded. Audits (n = 3) for the neonatal intensive care unit revealed no areas for improvement. Adult intensive care unit nurses (n = 36) performed checks for the right medication 35 times (97%) and patient identity 25 times (69%). Sixteen administrations (44%) were interrupted. Four themes were synthesized from the interview data: Trust in the nursing profession; Availability of policies and procedures; Adherence to the '5 rights' and departmental culture; and Adequate staffing. The interventional functions most likely to bring about behaviour change were environmental restructuring, enablement, restrictions, education, persuasion and modelling. This study reveals insights about the medication administration practices of nurses in intensive care. Although there were areas for improvement there was widespread awareness among nurses regarding their responsibilities to safely administer medications. Interview data indicated high levels of trust among patients and parents in the nurses. This novel study indicated that nurses in intensive care are aware of their responsibilities to safely administer medications. Mapping of contextual data to the Behaviour Change Wheel resulted in the identification of Intervention functions most likely to change medication administration practices in the adult intensive care setting that is environmental restructuring, enablement, restrictions, education, persuasion and modelling.

Intensive care unit nurses’ perceptions of debriefing after critical incidents: A qualitative descriptive study

BackgroundIntensive care unit (ICU) nurses are exposed to critical incidents daily at their workplace, which may have long-term physical and psychological impacts. Despite the growing evidence supporting clinical debriefing in health care to prevent these impacts, a scarcity of literature exists to support its use in the adult intensive care setting. ObjectivesThe objective of this study was to explore nurses’ perceptions of clinical debriefing after critical incidents in an adult ICU. MethodsA qualitative descriptive design was utilised. Thematic analysis of data from individual semistructured interviews with six ICU nurses was undertaken. FindingsIn this study, two themes were identified. Firstly, participants valued hot debriefing after critical incidents for the key reasons of having an opportunity to reflect on and learn from a critical incident and reduce normalisation of stressful situations. Secondly, when logistical factors such as communication, timing, and location were not considered, the attendance at debriefings was negatively influenced. Participants identified that ICU nurses commonly prioritised patient tasks over attending a debrief; therefore, teamwork and flexibility with logistics was crucial. ConclusionsHot debriefing, of a short duration and close to the time of the event, was valued and played an important role in staff wellbeing and self-care, contributing to preventing self-blame and normalisation of stressful situations. A clearer definition of the term along with greater recognition of types of events that could be considered critical incidents is required for staff support after critical incidents in the complex intensive care setting.

Non-pharmacological delirium prevention practices among critical care nurses: a qualitative study

BackgroundDelirium is common among critically ill patients, leading to increased mortality, physical dependence, and cognitive impairment. Evidence suggests non-pharmacological delirium prevention practices are effective in preventing delirium. However, only a few studies explore the actual implementation and its associated challenges among critical care nurses.AimTo explore critical care nurses’ perceptions of current non-pharmacological delirium prevention practices in adult intensive care settings, including delirium screening, early mobilisation, sleep promotion, family engagement, and sensory stimulation.MethodsA qualitative design adopting a thematic analysis approach. Semi-structured interviews with 20 critical care nurses were conducted in ten acute hospitals in mainland China.ResultsThree themes emerged: (a) importance of family engagement; (b) influence of organisational factors, and (c) suggestions on implementation. The implementation of non-pharmacological delirium prevention practices was limited by a strict ICU visitation policy, lack of routine delirium screening and delirium training, light and noise disturbances during nighttime hours, frequent resuscitation and new admissions and strict visitation policy. Case-based training, adopting a sensory stimulation protocol, and family engagement may be enablers.ConclusionICU care routine that lacks delirium assessment and the strict family visitation policy made it challenging to implement the complete bundle of non-pharmacological practices. Resource deficiency (understaffing, lack of training) and ICU environment (frequent resuscitation) also limited the implementation of non-pharmacological practices. Clinicians could implement case-based training and sensory-stimulation programs and improve communication with family caregivers by instructing family caregivers to recognise delirium symptoms and delirium prevention strategies.

