Bedside Evaluations Research Articles

Rapid response: A quality improvement conundrum

Many in-hospital cardiac arrests and other adverse events are heralded by warning signs that are evident in the preceding 6 to 8 hours. By promptly intervening before further deterioration occurs, rapid response teams (RRTs) are designed to decrease unexpected intensive care unit (ICU) transfers, cardiac arrests, and inpatient mortality. While implementing RRTs is 1 of the 6 initiatives recommended by the Institute for Healthcare Improvement, data supporting their effectiveness is equivocal. Before implementing an RRT in our institution, we reviewed cases of failure to rescue and found that (1) poor outcomes were often associated with attempts to manage early decompensations without a bedside evaluation, and (2) the common causes of decompensation for floor patients (early sepsis, aspiration, pulmonary embolism) were within the scope of our primary teams' practice. Therefore, we felt that prompt, mandatory bedside evaluations by the primary team would decrease untoward outcomes.

A novel system using the Forced Oscillations Technique for the biomechanical analysis of swallowing

Physiological studies of swallowing and the diagnosis and treatment of dysphagia are crucially dependent of detailed information of respiratory and feeding events. However, this information has been obtained by indirect and/or expensive methods, as well as by methods demanding exposure to radiation. In this context, the purpose of this study was twofold: (1) describe a new low-cost system for the analysis of the respiratory events during swallowing using the Forced Oscillation Technique and (2) evaluate the performance of this device in the description of physiological events during water swallowing. The device consists of a personal computer adapted to measurement modules able to characterize the soft palate movement, the elevation of the larynx, the duration of deglutition apnoea, and the direction of airflow at the end of the swallow apnoea. These parameters were studied in eight healthy subjects under conditions of saliva swallowing and three doses of water (5,10 and 20 mL). The system allowed a real time description of the respiratory and feeding events, which were in close agreement with physiological principles. Mean results showed an increase of the apnoea time that was not statistically significant. In contrast, a highly significant increase of respiratory impedance during swallowing was observed (p < 0.0001). The described instrument does not use radiation. It shows itself particularly well suited for studies of deglutition physiology, including mechanisms involved in airway protection during swallowing. It can also be potentially useful contributing to easy clinical bedside evaluations and biofeedback procedures for the rehabilitation of paediatric and elderly patients.

Individual delirium symptoms: Do they matter?*

To evaluate the impact of individual manifestations of delirium on outcome, describe them in critically ill adults, and validate nurses' bedside item assessments from the Intensive Care Delirium Screening Checklist (ICDSC). Prospective study. Single 16-bed medical/surgical university hospital intensive care unit. Six hundred consecutive patients admitted to the intensive care unit for >24 hrs. All patients were evaluated with the eight-item ICDSC throughout their intensive care unit stay. In all patients scoring positive on any ICDSC item, individual checklist items were tallied throughout the intensive care unit stay and assessed for impact on mortality. In addition, when the ICDSC score indicated delirium (> or = 4 of 8), the subsequent overall frequency of each item was also independently documented to describe delirious patient symptoms. ICDSC items were tested for discrimination between delirious and nondelirious patients. Throughout the study, the validity of bedside delirium assessments was assessed in 30 nurses. We were able to assess 537 patients. In nondelirious patients, psychomotor agitation by ICDSC assessment was associated with a higher risk of mortality after adjustment for Acute Physiology and Chronic Health Evaluation, age, and the presence of coma. One hundred eight-nine patients (35.1%) developed delirium (i.e., ICDSC score > or = 4). On presentation (and throughout the intensive care unit stay), the most frequent features of delirium were inattention, disorientation, and psychomotor agitation. Each ICDSC item was highly discriminating between delirious vs. nondelirious patients. Correlation between gold standard adjudicators and nurses for the overall bedside evaluations of delirium were excellent (Pearson's correlation R = 0.924, p < .0005). Individual symptom evaluation by nurses varied: Alteration in level of consciousness was poorest (R = 0.681, p < .0005), and both disorientation and hallucinations evaluated best (R = 1.000). In nondelirious patients, agitation was associated with a higher risk of mortality. Each of the eight ICDSC items is highly discriminating for the diagnosis of delirium, suggesting that any screening or diagnostic scales should incorporate them. Quality assurance and educational efforts should, therefore, emphasize independent assessment of the individual features of delirium.

