Care Bundle Research Articles

Rationale and development of a prehospital goal-directed bundle of care to prevent rearrest after return of spontaneous circulation.

In patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC), rearrest while in the prehospital setting represents a significant barrier to survival. To date, there are limited data to guide prehospital emergency medical services (EMS) management immediately following successful resuscitation resulting in ROSC and prior to handoff in the emergency department. Post-ROSC care encompasses a multifaceted approach including hemodynamic optimization, airway management, oxygenation, and ventilation. We sought to develop an evidenced-based, goal-directed bundle of care targeting specified vital parameters in the immediate post-ROSC period, with the goal of decreasing the incidence of rearrest and improving survival outcomes. Here, we describe the rationale and development of this goal-directed bundle of care, which will be adopted by several EMS agencies within California. We convened a group of EMS experts, including EMS Medical Directors, quality improvement officers, data managers, educators, EMS clinicians, emergency medicine clinicians, and resuscitation researchers to develop a goal-directed bundle of care to be applied in the field during the period immediately following ROSC. This care bundle includes guidance for prehospital personnel on recognition of impending rearrest, hemodynamic optimization, ventilatory strategies, airway management, and diagnosis of underlying causes prior to the initiation of transport.

Impact of quality of care on outcomes in survivors of stroke with aphasia: A linked registry and hospital data observational study

BackgroundThe impact of hospital care quality on patient outcomes in post-stroke aphasia remains unclear. We investigated the impact of nationally-endorsed acute stroke treatments on outcomes post-stroke, by aphasia status. MethodsPatient-level data from the Australian Stroke Clinical Registry (2009–2013) linked to national deaths, hospital emergency presentations and admissions data were used. Aphasia was identified for the index stroke event (ICD-10 diagnosis code R47.0). Impact of receiving an optimal stroke care bundle (stroke unit care, antihypertensive medication at discharge and discharge care plan) and an acute ischemic stroke (AIS) care bundle (stroke unit care, intravenous thrombolysis and aspirin within 48 h of admission) on outcomes were analysed using multivariable regression models with propensity score adjustment. ResultsThe study included 12,690 patients with a median age of 76, 54 % male, and 26 % with aphasia. Non-receipt of the optimal stroke care bundle was associated with worse survival, compared to optimal care, in people with aphasia (HR: 3.37; 95 % CI 2.10, 5.40; p < 0.05) and without aphasia (HR: 2.10; 95 % CI 1.19, 3.69; p < 0.05). Notably, the dose-response effect on survival was more pronounced in individuals with aphasia. In those who received the AIS care bundle, readmission within 12 months was greater in those without aphasia (vs aphasia, p-value interaction = 0.001), whereas survival was similar (p-value interaction = 0.731). ConclusionsSurvivors of stroke with aphasia who did not receive the optimal stroke care bundle, had worse survival at 12 months post-stroke. Ensuring eligible patients receive the optimal stroke care bundle is crucial for improving their 12-month survival.

New horizons in hospital-associated deconditioning: a global condition of body and mind.

Hospital-associated deconditioning is a broad term, which refers non-specifically to declines in any function of the body secondary to hospitalisation. Older people, particularly those living with frailty, are known to be at greatest risk. It has historically been most commonly used as a term to describe declines in muscle mass and function (i.e. acute sarcopenia). However, declines in physical function do not occur in isolation, and it is recognised that cognitive deconditioning (defined by delayed mental processing as part of a spectrum with fulminant delirium at one end) is commonly encountered by patients in hospital. Whilst the term 'deconditioning' is descriptive, it perhaps leads to under-emphasis on the inherent organ dysfunction that is associated, and also implies some ease of reversibility. Whilst deconditioning may be reversible with early intervention strategies, the long-term effects can be devastating. In this article, we summarise the most recent research on this topic including new promising interventions and describe our recommendations for implementation of tools such as the Frailty Care Bundle.