Noninvasive Hemoglobin Monitoring for Postoperative Pediatric Orthopaedic Patients: A Preliminary Study

Hemoglobin (Hgb) levels are frequently checked through venipuncture [invasive hemoglobin (iHgb)] in pediatric orthopaedic patients after high blood loss procedures. This needlestick may causes further anxiety and fear in hospitalized children. Noninvasive hemoglobin (nHgb) monitoring has been effectively utilized in the adult intensive care and postoperative total joint arthroplasty setting. nHgb monitoring has not yet been validated in children for routine postoperative Hgb assessment in pediatric orthopaedics. In this prospective study, 46 pediatric orthopaedic patients were enrolled who were undergoing surgery and postoperative standard of care iHgb testing. On postoperative day 1, Hgb levels were obtained through venipuncture and nHgb monitor (Pronto-7; Masimo) within a 2-hour period. Patient preferences, iHgb and nHgb values, time to result, and provider preferences were recorded. Cost data were estimated based on the standard Medicare payment rates for lab services versus the cost of nHgb probe. nHgb results were obtained after 1 attempt in 38 patients (83%), after multiple attempts in 7 patients (15%), and could not be obtained in 1 patient. The mean time to obtain nHgb value was significantly shorter than that to obtain iHgb results (1.3±1.5 vs. 40±18.1min; P <0.0001). The mean nHgb value was significantly higher than the mean iHgb value (11.7±1.5 vs. 10.6±1.1g/dL, P <0.0001). nHgb exceeded iHgb by 2g/dL or more in 12 (26%) patients (2.64±0.9 vs. 0.54±0.84g/dL; P <0.0001). The concordance correlation coefficient between the 2 Hgb methods was 0.59, indicating moderate agreement. Forty-three (93%) of our patients and 34 (74%) of the care providers preferred nHgb over iHgb if results were equivalent. At our institution, the cost per iHgb monitoring is approximately $28 per blood draw as compared with $5 for nHgb monitoring. Interestingly, no patients required postoperative transfusion during the study period, as asymptomatic patients with no cardiac disease are typically observed unless the Hgb is <6. nHgb monitoring in postoperative pediatric patients overestimated Hgb levels compared with the standard of care methods; however, nHgb had high patient and provider satisfaction and had moderate agreement with iHgb. As no patients required transfusion, postoperative Hgb checks could likely be discontinued in some portion of our population. Level Ib-Diagnostic study.

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis

BackgroundPatients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. Structured handover recommendations often underestimate the challenges and complexity...

The clinical effects of cerebral near-infrared spectroscopy monitoring (NIRS) versus no monitoring: a protocol for a systematic review with meta-analysis and trial sequential analysis

BackgroundMultiple clinical conditions are associated with cerebral hypoxia/ischaemia and thereby an increased risk of hypoxic-ischaemic brain injury. Cerebral near-infrared spectroscopy monitoring (NIRS) is a tool to monitor brain oxygenation and perfusion, and the clinical uptake of NIRS has expanded over recent years. Specifically, NIRS is used in the neonatal, paediatric, and adult perioperative and intensive care settings. However, the available literature suggests that clinical benefits and harms of cerebral NIRS monitoring are uncertain. As rates of clinically significant hypoxic-ischaemic brain injuries are typically low, it is difficult for randomised clinical trials to capture a sufficiently large number of events to evaluate the clinical effect of cerebral NIRS monitoring, when focusing on specific clinical settings. The aim of this systematic review will be to evaluate the benefits and harms of clinical care with access to cerebral NIRS monitoring versus clinical care without cerebral NIRS monitoring in children and adults across all clinical settings.MethodsWe will conduct a systematic review with meta-analysis and trial sequential analysis. We will only include randomised clinical trials. The primary outcomes are all-cause mortality, moderate or severe persistent cognitive or neurological deficit, and proportion of participants with one or more serious adverse events. We will search CENTRAL, EMBASE, MEDLINE, and the Science Citation Index Expanded from their inception and onwards. Two reviewers will independently screen all citations, full-text articles, and extract data. The risk of bias will be appraised using the Cochrane risk of bias tool version 2.0. If feasible, we will conduct both random-effects meta-analysis and fixed-effect meta-analysis of outcome data. Additional analysis will be conducted to explore the potential sources of heterogeneity (e.g. risk of bias, clinical setting).DiscussionAs we include trials across multiple clinical settings, there is an increased probability of reaching a sufficient information size. However, heterogeneity between the included trials may impair our ability to interpret results to specific clinical settings. In this situation, we may have to depend on subgroup analyses with inherent increased risks of type I and II errors.Systematic review registrationPROSPERO CRD42020202986. This systematic review protocol has been submitted for registration in the International Prospective Register of Systematic Reviews (PROSPERO) (http://www.crd.york.ac.uk/prospero) on the 12th of October 2020 and published on the 12th of November 2020 (registration ID CRD42020202986).

