Adult Intensive Care Unit Setting Research Articles

Y-site simulation compatibility study of 10% calcium salts with various injectable solutions during toxicological resuscitation

PurposeTo determine the physical compatibility of 10% calcium chloride and 10% calcium gluconate in combination with injectable solutions, administered in the paediatric and adult intensive care unit setting during toxicological...

A Concept Analysis of Trust Within the Surrogate Decision Maker to Health Care Professional Relationship in the Adult ICU Setting.

Surrogate decision maker (SDM)-health care professional (HCP) trust is vital to the provision of high-quality care in the adult intensive care unit setting. This concept analysis, using Walker and Avant's methodology, examines the concept of SDM-HCP trust and provides a conceptual definition conducive to instrument development and future quantitative research into this topic. Trust in the SDM-HCP relationship exists on a spectrum and involves the voluntary placement of oneself into a position of vulnerability in relation to another party who is believed to have integrity, be reliable, and hold beneficent intent toward the truster.

1199. Implementation of a Nasal Antiseptic Decolonization Program Reduces the Occurrence of Healthcare-Associated Infections in the Adult Intensive Care Unit Setting

Abstract Background Universal decolonization programs effectively reduce methicillin-resistant Staphylococcus aureus (MRSA) infections, bloodstream infections, and healthcare costs. However, universal decolonization programs that utilize mupirocin may promote antimicrobial resistance. Non-antibiotic interventions, such as nasal antiseptic decolonization, can contribute to the prevention of healthcare-associated infections (HAIs). A large hospital system sought to evaluate the impact of a universal nasal antiseptic program on HAIs in the adult intensive care unit (ICU) setting. Methods A nasal antisepsis decolonization quality improvement project (QIP) was implemented to reduce ICU HAIs by applying a 62% nasal antiseptic swab with emollients bilaterally to the nares every 12 hours for all adult ICU patients. The program was piloted across nine ICUs at three large hospitals from November 2021 to January 2022 and captured data from 12,404 patient days and 4,058 treatment days. Central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and MRSA bacteremia rates were compared a) between treated and non-treated patients during the QIP period and b) to rates during a three-month period prior to the QIP. Results The results of the pilot program indicated that patients who received treatment with the 62% nasal swab developed fewer HAIs than patients who did not receive the treatment. Two HAIs occurred in the treatment group (two CAUTIs) compared to 14 HAIs in the non-treatment group (three CAUTIs, nine CLABSIs, and two MRSA bacteremia). Figures 1 and 2 below demonstrate HAI rates in the non-treatment and the treatment groups. Figure 1Figure 2 Conclusion Based on pilot results, the system approved implementation of a universal nasal antisepsis program using the 62% alcohol based nasal swab with emollients for expansion to all adult critical care units. Considerations for the future implementation of the program include broadening patient inclusion and performing ongoing HAI surveillance of treated and untreated patient groups. Disclosures All Authors: No reported disclosures.

Exploring physician approaches to conflict resolution in end-of-life decisions in the adult intensive care unit: protocol for a systematic review of qualitative research

IntroductionConflict is unfortunately well-documented in the adult intensive care unit (AICU). In the context of end-of-life (EOL) decision-making (ie, the withdrawal or withholding of life-sustaining treatment), conflict commonly occurs when...

Dynamic Risk Prediction for Hospital-Acquired Pressure Injury in Adult Critical Care Patients