Implementation of nutritional care bundle is associated with improved growth in preterm infants born before 32 gestational weeks

Implementation of nutritional care bundle is associated with improved growth in preterm infants born before 32 gestational weeks

Postoperative continuation of antibiotic prophylaxis beyond 24 h is unnecessary for abdominal surgeries in children and neonates

PurposeDespite recent WHO recommendations, antibiotic prophylaxis is routinely continued for several days after surgery. We conducted a retrospective study to evaluate the safety and efficacy of antibiotic prophylaxis cessation within 24 h after abdominal surgeries MethodsWe retrospectively reviewed the charts of patients who underwent 3 representative gastrointestinal surgeries (1; transumbilical small bowel procedure for intestinal atresia or stenosis, 2; extrahepatic bile duct resection, and hepaticojejunostomy for congenital biliary dilatation, 3; stoma closure for intestinal perforation, anorectal malformation, or inflammatory bowel disease) at our institution between 2011 and 2023. The demographic data collected included age, preoperative hemoglobin level, albumin level, body mass index, and ASA class. Intraoperative and postoperative data were also collected. The patients were divided into 2 groups according to the duration of perioperative antibiotics (‘within 24 h’ and ‘beyond 24 h’), and the incidence of superficial incisional SSI (siSSI) was compared between the 2 groups in each procedure ResultsDuring the study period, 25 cases underwent transumbilical small bowel procedure, 23 cases underwent hepaticojejunostomy, and 45 cases underwent stoma closure. The preoperative care bundle including bowel preparation, cleansing, and operative procedures has not changed during the study period. First- and third-generation cephalosporins were administered to all the patients. All patients received their first single dose of antibiotics within 60 min before the skin incision. In particular, 14 patients who underwent small-bowel procedures received only a single dose. The SSI rates for small bowel procedures, hepaticojejunostomy, and stoma closure were 0%, 4.4%, and 4.4%, respectively. No SSIs were observed in any of the procedures in the 'within 24 h' group ConclusionBased on our study, we conclude that ≤24 h of postoperative continuation of antibiotic prophylaxis is sufficient for siSSI prevention in hepaticojejunostomy and stoma closure. Additionally, single-dose antibiotic prophylaxis is adequate for neonatal small bowel procedures.

The association of early passive mobilization with intracranial pressure in the adult intensive care unit: A prospective, cohort study.

Early mobilization are key components of the ABCDEF Care Bundle and critical treatments to reduce acquired muscle weakness, delirium and prolonged intensive care unit (ICU) stay. This study aimed to determine whether routine early mobilization related to intracranial pressure in intensive care patients on mechanical ventilation, using optic nerve sheath diameter measurement (ONSD). This study was planned as a prospective, cohort study in the third-step adult ICU of a faculty hospital. The study included only patients who were intubated and followed up on a mechanical ventilator and were clinically stable. Passive range of motion (PROM) exercises were performed daily by the physiotherapists as part of routine care from the day of hospitalization. ONSD was assessed before, during and 10 min after PROM exercises. The study included 20 eligible patients out of the 142 who were evaluated upon admission to the ICU. The median age of the patients was 65 years, and nine (45%) of them were female. The analyses showed that there was no statistically significant change in ONSD during and at the end of the PROM (ONSD right eye p:.621, Partial η2: 0.025, ONSD left eye p:.935, Partial η2: 0.004). Similarly, there was no statistically significant change in haemodynamic parameters in during and at the end of the PROM (Heart beat p:.849, Partial η2: 0.009, Systolic Pressure p:.435, Partial η2: 0.043, Diastolic Pressure p:.128, Partial η2:0.103, Saturation p:.103, Partial η2: 0.113 and Respiratory rate p:.071, Partial η2:0.130). This study suggests that daily extremity physiotherapy exercises can be safely applied without causing increased intracranial pressure or haemodynamic instability in intensive care patients followed up on mechanical ventilation, including patients with vasopressor therapy. Early mobilization, including PROM, is considered safe in terms of intracranial pressure for intubated patients in the ICU.