Effectiveness of an Alcohol-Based Nasal Antiseptic in Reducing MRSA Bacteremia in an Adult Intensive Care Population

Background: Hospitalized patients are at an increased risk of invasive infection with Staphylococcus aureus when colonized with the bacteria on admission. Rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are directly correlated with overall patient acuity, placing patients in intensive care areas at greatest risk. Universal decolonization with nasal antibiotic ointments has been shown to reduce the incidence of invasive MRSA in critically ill patients; however, debate remains regarding the long-term efficacy of this strategy and the possibility of developing antimicrobial resistance. An alcohol-based nasal antimicrobial may be an effective alternative. This study evaluated the effectiveness of a twice daily alcohol-based product in reducing the rate of MRSA bacteremia in an academic tertiary-care adult intensive care setting. Methods: Our study was an observational design with retrospective and prospective cohorts each consisting of 61 critical care beds. The baseline incidence of MRSA bacteremia was determined from a 7-month period preceding the implementation of the nasal antimicrobial. At implementation, each admission received an electronic order for an alcohol-based nasal antiseptic that was applied twice daily during the intensive care stay. The primary outcome was the incidence of MRSA bacteremia in each group. MRSA bacteremia was defined by the CDC NHSN criteria after review by an infection prevention nurse. The 2 test was used to compare the rates between the 2 groups, and P &lt; .005 was considered significant. Results: The study periods contained similar patient days, with 12,475 in the retrospective group and 12,733 in the prospective group. The rate of MRSA bacteremia in the retrospective cohort was 0.2404 compared to 0 in the prospective cohort. This rate change was statistically significant, with P &lt; .0001. Conclusions: The alcohol-based nasal antiseptic was effective in reducing healthcare-onset MRSA bacteremia in this intensive care population. This approach may be a safe and effective alternative to nasal antibiotic ointment that avoids antibiotic resistance risks.Funding: NoneDisclosures: None

A pilot randomised controlled trial of dressing and securement methods to prevent arterial catheter failure in intensive care

BackgroundCritically ill patients in an intensive care setting often require arterial catheters for blood pressure monitoring and arterial blood collection. Arterial catheter failure, which manifests in both mechanical and infective forms, remains common. Dressing and securement inadequacies may impact this failure; however, the best method for dressing and securing arterial catheters is yet to be determined. ObjectivesThe objective of this study was to establish the feasibility of a definitive randomised controlled trial comparing methods for dressing and securing arterial catheters and to prevent device failure in an adult intensive care setting. MethodsA pilot, parallel-group, randomised controlled trial was conducted between April 2017 and June 2018. Patients receiving treatment in two adult intensive care units (Queensland, Australia) were eligible for inclusion and were allocated to receive either (i) an integrated securement dressing or (ii) a simple polyurethane dressing (with gauze/foam), applied to their newly inserted arterial catheters. Main outcome measuresPrimary outcomes were (i) feasibility (defined by pre-established criteria: patient eligibility, consent, protocol adherence, retention, and staff acceptability) and (ii) all-cause arterial catheter failure (a composite of local and bloodstream infection, occlusion, dislodgement, infiltration/extravasation, arterial inflammation, thrombosis, and/or inaccurate trace). Secondary outcomes included: failure type, dwell time, dressing adhesion, adverse event profiles, and staff acceptability. ResultsIn total, 109 patients were studied (n = 53 integrated securement dressing; n = 56 simple polyurethane). The feasibility criterion was met by most patients (including rates of consent [86%], protocol adherence [93%], and retention [100%]); however, the criteria for patient eligibility were not met (73%). All-cause device failure did not differ significantly between the integrated securement device group (n = 12/53, 23%) and the simple polyurethane group (n = 6/56, 11%) (hazard ratio = 2.39, 95% confidence interval = 0.89–6.37, p = 0.083). ConclusionsFindings indicate a larger study is feasible, with minor alterations to recruitment methods required. Arterial catheter failure remains unacceptably common; further research to determine optimal dressing/securement practices is urgently needed.

Usability study of a new tool for nutritional and glycemic management in adult intensive care: Glucosafe 2.