To develop and validate a dynamic risk prediction model to estimate the risk of developing a hospital-acquired pressure injury among adult ICU patients. ICU admission data were split into training and validation sets. With death as a competing event, both static and dynamic Fine-Gray models were developed to predict hospital-acquired pressure injury development less than 24, 72, and 168 hours postadmission. Model performance was evaluated using Wolbers' concordance index, Brier score, net reclassification improvement, and integrated discrimination improvement. We performed a retrospective cohort study of ICU patients in a tertiary care hospital located in San Francisco, CA, from November 2013 to August 2017. Data were extracted from electronic medical records of 18,019 ICU patients (age ≥ 18 yr; 21,220 encounters). Record of hospital-acquired pressure injury data was captured in our institution's incident reporting system. The information is periodically reviewed by our wound care team. Presence of hospital-acquired pressure injury during an encounter and hospital-acquired pressure injury diagnosis date were provided. The dynamic model predicting hospital-acquired pressure injury more than 24 hours postadmission, including predictors age, body mass index, lactate serum, Braden scale score, and use of vasopressor and antifungal medications, had adequate discrimination ability within 6 days from time of prediction (c = 0.73). All dynamic models produced more accurate risk estimates than static models within 26 days postadmission. There were no significant differences in Brier scores between dynamic and static models. A dynamic risk prediction model predicting hospital-acquired pressure injury development less than 24 hours postadmission in ICU patients for up to 7 days postadmission was developed and validated using a large dataset of clinical variables readily available in the electronic medical record.

Physician Approaches to Addressing Conflict Arising in End-of-Life Decision-Making in the Adult Intensive Care Unit: A Systematic Review

"Background: Conflict is unfortunately well-documented in the adult intensive care unit (AICU). In the context of end-of-life (EOL) decision-making (i.e. the withdrawal or withholding of life-sustaining treatment), conflict commonly occurs when a consensus cannot be reached between the healthcare team and the patient’s family on the “best interests” of the critically ill, incapacitated patient, as per England’s Mental Capacity Act 2005. Whilst existing literature has identified potential routes for conflict resolution, it is less clear how these approaches are perceived and utilised by stakeholders in the EOL decision-making process. Aim: We aim to explore this by systematically reviewing and synthesising the published evidence, which addresses the following research question: what does existing qualitative research reveal about physician approaches to addressing conflict arising in EOL decisions in the AICU? Methods: Peer-reviewed qualitative studies (retrieved from MEDLINE, Project Muse, EMBASE, Web of Science, PsycINFO, CINAHL and LILACS) examining conflict and dispute resolution in the context of EOL decisions in the AICU setting will be included. Two reviewers will independently screen for eligibility and extract data from either all or 10% of the included studies, with a third reviewer independently screening studies of uncertain eligibility. The ‘thematic synthesis’ approach will be utilised to analyse the resulting data (Thomas & Harden, 2008). The systematic review is currently underway, laying the foundations for a larger empirical study, undertaken for a PhD, funded by the Wellcome Trust BABEL (Balancing Best Interests in Healthcare, Ethics, and Law) Collaborative Award. The results will be presented at the conference. "

Physiological and Psychological Effects of Listening To Holy Quran Recitation in the Intensive Care Unit Patients: A Systematic Review

Stress and anxiety are common among intensive care unit (ICU) patients especially those who are on mechanical ventilation. Non-pharmacological interventions such as music and prayer are recommended because they are opioid sparing, easy to provide, cheap and safe. There is a growing body of evidence on the effects of Holy Quran Recitation (HQR) in reducing stress and anxiety in critically ill Muslim patients. The aim of this review is to evaluate the physiological and psychological effects of HQR specifically in ICU setting. This review was performed on articles published between 2007 and 2018. Extensive search was done using PubMed, ISI Web of Knowledge, Scopus and Google Scholar. Systematic review articles are also assessed and relevant literatures are hand searched based on reference lists and citations made in key publications. Studies related to HQR which were done outside adult ICU setting were excluded. A total of nine articles are included in the final list for detail analysis. Findings of this review revealed six studies with significant results in improving stress responses, hemodynamic stability and conscious levels. HQR is a potential nonpharmacological tool to reduce stress and can also be used as auditory stimulus to improve conscious level in comatose patients. More studies in this area are recommended aiming for low risk of bias, appropriate calculation of sample size and adequately powered to detect significant outcomes.

'Intensive care unit survivorship' - a constructivist grounded theory of surviving critical illness.