74 Reducing unplanned extubations in a level 3 neonatal intensive care unit - the nuts and bolts of UE bundle implementation

Abstract Background Unplanned extubations (UEs) are preventable adverse events that may lead to short term consequences (e.g. cardiopulmonary collapse) and long term sequelae (e.g. acquired airway injury, brain injury) for patients admitted to the Neonatal Intensive Care Unit (NICU). UE prevention care bundles have been demonstrated to reduce UE rates in NICUs; however, implementation of bundle elements is unit dependent. Objectives To describe the work of a UE Prevention Team in a Level 3 NICU with rising UE rates despite implementation of UE prevention bundle per Children’s Hospital Solutions for Patient Safety (SPS). Design/Methods A neonatologist / respiratory therapist pair was assembled in March 2022 to tackle rising UE rates in a 69 bed NICU. Contributing unit stressors included implementation of a new electronic health record, COVID-19 policies, and nursing shortages. Baseline UE rates were &amp;gt;3x the centerline for SPS network NICUs and likely underreported. Steps undertaken include: 1) daily audit to ensure reporting of all UEs, 2) structured post-event team debriefs, 3) unit education campaign to raise awareness of UE prevention and bundle elements, 4) prominent posting of last UE date and reporting on daily team huddle, 5) rapid UE case reviews and apparent cause analysis with reporting of findings unit-wide, 6) optimize endotracheal tube (ETT) securement methods, 6) enforce T2-T3 ETT tip position, 7) standardize x-ray frequencies and reporting, 8) trial of daily rounds ETT safety checklist. Results From rapid case reviews, apparent causes were determined to be incorrect ETT securement device sizing, taping method prone to loss of tape integrity in high humidity, high ETT positions, and inadequate ETT monitoring during high risk activities other than repositioning (invasive/painful procedures, diaper changes). Post-event structured debriefs and unit-wide vigilance increased reporting of UE events to 100%. UE rates fell from a peak of &amp;gt;4 UEs/month, &amp;gt;2.4/100 ventilation days to 1 UE/month, 0.465/100 ventilation days, a 80% reduction.(Figure 1) Most impactful interventions were standard x-ray reporting template in the electronic health record, reinforcing T2-T3 ETT tip positioning, correcting ETT holder sizing, and change in ETT method (Figure 2). Daily rounds checklist was not effective. UE reductions were achieved without changing patient ratios as nurse staffing shortages continued. Conclusion A nimble systems approach is needed to ensure success in implementation of UE prevention care bundles. Simple changes can be made to decrease UEs, guided by rapid case reviews.

Mitigating Medical Adverse Events Following Spinal Surgery: The Effectiveness of a Postoperative Quality Improvement (QI) Care Bundle.

Spine surgery is associated with a high incidence of postoperative medical adverse events (AEs). Many of these events are considered "minor" though their cost and effect on outcome may be underestimated. We sought to examine the clinical and cost-effectiveness of a postoperative quality improvement (QI) care bundle in mitigating postoperative medical AEs in adult surgical spine patients. We collected 14-year prospective observational interrupted time series (ITS) with two historical cohorts: 2006 to 2008, pre-implementation of the postoperative QI care bundle; and 2009 to 2019, post-implementation of the postoperative QI care bundle. Adverse Events were identified and graded (Minor I and II) using the previously validated Spine AdVerse Events Severity (SAVES) system. Pearson Correlation tested for changes across patient and surgical variables. Adjusted segmented regression estimated the effect of the postoperative QI care bundle on the annual and absolute incidences of medical AEs between the two periods. A cost model estimated the annual cumulative cost savings through preventing these "minor" medical AEs. We included 13,493 patients over the study period with a mean of 964 per year (SD±73). Mean age, mean Charlson Comorbidity Index (CCI), and mean spine surgical invasiveness index (SSII) increased from 48.4 to 58.1years; 1.7 to 2.6; and 15.4 to 20.5, respectively (p<0.001). Unadjusted analysis confirmed a significant decrease in the annual number of all medical AEs (p<0.01). When adjusting for age, CCI and SSII, segmented regression demonstrated a significant absolute reduction in the annual incidence of cardiac, pulmonary, nausea and medication-related AEs by 9.58%, 7.82%, 11.25% and 15.01%, respectively (p<0.01). The postoperative QI care bundle was not associated with reducing the annual incidence of delirium, electrolyte levels or GI AEs. Annual projected cost savings for preventing Grade I and II medical AEs were $1,808,300 CAD and $11,961,500 CAD. Postoperative QI care bundles are effective for improving patient care and preventing medical care-related AEs, with significant cost savings. Postoperative QI care bundles should be tailored to the specific vulnerability of the surgical population for experiencing AEs.