Evaluation of a brief cardiovascular autonomic screen

Objective To test the validity and practicality of a simple, rapid autonomic cardiovascular evaluation (RACE). Introduction Assessment of the autonomic nervous system is costly and time consuming. Consequently, briefer measures are often utilized as evaluations of autonomic function. We therefore set out to assess the validity and practicality of a simple, rapid autonomic cardiovascular evaluation protocol which mimicked the bedside evaluations used in many healthcare centers. Design/methods Every eligible patient undergoing full autonomic testing (FAT) in our laboratory was enrolled. The protocol, performed blinded to FAT results, consisted of one breath in the supine position, and supine and standing (1 and 3 min) pressures and pulse. Results were scored for cardiac variation during the breath, a drop in pressure during the stand. Pulse increase was also scored. Aggregate RACE score was regressed against a similarly scored FAT. Results The single breath response correlated poorly with the standard response to deep breathing with convergent results in only 26/37 patients, with a specificity of 30%, and sensitivity of 85%. HR and BP changes standing showed little regression against matching values during FAT. Only 5/11 patients who met the criteria for postural tachycardia syndrome by FAT demonstrated a > 20 bpm increase in HR by 3 min standing. Finally, aggregate scores for FAT and RACE correlated poorly. Discussion The RACE does not satisfy the criteria to serve as a robust dysautonomia screen. Full autonomic testing provides more complete and accurate information than simple bedside assessment.

Learning while evaluating: the use of an electronic evaluation portfolio in a geriatric medicine clerkship

BackgroundElectronic evaluation portfolios may play a role in learning and evaluation in clinical settings and may complement other traditional evaluation methods (bedside evaluations, written exams and tutor-led evaluations).Methods133 third-year medical students used the McGill Electronic Evaluation Portfolio (MEEP) during their one-month clerkship rotation in Geriatric Medicine between September 2002 and September 2003. Students were divided into two groups, one who received an introductory hands-on session about the electronic evaluation portfolio and one who did not. Students' marks in their portfolios were compared between both groups. Additionally, students self-evaluated their performance and received feedback using the electronic portfolio during their mandatory clerkship rotation. Students were surveyed immediately after the rotation and at the end of the clerkship year. Tutors' opinions about this method were surveyed once. Finally, the number of evaluations/month was quantified. In all surveys, Likert scales were used and were analyzed using Chi-square tests and t-tests to assess significant differences in the responses from surveyed subjects.ResultsThe introductory session had a significant effect on students' portfolio marks as well as on their comfort using the system. Both tutors and students reported positive notions about the method. Remarkably, an average (± SD) of 520 (± 70) evaluations/month was recorded with 30 (± 5) evaluations per student/month.ConclusionThe MEEP showed a significant and positive effect on both students' self-evaluations and tutors' evaluations involving an important amount of self-reflection and feedback which may complement the more traditional evaluation methods.

Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients*

Elevated residual volumes (RV), considered a marker for the risk of aspiration, are used to regulate the delivery of enteral tube feeding. We designed this prospective study to validate such use. Critically ill patients undergoing mechanical ventilation in the medical, coronary, or surgical intensive care units in a university-based tertiary care hospital, placed on intragastric enteral tube feeding through nasogastric or percutaneous endoscopic gastrostomy tubes, were included in this study. Patients were fed Probalance (Nestle USA) to provide 25 kcal/kg per day (to which 10 yellow microscopic beads and 4.5 mL of blue food coloring per 1,500 mL was added). Patients were randomized to one of two groups based on management of RV: cessation of enteral tube feeding for RV >400 mL in study patients or for RV >200 mL in controls. Acute Physiology and Chronic Health Evaluation (APACHE) III, bowel function score, and aspiration risk score were determined. Bedside evaluations were done every 4 hrs for 3 days to measure RV, to detect blue food coloring, to check patient position, and to collect secretions from the trachea and oropharynx. Aspiration/regurgitation events were defined by the detection of yellow color in tracheal/oropharyngeal samples by fluorometry. Analysis was done by analysis of variance, Spearman's correlation, Student's t-test, Tukey's method, and Cochran-Armitage test. Forty patients (mean age, 44.6 yrs; range, 18-88 yrs; 70% male; mean APACHE III score, 40.9 [range, 12-85]) were evaluated (21 on nasogastric, 19 on percutaneous endoscopic gastrostomy feeds) and entered into the study. Based on 1,118 samples (531 oral, 587 tracheal), the mean frequency of regurgitation per patient was 31.3% (range, 0% to 94%), with a mean RV for all regurgitation events of 35.1 mL (range, 0-700 mL). The mean frequency of aspiration per patient was 22.1% (range, 0% to 94%), with a mean RV for all aspiration events of 30.6 mL (range, 0-700 mL). The median RV for both regurgitation and aspiration events was 5 mL. Over a wide range of RV, increasing from 0 mL to >400 mL, the frequency of regurgitation and aspiration did not change appreciably. Aspiration risk and bowel function scores did not correlate with the incidence of aspiration or regurgitation. Blue food coloring was detected on only three of the 1,118 (0.27%) samples. RV was < or =50 mL on 84.1% and >400 mL on 1.4% of bedside evaluations. Sensitivities for detecting aspiration per designated RV were as follows: 400 mL = 1.5%; 300 mL = 2.3%; 200 mL = 3.0%; and 150 mL = 4.5%. Low RV did not assure the absence of events, because the frequency of aspiration was 23.0% when RV was <150 mL. Raising the designated RV for cessation of enteral tube feeding from 200 mL to 400 mL did not increase the risk, because the frequency of aspiration was no different between controls (21.6%) and study patients (22.6%). The frequency of regurgitation was significantly less for patients with percutaneous endoscopic gastrostomy tubes compared with those with nasogastric tubes (20.3% vs. 40.7%, respectively; p = .046). There was no correlation between the incidence of pneumonia and the frequency of regurgitation or aspiration. Blue food coloring should not be used as a clinical monitor. Converting nasogastric tubes to percutaneous endoscopic gastrostomy tubes may be a successful strategy to reduce the risk of aspiration. No appropriate designated RV level to identify aspiration could be derived as a result of poor sensitivity over a wide range of RV. Study results do not support the conventional use of RV as a marker for the risk of aspiration.

Evaluation of peripheral arterial occlusive disease and postsurgical viability using reflectance spectroscopy of skin

Hypothesis: Stress-induced changes in skin microcirculation allow staging of peripheral arterial vascular pathology using diffuse reflectance spectroscopy (DRS) of the skin. Design and Methods: The changes in relative concentration of oxyhemoglobin and deoxyhemoglobin in the cutaneous microvasculature were assessed at rest, during limb elevation, dependency, and cuff-mediated reactive hyperemia for the forearm of 25 normal subjects and 105 feet of patients with peripheral arterial occlusive disease (PAOD) (normal = 28, claudication = 34, limb threatening ischemia = 44). Thirty-four patients who had revascularization procedures were again evaluated within the first week postoperatively. Results: Two measurements correlated with clinical staging: (1) the relative absorbance of oxyhemoglobin after 225 s of limb dependency and (2) the time to reach 50% of peak reactive hyperemia response (Spearman's rank: r s = 0.625, P < 0.001). Using these criteria alone, ischemic limbs were identified to a sensitivity of 69% and specificity of 95%. Significant post-revascularization improvement was identified in 14 of 34 patients' legs which had previously been classified as limb-threatening ischemia ( n = 14, W = 105, P < 0.001). Conclusions: These simple bedside evaluations of the superficial skin microvasculature allow staging of large vessel vascular insufficiency and may suggest and differentiate focal areas of tissue at risk for ulceration or necrosis.