To theorise intensive care unit survivorship after a critical illness based on longitudinal qualitative data. Increasingly, patients survive episodes of critical illness. However, the short- and long-term impact of critical illness includes physical, psychological, social and economic challenges long after hospital discharge. An appreciation is emerging that care needs to extend beyond critical illness to enable patients to reclaim their lives postdischarge with the term 'survivorship' being increasingly used in this context. What constitutes critical illness survivorship has, to date, not been theoretically explored. Longitudinal qualitative and constructivist grounded theory. Interviews (n=46) with 17 participants were conducted at four time points: (1) before discharge from hospital, (2) four to six weeks postdischarge, (3) six months and (4) 12months postdischarge across two adult intensive care unit setting. Individual face-to-face interviews. Data analysis followed the principles of Charmaz's constructivist grounded theory. 'Intensive care unit survivorship' emerged as the core category and was theorised using concepts such as status passages, liminality and temporality to understand the various transitions participants made postcritical illness. Intensive care unit survivorship describes the unscheduled status passage of falling critically ill and being taken to the threshold of life and the journey to a life postcritical illness. Surviving critical illness goes beyond recovery; surviving means 'moving on' to life postcritical illness. 'Moving on' incorporates a redefinition of self that incorporates any lingering intensive care unit legacies and being in control of one's life again. For healthcare professionals and policymakers, it is important to realise that recovery and transitioning through to survivorship happen within an individual's time frame, not a schedule imposed by the healthcare system. Currently, there are no care pathways or policies in place for critical illness survivors that would support intensive care unit survivors and their families in the transitions to survivorship.

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Introduction: High quality physician-family communication in the intensive care unit (ICU) is essential in order to provide comprehensive, family-centered care. However, prior research has shown that the quality of physician-family communication in the ICU is often sub-optimal, and may be even worse for families with limited English proficiency. Most existing data in this area come from retrospective, survey based studies performed in the adult ICU setting. We performed the first prospective analysis of the quality of physician-family communication during interpreted and non-interpreted family meetings in the pediatric ICU setting by audio-recording 30 family meetings in English and Spanish. After examining our transcripts, we hypothesized that the quality of communication during interpreted meetings may actually be superior to non-interpreted meetings due to simpler physician speech, increased opportunity for family speech, and interpreter clarifications that facilitate shared decision-making. Methods: Thirty pediatric ICU family meetings (21 English and 9 Spanish) were audio-recorded, transcribed, and analyzed using the qualitative method of directed content analysis. Quality of communication was analyzed in three ways: 1) presence of elements of shared decision-making, 2) balance between physician and family speech, and 3) complexity of physician speech. Only meetings containing a decisional component were analyzed for the elements of shared decision-making. The balance between physician and family speech was measured by time spent speaking during meetings, as well as weighted percentage of total meeting time spent speaking (speech time divided by physician plus family speech time). Complexity of physician speech was determined by analyzing physician speech passages and assigning a Flesch-Kincaid grade level score. Results: Elements of shared decision making occurred infrequently during both interpreted and non-interpreted meetings. Only 4 of the 11 elements were present in over half of English meetings, and only 3 of the 11 were present in over half of Spanish meetings. Physicians spent more time speaking than families. Physicians spoke for a mean of 20.7 minutes (95% CI 16 - 25.4), while families spoke for 9.3 minutes (95% CI 5.3 - 13.4) during English meetings. During Spanish meetings, physicians spoke for a mean of 14.9 minutes (95% CI 9.7 - 20.1) versus just 3.7 minutes (95% CI 1.5 - 5.9) of family speech. By weighted percentage, English meetings contained 71% physician speech (95% CI 63% - 78%) versus 29% family speech (95% CI 22% - 37%), compared to 80% physician speech (95% CI 73% - 88%) versus 20% family speech (95% CI 12% - 27%) in Spanish meetings. Physician speech complexity received a mean grade level score of 8.2 (95% CI 7.3 - 9.1) in English meetings, compared to 7.2 (95% CI 5.8 - 8.6) in Spanish meetings. Conclusions: The quality of physician-family communication during interpreted and non-interpreted family meetings in the pediatric ICU is poor overall. Interpreted meetings had poorer communication quality as evidenced by fewer elements of shared decision-making and greater imbalance between physician and family speech. However, physician speech may be less complex during interpreted meetings versus non-interpreted meetings. Our data suggest that physicians can improve communication in both interpreted and non-interpreted family meetings by increasing the use of elements of shared decision-making, improving the balance between physician and family speech, and decreasing the complexity of physician speech.