Effect of new care bundle on enhancing nurses' Knowledge, practice and self-efficacy regarding Primary Postpartum Haemorrhage

Effect of new care bundle on enhancing nurses' Knowledge, practice and self-efficacy regarding Primary Postpartum Haemorrhage

Predictive accuracy of clinicians estimates of death and recovery after acute intracerebral hemorrhage: pre-specified analysis in INTERACT3 study.

Accurately predicting a patient's prognosis is an important component of decision-making in intracerebral hemorrhage (ICH). We aimed to determine clinicians' ability to predict survival, functional recovery, and return to premorbid activities in patients with ICH. Pre-specified secondary analysis of the third INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3), an international, multicenter, stepped-wedge cluster randomized controlled trial. Clinician perspectives on prognosis were collected at hospital admission and Day 7 (or before discharge). Prognosis questions were the likelihood of (i) survival at 48 hours and 6 months, (ii) favorable functional outcome (recovery walking and self-care) and (iii) return to usual activities at 6 months. Clinician predictions were compared with actual outcomes. Most clinician participants were from neurosurgery (75%) with a median of 8 working years (IQR 5-14) of experience. Of the 6305 randomized patients who survived 48 hours, 213 (3.4%) were predicted to die (positive predictive value [PPV] 0.99, 95% confidence interval [CI] 0.99-0.99). Of 5435 patients who survived 6 months, 209 (3.8%) were predicted to die (PPV 0.93, 95% CI 0.92-0.93). Predictions on favorable functional outcome (PPV 0.54, 95% CI 0.52-0.56) and satisfied ability to return to usual activities (PPV 0.50, 95% CI 0.49-0.52) were poor. Prediction accuracy varied by working years and region of practice. In patients with ICH, clinician estimates of death are very good but conversely they are poor in predicting higher levels of functional recovery and activities.

Management of adult mechanically ventilated patients: A UK-wide survey

Background: Mechanical ventilation is a common and often lifesaving intervention that is utilised in intensive care. However, the practices can vary between centres. Through this national survey we aim to gain more information about different strategies adopted across the UK. Methods: All adult intensive care units in the UK were approached to participate. The questionnaire was developed with an electronic survey engine and conducted between 09/11/2023 and 01/04/2024 (Survey Monkey®). The survey included questions on ventilator modes, settings, protocols/pathways, rescue strategies, immediate post-extubation period and follow-up. Results: There were 196 responses from 104 hospitals. The most widely adopted start-up ventilation mode was pressure-regulated volume-controlled mode. For acute hypoxaemic respiratory failure (AHRF), most of respondents reported full (39.8%) or partial compliance (58.1%) with the ARDSnet protocol, with PEEP settings being the commonest deviation. Prone positioning (99.0%), followed by recruitment manoeuvres (91.3%) were commonly used rescue measures during AHRF. APRV (55.7%), inhaled (51.3%) and systemic pulmonary vasodilators (44.1%) were also commonly used. Conservative oxygen targets (SaO2 of 88%–92%) were commonly adopted (70.6%). As a care bundle, intermittent ETT cuff pressure monitoring was more common (65.5%) than continuous cuff pressure monitoring (20.0%). Propofol and alfentanil were the most common initial sedative and analgesia (99.5% and 56.9%) respectively. Routine volatile anaesthetic use was rare. Conclusions: Our survey has shown significant variation of practice in common but crucial elements of management of patients receiving mechanical ventilation. We hope the results in our survey highlight potential future areas of research. Collaborators South-coast Peri-operative Audit and Research Collaborative (SPARC) Severn Trainee Anaesthetic and Critical Care Research group (STAR) Collaborative research in Anaesthesia in the Northeast (CRANE)

Evaluation of ventilator-associated pneumonia care practice in the intensive care units of a comprehensive specialized hospital in Northwest Ethiopia: a 1.5-year prospective observational study.