Reliability of two behavioral tools to assess pain in preterm neonates.

One of the main difficulties in adequately treating the pain of neonatal patients is the scarcity of validated pain evaluation methods for this population. To analyze the reliability of two behavioral pain scales in neonates. Cross-sectional. University hospital neonatal intensive care unit. 22 preterm neonates were studied, with gestational age of 34 +/- 2 weeks, birth weight of 1804 +/- 584 g, 68% female, 30 +/- 12 hours of life, and 30% intubated. Two neonatologists (A and B) observed the patients at the bedside and on video films for 10 minutes. The Neonatal Facial Coding System and the Clinical Scoring System were scored at 1, 5, and 10 minutes. The final score was the median of the three values for each observer and scale. A and B were blinded to each other. Video assessments were made three months after bedside evaluations. End scores were compared between the observers using the intraclass correlation coefficient and bias analysis (paired t test and signal test). For the Neonatal Facial Coding System, at the bedside and on video, A and B showed a significant correlation of scores (intraclass correlation score: 0.62), without bias between them (t test and signal test: p > 0.05). For the Clinical Scoring System bedside assessment, A and B showed correlation of scores (intraclass correlation score: 0.55), but bias was also detected between them: A scored on average two points higher than B (paired t test and signal test: p < 0.05). For the Clinical Scoring System video assessment, A and B did not show correlation of scores (intraclass correlation score: 0.25), and bias was also detected between them (paired t-test and signal test: p < 0.05). The results strengthen the reliability of the Neonatal Facial Coding System for bedside pain assessment in preterm neonates.

The feasibility and accuracy of diagnostic laparoscopy in the septic ICU patient.

Systemic inflammatory response syndrome (SIRS) and sepsis of unknown origin are common complications of critically ill patients in the ICU. These patients frequently have unreliable clinical exams and are candidates for exploratory laparotomy. Although abdominal CT is commonly used because it is less invasive than laparotomy, it is often unreliable or unobtainable. Bedside laparoscopy is an alternative technique that may be more accurate than CT in selected patients and less invasive than laparotomy. We performed diagnostic laparoscopy (DL) in a series of ICU patients with SIRS/septic state of unknown origin between May 1997 and June 1998. All patients were unstable and required significant respiratory and hemodynamic support. Laparoscopy was either performed in the ICU at the patient's bedside or in the operating room. CT scan of the abdomen had been performed on most of the patients who were stable enough to transport. Confirmation of diagnosis was obtained either by laparotomy, autopsy, or clinical recovery. Among the 17 eligible patients, 16 underwent successful DL. Insufflation was impossible in one patient because of high intraabdominal pressure. Bedside evaluations were performed in 14 of the 17 patients. There were no complications from the laparoscopy. Six patients were identified as positive (four intestinal ischemia, two cholecystitis); the other 10 had negative explorations. Follow-up on two patients with negative laparoscopy was incomplete due to denied postmortem. Laparoscopic diagnoses were confirmed in the remaining 14 patients by laparotomy (six cases), postmortem (three cases), or recovery (five cases), with an accuracy of 100%. The overall accuracy of abdominal CT obtained in nine of the 14 patients was 33%. DL in a select group of critical ICU patients is safe and accurate, whereas CT scan tends to be inaccurate and is often unobtainable due to patient instability. Performing the procedure at the bedside can expedite the diagnosis, eliminate the burden for transfer, and save on anesthesia and operating room charges.