The new decision support tool Glucosafe 2 (GS2) is based on a mathematical model of glucose and insulin dynamics, designed to assist caregivers in blood glucose control and nutrition. This study aims to assess end-user acceptance and usability of this bedside decision support tool in an adult intensive care setting. Caregivers were first trained and then invited to trial GS2 prototype on bedside computers. Data for qualitative analysis were collected through semi-structured interviews from twenty users after minimum three trial days. Most caregivers (70%) rated GS2 as convenient and believed it would help improving adherence to current guidelines (85%). Moreover, most nurses (80%) believed that GS2 would be timesaving. Nurses' risk perceptions and manual data entry emerged as central barriers to use GS2 in routine practice. Issues emerged from the caregivers were compiled into a list of 12 modifications of the GS2 prototype to increase end-user acceptance and usability. This usability study showed that GS2 was considered by ICU caregivers as helpful in daily clinical practice, allowing time-saving and better standardization of ICU patient's care. Important issues were raised by the users with implications for the development and deployment of GS2. Integrating the technology into existing IT infrastructure may facilitate caregivers' acceptance. Further clinical studies of the performance and potential health outcomes are warranted.

Effect of the use of an antiseptic barrier cap on the rates of central line–associated bloodstream infections in neonatal and pediatric intensive care

The use of antiseptic barrier caps reduced the occurrence of central line-associated bloodstream infections (CLABSI) in adult intensive care settings. We assessed the effect of the use of antiseptic barrier caps on the incidence of CLABSI in infants and children and evaluated the implementation process. We performed a mixed-method, prospective, observational before-after study. The CLABSI rate was documented during the "scrub the hub method" and the antiseptic barrier cap phase. Main outcomes were the number of CLABSIs per 1,000 catheter days (assessed with a Poisson regression analysis) and nurses' adherence to antiseptic barrier cap protocol. In total, 2,248 patients were included. The rate of CLABSIs per 1,000 catheter days declined from 3.15 to 2.35, resulting in an overall incidence reduction of 22% (95% confidence interval, -34%, 55%; P = .368). Nurses' adherence to the antiseptic barrier cap protocol was 95.2% and 89.0% for the neonatal intensive care unit and pediatric intensive care unit, respectively. The CLABSI reducing effect of the antiseptic barrier caps seems to be more prominent in the neonatal intensive care unit population compared with the pediatric intensive care unit population. The antiseptic barrier cap did not significantly reduce the CLABSI rates in this study.

Interventions to promote patients and families\u2019 involvement in adult intensive care settings: a protocol for a mixed-method systematic review

BackgroundThere has been an identified need for greater patient and family member involvement in healthcare. This is particularly relevant in an intensive care unit (ICU), as the family provides a key communicative and practical link between patient and clinician. Family members have been deemed a positive beneficial influence on ICU care and recovery processes, yet they themselves are often emotionally affected after discharge. There has been no standardised evidenced-based approach which explores research on family member involvement and the range and quality of contributions remain unclear. This project will undertake a systematic review to assess the evidence base for interventions designed to promote patient and family member involvement in adult intensive care settings and develop a comprehensive typology of interventions for use by clinicians, patients and carers.MethodsThe following databases will be searched without date restriction: MEDLINE, EMBASE and CINAHL, as well as the Cochrane Central Register of Controlled Trials, Joanna Briggs and Cochrane Libraries. Manual searches of recent back issues of leading ICU and patient experience journals will also be undertaken, as will the reference lists of included studies. Unpublished literature will be sought through grey literature databases, including GreyLit and OpenGrey. All evaluation studies that consider intervention activities to promote patient and family member involvement in adult ICUs will be included; all research designs will be eligible. We will seek to include studies that report on a mixture of relevant outcomes for patients and family members. s and papers will be independently screened by at least two members of the team to determine their inclusion. Included papers will be assessed for methodological rigour using a standard rating approach, which assesses ‘quality of study’ and ‘quality of information’. Quality assessment will be completed by at least two members of the team. Data on interventions, evaluation methods and outcomes will be collated using a predetermined extraction table. These are likely to be heterogeneous in nature, which will mean that the review will follow a narrative approach to synthesis.DiscussionThe review will provide valuable and rigorous insight into the range and quality of interventions available to promote patient and family member involvement in ICU. This is the first step towards addressing the absence of a synthesis of research for this context, and will, in addition, develop a typology of available interventions that will help service users and clinicians make informed decisions about the approaches to patient and family member involvement which they might want to adopt.Systematic review registrationPROSPERO (CRD42018086325).