Nosocomial infections pose a global health threat, with Ventilator-Associated Pneumonia (VAP) emerging as a prominent hospital-acquired infection, particularly in intensive care units (ICU).VAP is the commonest form of pneumonia in ICUs, contributing significantly to morbidity and mortality rates, which can reach around 30%. Despite the substantial impact of VAP on healthcare, there is a lack of data on adherence to VAP prevention protocols in our hospital. Consequently, this study aims to assess the adherence to ventilator-associated pneumonia care bundles in critical care units at a comprehensive specialized hospital in northwest Ethiopia. A hospital-based prospective observational study was conducted from July 3, 2022, to January 7, 2024. All adult patients who were on mechanical ventilators for more than 48h during the study period were included. Data were collected using the Institute of Healthcare Improvement VAP prevention standards as checklists via direct observation and chart review. The data were entered and analyzed using SPSS version 20. A total of 300 surgical and medical ICU patients were observed. Among the patients, 66.3% were from the medical ICU. In terms of admission reasons, 22.3%, 15.7% and, 12% were attributed to infections excluding respiratory origin, respiratory disorders, and other causes, respectively. The rate of compliance with all components of the bundle was 70%. A 100% adherence rate was observed for the prophylaxis for peptic ulcer and deep vein thrombosis (DVT). The lowest adherence rate was observed in the practice of oral hygiene with 0.5% chlorhexidine solution (0%) followed by humidification with heat and moisture exchangers (23.3%). Endotracheal tube cuff pressure measurement and use of endotracheal tubes with subglottic suction were not applicable. The study revealed suboptimal compliance with the VAP care bundle, indicating unsatisfactory overall practice. Specific attention is warranted for subglottic suction, cuff pressure measurement, humidification, oral care with chlorhexidine, and sedation vacation.

Community-Acquired Pressure Injuries: Prevalence, Risk Factors and Effect of Care Bundles-An Integrative Review.

To summarise the evidence and present the state of the science on pressure injury care bundles in the community. Specifically, this review examined (i) the extent of pressure injury by studying its prevalence and incidence in the last 10 years, (ii) the risk factors associated with community-acquired pressure injury and (iii) the components and outcomes associated with effective pressure injury care bundles in the community. PI care bundles have effectively reduced PI rates; however, there is limited evidence of care bundles used in community settings. Integrative review. This integrative review is guided by the Whittemore and Knafl framework and follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Quality appraisal was applied to assess the quality of selected articles. Data relevant to the review aims were extracted, and findings were synthesised and presented. PubMed, Medline, CINAHL and Web of Science were searched. Studies published in the English language between 2012 and 2022 were retrieved. A total of 89 articles were retrieved; 25 met the inclusion criteria. Most studies reported the point prevalence and period prevalence of community-acquired pressure injuries, and only one study reported the incidence of community-acquired pressure injuries. The point prevalence and period prevalence of community-acquired pressure injury were 0.02% to 10.8% and 2.7% to 86.4%, respectively, and the cumulative incidence was 1.3%. The risk factors for community-acquired pressure injury assessed vary between studies; older age, poor nutrition, immobility and multiple comorbidities are commonly reported. Socioeconomic and caregiving factors were not studied. Very few studies evaluated pressure injury care bundles in the community. Even so, the components of the pressure injury care bundle vary between studies. Pressure injury development is associated with a complex interplay of factors. Socioeconomic and caregiving factors were not examined in any of the papers. There is a lack of understanding of the components and outcomes associated with effective pressure injury care bundles in the community. Despite their prevalence, community-acquired pressure injuries (CAPIs) are often underreported due to inadequate follow-up and reporting mechanisms. Although the risk factors for CAPIs vary across studies, older age, impaired mobility, multiple comorbidities and malnutrition consistently emerge as key contributors. Pressure injury preventive care bundles are more commonly used in the acute care setting rather than the community setting. No Patient or Public Contribution.