What’s shaking in the ICU? The differential diagnosis of seizures in the intensive care setting

To analyze what conditions mimic seizures in the intensive care unit (ICU) setting, we reviewed all bedside electroencephalography (EEG)-videos obtained in the adult ICU setting over an 18-month period. Only those studies performed for "possible seizures" due to motor phenomena and whose clinical events were captured on video were analyzed. A total of 52 studies were performed. Fourteen patients (27%) had epileptic seizures. Thirty-eight (73%) had nonepileptic events. These consisted of 12 (23%) with tremor-like movements, 7 (13.5%) with multifocal myoclonic jerks without electrographic changes, 7 (13.5%) with slow semipurposeful movements, and 10 with other movements. Therefore, seizure mimics in the ICU setting were diverse and distinct from the usual differential diagnosis of seizures seen in ambulatory patients.

Management of candidiasis in the intensive care unit

In the last two decades, Candida has emerged as an important opportunistic pathogen. Patients admitted to the intensive care unit (ICU) are particularly susceptible to this infection because of the severity of their underlying illness and the excess use of medical and surgical interventions. The frequent use of antibiotics, central venous catheters and other intravascular devices as well as poor gut motility or abdominal surgery place these patients at high risk of infection, which contributes to the morbidity and mortality of the already critically ill patient. Early recognition and appropriate management of invasive candidiasis are therefore important. This article addresses important management issues such as the role of screening for Candida colonization, the use of prophylaxis and the choice of antifungal agents for the treatment of presumed and proven invasive candidiasis in the adult ICU setting.

The low frequency of futility in an adult intensive care unit setting: A. Halevy, R.C. Neal, B.A. Brody. General Medicine Section, Ben Taub General Hospital, Houston, TX. Arch Intern Med 1996;156:100–4

The low frequency of futility in an adult intensive care unit setting: A. Halevy, R.C. Neal, B.A. Brody. General Medicine Section, Ben Taub General Hospital, Houston, TX. Arch Intern Med 1996;156:100–4

The low frequency of futility in an adult intensive care unit setting

The low frequency of futility in an adult intensive care unit setting

The Low Frequency of Futility in an Adult Intensive Care Unit Setting

It is widely assumed that "futile" treatment consumes significant health care resources. This is a prospective cohort study. The setting was the medical intensive care unit of Ben Taub General Hospital, a large public hospital in Houston, Tex. To assess the frequency of intensive care unit patients meeting any of three broad definitions of futility. Subjects consisted of 129 consecutive patients admitted to the study intensive care unit during a 6-week period in the fall of 1993. Operational definitions for three types of futility described in the literature were developed: Imminent demise futility, death imminent regardless of intervention, was assessed by using the APACHE II (Acute Physiology and Chronic Health Evaluation II) scoring system to determine the likelihood of mortality at more than the 90%, 95%, and 99% probabilities. Lethal condition futility, conditions incompatible with long-term survival, included five separate disease processes. Qualitative futility, conditions with an unacceptable quality of life, was assessed as a persistent vegetative state or as meeting criteria for poor prognosis due to a hypoxic ischemic coma. Only 2 bed-days (0.3%) were used by patients with more than 90% predicted mortality; 22 bed-days (3.6%) were used by patients with poor prognosis due to hypoxic ischemic coma; and 101 bed-days (16.4%) were used by patients satisfying criteria for the five lethal conditions. The frequency of futile interventions appears to be low unless one is willing to accept a definition that includes patients who could survive for many months. If confirmed in other settings, this suggests that concepts of futility will not play a major role in costs containment.

A pediatric client in an adult ICU setting requiring a mechanical assist device and heart transplantation: Case study

Intensive care unit nurses are often faced with challenging situations. This case study focuses on an older school-age child in an adult intensive care unit (ICU) for the placement of a biventricular assist device (BIVAD) and eventual heart transplantation. Discussion of the assist device and transplantation is included as well as a discussion of the nursing care issues. The care issues discussed include alteration in family processes, alteration in body image, and grieving related to the possibility of death.