Enteral tube feeding in the intensive care unit: factors impeding adequate delivery.

To evaluate those factors that impact on the delivery of enteral tube feeding. Prospective study. Medical intensive care units (ICU) and coronary care units at two university-based hospitals. Forty-four medical ICU/coronary care unit patients (mean age, 57.8 yrs; 70% male) who were to receive nothing by mouth and were placed on enteral tube feeding. Rate of enteral tube feeding ordered, actual volume delivered, patient position, residual volume, flush volume, presence of blue food coloring in oropharynx, and stool frequency were recorded every 4 hrs. Duration and reason for cessation of enteral tube feeding were documented. Physicians ordered a daily mean volume of enteral tube feeding that was 65.6% of goal requirements, but an average of only 78.1% of the volume ordered was actually infused. Thus, patients received a mean volume of enteral tube feeding for all 339 days of infusion that was 51.6% of goal (range, 15.1% to 87.1%). Only 14% of patients reached > or = 90% of goal feeding (for a single day) within 72 hrs of the start of enteral tube feeding infusion. Of 24 patients weighed before and after, 54% were noted to lose weight on enteral tube feeding. Declining albumin levels through the enteral tube feeding period correlated significantly with decreasing percent of goal calories infused (p = .042; r2 = .13). Diarrhea occurred in 23 patients (52.3%) for a mean 38.2% of enteral tube feeding days. In >1490 bedside evaluations, patients were observed to be in the supine position only 0.45%, residual volume of >200 mL was found 2.8%, and blue food coloring was found in the oropharynx 5.1% of the time. Despite this, cessation of enteral tube feeding occurred in 83.7% of patients for a mean 19.6% of the potential infusion time. Sixty-six percent of the enteral tube feeding cessations was judged to be attributable to avoidable causes. The current manner in which enteral tube feeding is delivered in the ICU results in grossly inadequate nutritional support. Barely one half of patient caloric requirements are met because of underordering by physicians and reduced delivery through frequent and often inappropriate cessation of feedings.

Formal swallowing evaluation and therapy after traumatic brain injury improves dysphagia outcomes.

The incidence of swallowing dysfunction after brain injury is unknown. The efficacy of dysphagia therapy is also unknown. We reviewed our experience to define the incidence of swallowing dysfunction and efficacy of therapeutic intervention. Patients with brain injury sustained between January of 1996 and December of 1997 were reviewed. All were screened with trials of oral intake. Abnormal findings were confirmed with a videofluoroscopic swallow study. Standard therapies included diet, posture, and behavior modifications. A total of 47 patients were evaluated. Bedside evaluations were normal in 14 patients, 2 patients had overt aspiration and underwent gastrostomy, and 31 patients were referred for a videofluoroscopic swallow study (66%). The videofluoroscopic swallow study was abnormal in 22 of 31 patients (71%). Of these, 4 additional patients required gastrostomy, 13 patients had laryngeal penetration or minor aspiration responsive to dysphagia therapy and were fed. Five other patients had silent aspiration and were fed by means of nasogastric tube; these five patients responded to dysphagia therapy and were able to resume oral intake. Dysphagia is common after severe head injury. With formal swallowing service intervention, aspiration is avoided. Therapeutic interventions can be used to restore oral intake.

Complications and outcome after acute stroke. Does dysphagia matter?