Predictive value of serological indices for guiding bundle of care to prevent the occurrence of poststroke fatigue for ischemic stroke survivors.

Almost half of ischemic stroke (IS) survivors have poststroke fatigue (PSF) during rehabilitation, which can reduce their rehabilitation compliance and quality of life. The primary link of PSF management is early identification, which can guide bundle of care for prevention. This study aimed to explore the predictive value of serological indicators for guiding bundle of care to prevent the occurrence of PSF among IS survivors. This study was a prospective observational study. A total of 350 patients with IS who were hospitalized in 2 tertiary hospitals in Nanning from October 2022 to September 2023 were selected. The general data of patients and serological indicators within 24 hours of admission were collected. Based on the follow-up results, the patients were divided into the PSF group and the NPSF group. Multivariate logistic regression analysis was used to screen the risk factors affecting the occurrence of PSF, and the receiver operating characteristic curve (ROC curve) method was used to analyze the predictive value of this factor. The incidence of acute-phase PSF among elderly patients with IS was 49.26%. The elevated levels of fasting plasma glucose (FPG) (OR = 1.485, 95% CI: 1.145-1.925, P = .003), total cholesterol (TC) (OR = 1.394, 95% CI: 1.013-1.917, P = .041), C-reactive protein (CRP) (OR = 1.394, 95% CI: 1.013-1.917, P = .041), and homocysteine (Hcy) (OR = 1.370, 95% CI: 1.233-1.524, P < .001) were risk factors of PSF in elderly patients with acute IS (P < .05). FPG (area under the curve = 0.632), TC (area under the curve = 0.621), CRP (area under the curve = 0.889), and Hcy (area under the curve = 0.807) had a good predictive value for acute-phase PSF, and the combination of the 4 indicators could further improve the predictive efficacy (area under the curve = 0.938, sensitivity 86.2%, specificity 90.7%, P < .05). The elevated levels of FPG, TC, CRP, and Hcy could predict the risk of PSF, and the combination of the 4 indicators can effectively improve prediction efficiency and provide a reference for guiding the formulation of bundle nursing programs.

Access to a Patient Portal is Associated with a Higher Rate of Diabetic Eye Examination Completion

ABSTRACT Purpose To evaluate factors associated with a higher completion rate of annual diabetic eye examinations. Methods This retrospective, cross-sectional study included patients diagnosed with diabetes mellitus (DM) who were aged 18–75 years and receiving primary care in a suburban integrated delivery network (IDN). Patient demographic, sociomedical, biometric characteristics, and Healthcare Effectiveness Data and Information Set (HEDIS) measures within the Comprehensive Diabetes Care bundle were extracted from the electronic health record (EHR) and analyzed by using multivariate logistic regression to assess factors associated with completion of an eye exam (retinal) performed during the study year. Results Among 19,901 primary care patients with DM, 35.15% completed an eye examination in 2021. After adjusting for demographic and biometric characteristics, the two factors most closely associated with completing a diabetic eye examination were having had a primary care office visit (adjusted odds ratio [aOR], 3.525; 95% confidence interval [CI], 3.210–3.871, p < 0.001) or an eye examination in the prior year (aOR, 2.948; 95% CI, 2.752–3.158, p < 0.001). The next most important factor to emerge was having an activated, online patient portal (PP; aOR, 1.737; 95% CI, 1.592–1.896; p < 0.001) or PP recently activated within the prior year (aOR, 1.387; 95% CI, 1.220–1.576, p < 0.001). Conclusions Surveillance for diabetic retinopathy relies on annual diabetic eye examinations yet adherence to that standard remains unacceptably low. Our study suggests that engagement of patients through an online PP could help increase this rate.