Skin complications associated with vascular access devices: A secondary analysis of 13 studies involving 10,859 devices

BackgroundVascular access devices are widely used in healthcare settings worldwide. The insertion of a vascular access device creates a wound, vulnerable to irritation, injury and infection. Vascular access-associated skin complications are frequently reported in the literature, however very little evidence is available regarding the incidence and risk factors of these conditions to inform practice and technology development. ObjectivesTo estimate the incidence of vascular access-associated skin complications, and to identify patient, catheter and healthcare-related characteristics associated with skin complication development. DesignSecondary data analysis from 13 multi-centre randomised controlled trials and observational studies evaluating technologies and performance of vascular access devices in clinical settings between 2008 and 2017. SettingsSix hospitals (metropolitan and regional) in Queensland, Australia. ParticipantsThe 13 studies involved paediatric and adult participants, across oncology, emergency, intensive care, and general hospital settings. A total of 7669 participants with 10,859 devices were included, involving peripheral venous (n = 9933), peripheral arterial (n = 341), and central venous access (n = 585) devices. AnalysisStandardised study data were extracted into a single database. Clinical and demographic data were descriptively reported. Cox proportional hazards regression models (stratified by peripheral vs central) were used for time-to-event, per-device analyses to examine risk factors. Univariate associations were undertaken due to complexities with missing data in both outcomes and covariates, with p < 0.01 to reduce the effect of multiple comparisons. ResultsOver 12% of devices were associated with skin complication, at 46.2 per 1000 catheter days for peripheral venous and arterial devices (95% confidence interval, CI 42.1–50.7), and 22.5 per 1000 catheter days for central devices (95% CI 16.5–306). The most common skin complications were bruising (peripheral n = 134, 3.7%; central n = 33, 6.8%), and swelling due to infiltration for peripheral devices (n = 296; 2.9%), and dermatitis for central devices (n = 13; 2.2%). The significant risk factors for these complications were predominantly related to device (e.g., skin tears associated with peripheral arterial catheters [hazard ratio, HR 16.0], radial insertion [HR 18.0] basilic insertion [HR 26.0])) and patient characteristics (e.g., poor skin integrity associated with increased risk of peripheral device bruising [HR 4.12], infiltration [HR 1.98], and skin tear [HR 48.4]), rather than management approaches. ConclusionsSignificant skin complications can develop during the life of peripheral and central vascular access devices, and these are associated with several modifiable and non-modifiable risk factors. Further research is needed to evaluate effectiveness technologies to prevent and treat skin complications associated with vascular access devices.

The experiences of new graduate nurses hired and retained in adult intensive care units

BackgroundIt is a common practice that new graduate Registered Nurses are hired into adult intensive care units as initial entry into practise. There exists a practice readiness gap between nursing curricula and actual clinical practise expectations at adult intensive care settings; this has led to negative consequences and subsequent nurse turnover, a concern nationwide. Nonetheless, some new graduate nurses survived their initial transition and continue to practise in adult settings. The purpose of this study was to explore the experiences of nurses who were hired into adult intensive care as a new graduate and survived their transition from novice to competent, starting the third year of practise. MethodologyThe study used the hermeneutic phenomenology research approach. FindingsData analysis revealed the overall meaning of the experience: coming to terms with being comfortable with being uncomfortable. The six themes associated with being comfortable with being uncomfortable were: confidence and uncertainty, gaining experiences and forever learning, intuitive knowing and intuition, difficult and stressful, being courageous and assertive, and the team and support people. ConclusionNew graduate nurses can survive to become competent adult intensive care nurses. This study reveals the need to promote exposure to a variety of clinical situations early, to promote resilience and self-care, and to foster unit teamwork and mentoring to ensure successful transition and overall retention of new nurses hired into in adult intensive care.

(50) Assessing nursing and healthcare provider comfort and knowledge of caring for the pediatric patient with delirium in the critical care setting: Where can we improve?

Purpose: Delirium is a serious, yet reversible disease process that affects many critically ill patients. The presence of delirium is independently associated with worse hospital outcomes and although protocols for screening and treatment are becoming standard of care in the adult intensive care setting, practices still vary drastically among pediatric units. In order to improve care, gaps in provider knowledge must be identified and …

Therapeutic Drug Monitoring of Beta-Lactams and Other Antibiotics in the Intensive Care Unit: Which Agents, Which Patients and Which Infections?