The published data on the relationship between dysphagia and both outcome and complications after acute stroke have been inconclusive. We examined the relationship between these, using bedside assessment and videofluoroscopic examination. We prospectively studied 121 consecutive patients admitted with acute stroke. A standardized bedside assessment was performed by a physician. We performed videofluoroscopy blinded to this assessment within 3 days of stroke onset and within a median time of 24 hours of the bedside evaluations. The presence of aspiration was recorded. Mortality, functional outcome, lengthy of stay, place of discharge, occurrence of chest infection, nutritional status, and hydration were the main outcome measures. Patients with an abnormal swallow (dysphagia) on bedside assessment had a higher risk of chest infection (P=.05) and a poor nutritional state (P=.001). The presence of dysphagia was associated with an increased risk of death (P=.001), disability (P=.02), length of hospital stay (P<.001), and institutional care (P<.05). When other factors were taken into account, dysphagia remained as an independent predictor of outcome only with regard to mortality. The use of videofluoroscopy in detecting aspiration did not add to the value of bedside assessment. Bedside assessment of swallowing is of use in identifying patients at risk of developing complications. The value of routine screening with videofluoroscopy to detect aspiration is questioned.

Swallowing Dysfunction in Patients Receiving Prolonged Mechanical Ventilation

Several studies have suggested that swallowing dysfunction and pulmonary aspiration occur in patients receiving prolonged ventilation. However, the incidence of swallowing dysfunction, its rate of resolution, and the sensitivity of tests used to characterize swallowing abnormalities are not well defined. The goals of our study were to evaluate swallowing function in this group of patients by (1) defining the specific swallowing abnormalities that occur in this patient population, (2) comparing the sensitivity of bedside evaluations to modified barium swallow with videofluoroscopy (MBS/VF), (3) performing endoscopic evaluation of the upper airway to characterize glottic function during swallowing, (4) evaluating the relationship between swallowing dysfunction and neuromuscular disorders, and (5) studying the temporal resolution of swallowing abnormalities. Swallowing function was evaluated in 35 patients receiving prolonged ventilation (ie, > or = 3 weeks) admitted to a specialized rehabilitation unit dedicated to the care of patients requiring prolonged ventilation. The average age of the 35 patients was 61 +/- 15 years. The total duration of intubation at the time of the initial swallowing evaluation was 29 +/- 34 days via a cuffed tracheostomy tube and 15 +/- 9 days via an endotracheal tube. Neuromuscular disorders were present in 16 patients (45%). Thirty-four percent of the patients had at least one swallowing abnormality detected by bedside examination. Results of bedside swallowing examination were abnormal in 31% of patients with a neuromuscular disorder and 37% of patients without a neuromuscular disorder. MBS/VF was abnormal in 83% of patients (85% in patients with and 80% in patients without a neuromuscular disorder). Results of early (< 1 month) repeated MBS/VF examinations usually remained unchanged; however, in a small group of patients, later studies (> or = 1 month) revealed significant improvement. In 50% of patients who underwent direct laryngoscopy, important abnormalities were found that contributed to swallowing dysfunction. Our data show that patients requiring prolonged mechanical ventilation have a high incidence of swallowing abnormalities, regardless of the presence or absence of neuromuscular disorders. MBS/VF and direct laryngoscopy can provide useful information about laryngeal action and swallowing dysfunction, and can facilitate the implementation of corrective actions to prevent respiratory complications.

Protocol for the Use of Videofluoroscopy in Pediatric Swallowing Dysfunction

A clinical and research protocol was developed to compare the sensitivity and clinical value of videofluoroscopy with the traditional bedside clinical evaluation in the evaluation of children's swallowing dysfunction. The bedside and videofluoroscopic evaluations of 33 children were reviewed retrospectively. Our findings indicated that recommendations for feeding changed for 14 of the children as a result of the information gained from videofluoroscopic evaluation. The results suggest that videofluoroscopy provides therapists with more objective evidence than a bedside evaluation for determining the etiology of swallowing dysfunction and directing the management or treatment of this dysfunction.

The surgical clerkship: Assessment of clinical competence

The surgical academic achievements of the third-year class at Jefferson Medical College have been reviewed, comparing scores on an objective final examination and clinical performance based on bedside observations. These comparisons reveal a low correlation between examination scores and bedside evaluations, suggesting that they may measure different components of competence, each being necessary as a portion of the total assessment of performance. The observations also challenge the validity of present techniques of reporting clinical competence.