Safe external ventricular drain management for infection prevention and control: a narrative review

Introduction: External ventricular drain (EVD) placement is a common neurosurgical procedure. Nurses play a crucial role in care, troubleshooting, and monitoring of EVD-related complications, making their education and training in this area of paramount importance. A well-trained nurse possesses the necessary knowledge and skills to recognize and respond promptly to EVD-related complications, such as infections, bleeding, and blockages. External ventricular drainage is associated with a high rate of nosocomial meningitis. The introduction of a well- implemented EVD care bundle can significantly decrease EVD infection rates. The support of the multi-item bundle for EVD is considered very important to reduce EVD-related infections.Aim: To summarize the most recent available evidence for the prevention and control of EVD infections. Methods: Comprehensive literature search had been done using the PubMed (Medline), Embase, CINAHL, and Cochrane databases. The narrative review was performed according to the PRISMA Extension for Scoping Review checklist (PRISMA-ScR).Results: The query identified 4266 studies; after duplicate removal and exclusion of papers due to non-pertinent criteria, 26 studies were included. Only three papers were related to pediatric patients and all were about EVD anchoring. Regarding the risk of infection, bundles and protocols are important for the reduction of the occurrence rate; however, staff adherence to these is fundamental.Conclusion: Multidisciplinary staff and training are fundamental to improve EVD management. Avoiding routine or daily sampling reduces the EVD infection rate. When the procedure is requested, it is important to follow a strict protocol and to use sterile techniques. Hydrocolloid dressings, SecurAcath, gauze, and film dressings were used to anchor the cover EVD in the studies.

Detecting Delirium: The Missed Medical Emergency

Abstract Background Delirium is among the most common of medical emergencies with approximately 1 in 5 patients aged 65 and above presenting with or developing delirium, during their acute hospital admission. Delirium is more common in certain patient groups including those with hip fractures, dementia, previous delirium, frailty and other comorbidities. It is associated with poorer outcomes and complications. Delirium also has the potential to cause significant patient and carer stress. Despite the significance of delirium, it is frequently underdiagnosed. It can be prevented and treated if it is identified early. As per the National Dementia Office all acute Hospitals have to complete the Delirium care algorithm for all patients aged 65 years and above, admitted to hospital or who have any known risk factors for delirium. Methods The Delirium Multidisciplinary Care Bundle was rolled out across the hospital with education provided both face to face and via eLearning. Using the Quality Care Metrics (QCM) delirium indicator and a locally developed audit tool, medical and nursing records where reviewed to identify the level of concordance with the Delirium Multidisciplinary Care Bundle. Results The gradual increase in the compliance in use of the care bundle reached up to hundred percent. The bundle use was audited utilising the Quality Care Metrics (QCM) with the delirium indicator showing an improvement of an average of 60-80% hospital-wide. The hospital-wide audit on the compliance of the delirium care bundle was conducted and identified that compliance on the bundle had improved to 60-100%. Conclusion Continuous evaluation, monitoring and improvement plans are in place. This will be further supported by providing multiple methods of education delivery throughout the organisation to meet the needs of all learners. Ultimately continuing to improve delirium detection and management for our patient group.

The Use Of Simulation To Develop, Test And Implement A Multidisciplinary Team Care Pathway Bundle For Inpatients With Parkinson’s Disease

Abstract Background Hospitalised PD patients experience poorer outcomes. Model-2 hospitals lack onsite subspecialty neurology services whilst frequently managing PD inpatients. Aiming to enhance care of PD inpatients our multidisciplinary team (MDT) utilise simulation to design and deliver a new PD care pathway bundle. Methods The developed care bundle aims to facilitate i) screening for causes of PD deterioration, ii) identification of time sensitive and contraindicated medications and iii) prioritisation of timely MDT referral within the first 24 hours of admission. Using simulation of the NPO PD patient, usability of the bundle was tested through correct medication conversion (via Parkinsons calculator) and MDT clinical review for NG tube insertion with patient inclusion. Results Simulation delivery and structured debrief thereafter, further enhanced development and improvement of the simulation. It reinforced how the care bundle initiated early MDT referral and highlighted the pros/cons of MDT discussion with and without the patient. Once deemed satisfactory by all team members, ward-based simulation facilitated staff education and awareness of the new tool. Conclusion Simulation in the test and clinical environment facilitated implementation of a new MDT care pathway bundle at hospital level. Evaluation of effectiveness of the new care pathway require future audits and additional simulation campaigns.