Antibiotics are among the medications most frequently administered to the critically ill, a population with high levels of intra- and inter-individual pharmacokinetic variability. Our knowledge of the relationships among antibiotic dosing, exposure and clinical effect in this population has increased in recent decades. Therapeutic drug monitoring (TDM) of serum antibiotic concentrations is the most practical means of assessing adequate antibiotic exposure, though until recently, it has been underutilised for this end. Now TDM is becoming more widespread, particularly for the beta-lactam antibiotics, a class historically thought to have a wide therapeutic range. We review the basic requirements, indications, and targets for effective TDM of the glycopeptides, aminoglycosides, quinolones and beta-lactam antibiotics in the adult intensive-care setting, with a special focus on TDM of the beta-lactam antibiotics, the most widely used antibiotic class.

Clinical Evaluation of an Extended Dwell Peripheral IV in a Level 1 Trauma Center

Vascular access devices are widely used in healthcare settings worldwide. The insertion of a vascular access device creates a wound, vulnerable to irritation, injury and infection. Vascular access-associated skin complications are frequently reported in the literature, however very little evidence is available regarding the incidence and risk factors of these conditions to inform practice and technology development.To estimate the incidence of vascular access-associated skin complications, and to identify patient, catheter and healthcare-related characteristics associated with skin complication development.Secondary data analysis from 13 multi-centre randomised controlled trials and observational studies evaluating technologies and performance of vascular access devices in clinical settings between 2008 and 2017.Six hospitals (metropolitan and regional) in Queensland, Australia.The 13 studies involved paediatric and adult participants, across oncology, emergency, intensive care, and general hospital settings. A total of 7669 participants with 10,859 devices were included, involving peripheral venous (n = 9933), peripheral arterial (n = 341), and central venous access (n = 585) devices.Standardised study data were extracted into a single database. Clinical and demographic data were descriptively reported. Cox proportional hazards regression models (stratified by peripheral vs central) were used for time-to-event, per-device analyses to examine risk factors. Univariate associations were undertaken due to complexities with missing data in both outcomes and covariates, with p < 0.01 to reduce the effect of multiple comparisons.Over 12% of devices were associated with skin complication, at 46.2 per 1000 catheter days for peripheral venous and arterial devices (95% confidence interval, CI 42.1–50.7), and 22.5 per 1000 catheter days for central devices (95% CI 16.5–306). The most common skin complications were bruising (peripheral n = 134, 3.7%; central n = 33, 6.8%), and swelling due to infiltration for peripheral devices (n = 296; 2.9%), and dermatitis for central devices (n = 13; 2.2%). The significant risk factors for these complications were predominantly related to device (e.g., skin tears associated with peripheral arterial catheters [hazard ratio, HR 16.0], radial insertion [HR 18.0] basilic insertion [HR 26.0])) and patient characteristics (e.g., poor skin integrity associated with increased risk of peripheral device bruising [HR 4.12], infiltration [HR 1.98], and skin tear [HR 48.4]), rather than management approaches.Significant skin complications can develop during the life of peripheral and central vascular access devices, and these are associated with several modifiable and non-modifiable risk factors. Further research is needed to evaluate effectiveness technologies to prevent and treat skin complications associated with vascular access devices.

Patient and family involvement in adult critical and intensive care settings: a scoping review.

BackgroundDespite international bodies calling for increased patient and family involvement, these concepts remain poorly defined within literature on critical and intensive care settings.ObjectiveThis scoping review investigates the extent and range of literature on patient and family involvement in critical and intensive care settings. Methodological and empirical gaps are identified, and a future agenda for research into optimizing patient and family involvement is outlined.MethodsSearches of MEDLINE, CINAHL, Social Work s and PsycINFO were conducted. English‐language articles published between 2003 and 2014 were retrieved. Articles were included if the studies were undertaken in an intensive care or critical care setting, addressed the topic of patient and family involvement, included a sample of adult critical care patients, their families and/or critical care providers. Two reviewers extracted and charted data and analysed findings using qualitative content analysis.FindingsA total of 892 articles were screened, 124 were eligible for analysis, including 61 quantitative, 61 qualitative and 2 mixed‐methods studies. There was a significant gap in research on patient involvement in the intensive care unit. The analysis identified five different components of family and patient involvement: (i) presence, (ii) having needs met/being supported, (iii) communication, (iv) decision making and (v) contributing to care.ConclusionThree research gaps were identified that require addressing: (i) the scope, extent and nature of patient involvement in intensive care settings; (ii) the broader socio‐cultural processes that shape patient and family involvement; and (iii) the bidirectional implications between patient/family involvement and interprofessional teamwork.