An Audit of Time to Inpatient Bed In Patients With A Suspected Delirium

Abstract Background Our local Dementia/Delirium Combined Pathway and Care Bundle for Emergency Department (ED) and Acute Medical Assessment Unit sets a target door to ward admission in patients aged over 65 years with a suspected delirium at less than 6 hours. This audit assessed if this target is being met in patients with a suspected delirium. Methods Retrospective point prevalence audit of 240 randomly selected patients who were assessed by the Frailty Intervention Team (FIT) in the Mater Misericordiae University Hospital ED in 2022, aged ≥ 65 years with a suspected delirium (4AT ≥4) and no delirium (4AT=0). Time of presentation to ED, time of admission to ward bed, ward name and length of hospital stay were recorded. Results The median age in patient's with a 4AT ≥4 was 86 years (range 65-99). There was an equal spread across gender groups in patient's with a 4AT ≥4; 55.3% (n=52) females and 44.7% (n=42) male. The median wait time in ED for patients with a 4AT ≥4 was 25.26 hours (range 6.75-83.73) vs 21.65 hours (range 5.98-50.53) in patients with a 4AT=0. Only 19% (n=18) of patients with a 4AT ≥4 were admitted to a Specialist Geriatric Ward. The mean length of stay in patients with a 4AT ≥4 was 28.457 days vs 14.132 days in those with a 4AT=0 (p value=0.002, Mann-Whitney U test). Conclusion Older adults with a delirium spend prolonged periods of time in the ED. We are not meeting our local target of 6 hours from ED presentation to ward bed. Length of hospital stay is prolonged in patients with delirium. Our aim is to create a dedicated delirium bed on our Geriatric Specialty Ward so that we can provide delirium specific care and reduce overall length of hospital stay.

Obstetric Anal Sphincter Injury Care Bundle: A Quality Improvement Initiative.

The objective was to implement an evidence-based peri-partum care bundle for women sustaining obstetric anal sphincter injuries and to evaluate compliance with recommendations for antibiotics use, repair in the operating room, and follow-up before and after implementation. This project was reviewed by the Institutional Review Board and determined to be exempt. A clinical care bundle containing education and standardized orders in the electronic medical record was implemented. Characteristics of pre- (October 2017 to September 2019) and post-intervention (October 2019 to August 2021) cohorts were compared and compliance with recommendations for antibiotics use, surgical repair location, and follow-up were evaluated. Chi-squared, Fisher's exact, ANOVA F, and Kruskal-Wallis tests were performed, as indicated. Significance level was p < 0.05. A total of 185 cases were identified. Seventy-five percent of women were nulliparous. Mean gestational age was 39weeks. Pre- and post-intervention groups did not differ in age, BMI, race, parity, gestational age, comorbidities, birthweight, or delivery type. Ninety-eight cases were identified pre-implementation. Eighty-six (88%) had third-degree lacerations. Post-implementation, 87 cases were identified. Seventy (80%) had third-degree lacerations (p = 0.17). Recommended antibiotic-type use improved from 35% pre-implementation to 93% post-implementation (p < 0.001). Repair in the operating room was similar pre-implementation and post-implementation (16.0% vs 12.6%, p = 0.48). Post-partum follow-up within 2weeks improved from 16.3% pre-implementation to 52.8% post-implementation and mean time to follow-up was shorter post-implementation than pre-implementation (18 vs 33days; both p < 0.001). Implementation of an evidence-based peri-partum care bundle resulted in standardization of care in accordance with established recommendations. Compliance with recommendations for surgical repair in the operating room remained unchanged.