High Intensive Unit Research Articles

Multi‐Team Shared Expectations Tool (MT‐SET): An Exercise to Improve Teamwork Across Health Care Teams

Care transitions among high-intensity units caring for patients with complex needs are a critical yet undeveloped area of patient safety research. In addition, effective communication and coordination across disciplines remain elusive. This study introduces and tests the Multi-Team Shared Expectations Tool (MT-SET), an exercise that aims to engage health care teams in eliciting needs and establishing agreed-upon expectations teams and individuals within a multi-team system have of one another. We piloted the exercise within hospital-based workflows for oncology inpatients and later adopted it to elicit data on mutual needs and expectations of teams across units involved in patient transitions in two patient safety projects. Our studies demonstrated that the exercise identified common cross-unit coordination problems of delays in care, unwanted variations in care, and lack of standardized communication among units. It also revealed mismatched prioritization of each of these problems between specific unit types. The participants reported that the MT-SET helped establish positive relationships for building better cross-unit and cross-disciplinary teamwork and coordination. There is a need for systematic approaches to understand and facilitate cross-unit communication and coordination in care delivery and transitions. Future studies should broaden the application of the exercise to additional types of multi-unit and multidisciplinary teams and observe intervention ideas generated from the exercise, as well as their implementation.

Signatures of disease outcome severity in the intestinal fungal and bacterial microbiome of COVID-19 patients.

COVID-19, whose causative pathogen is the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), was declared a pandemic in March 2020. The gastrointestinal tract is one of the targets of this virus, and mounting evidence suggests that gastrointestinal symptoms may contribute to disease severity. The gut-lung axis is involved in the immune response to SARS-CoV-2; therefore, we investigated whether COVID-19 patients' bacterial and fungal gut microbiome composition was linked to disease clinical outcome. In May 2020, we collected stool samples and patient records from 24 hospitalized patients with laboratory-confirmed SARS-CoV-2 infection. Fungal and bacterial gut microbiome was characterized by amplicon sequencing on the MiSeq, Illumina's integrated next generation sequencing instrument. A cohort of 201 age- and sex-matched healthy volunteers from the project PRJNA661289 was used as a control group for the bacterial gut microbiota analysis. We observed that female COVID-19 patients had a lower gut bacterial microbiota richness than male patients, which was consistent with a different latency in hospital admittance time between the two groups. Both sexes in the COVID-19 patient study group displayed multiple positive associations with opportunistic bacterial pathogens such as Enterococcus, Streptococcus, and Actinomyces. Of note, the Candida genus dominated the gut mycobiota of COVID-19 patients, and adult patients showed a higher intestinal fungal diversity than elderly patients. We found that Saccharomycetales unassigned fungal genera were positively associated with bacterial short-chain fatty acid (SCFA) producers and negatively associated with the proinflammatory genus Bilophila in COVID-19 patients, and we observed that none of the patients who harbored it were admitted to the high-intensity unit. COVID-19 was associated with opportunistic bacterial pathogens, and Candida was the dominant fungal taxon in the intestine. Together, we found an association between commensal SCFA-producers and a fungal genus that was present in the intestines of patients who did not experience the most severe outcome of the disease. We believe that this taxon could have played a role in the disease outcome, and that further studies should be conducted to understand the role of fungi in gastrointestinal and health protection.

Staffing models in the cardiac intensive care unit.

The modern cardiac intensive care unit (CICU) has evolved into a high-intensity unit that cares for critically ill patients. Despite this transformation, changes to the staffing model and organizational structure in these specialized units have only recently begun to meet these challenges. We describe the most recent evidence which will inform future CICU staffing models. In the United States, the majority of CICUs are open as opposed to closed units, yet recent data suggests that transition to a closed staffing model is associated with a decrease in mortality. These reductions in mortality in closed CICUs are most pronounced in the most critically ill populations, such as patients with mechanical circulatory support, cardiac arrest, and respiratory failure. In addition, one study has shown that transition to a cardiac intensivist staffed CICU was associated with a reduction in mortality. Finally, multidisciplinary and protocolized teams imbedded within the CICU, specifically 'shock teams,' have recently been developed and may reduce mortality in this particularly sick patient population. Although the preponderance of data suggests improved outcomes with a closed, intensivist staffed CICU model, future multicenter studies are needed to better define the ideal staffing models for the contemporary CICU.

The role of Legal Aid NSW in addressing the civil legal needs of participants in High Intensity Units (HIPUs) in prisons

ABSTRACT Legal Aid NSW civil lawyers provide community outreach clinics and civil legal assistance to address the civil legal needs of participants in High Intensity Program Units (HIPUs) in prisons in New South Wales (NSW), Australia. Semi-structured interviews were conducted with Legal Aid NSW staff to explore their work in HIPUs. Interviews focused on the types of civil legal issues faced by HIPU participants, the value of providing such services in the HIPUs and the challenges and barriers associated with this work. The findings indicated that HIPU participants have a range of civil legal needs including issues relating to housing and tenancy, outstanding debts, welfare payments, victims’ compensation, driver disqualification, tort claims and family law matters. Successful resolution of these matters can be critical for ensuring the best chance of post-release desistance from crime. However, provision of civil legal services in prisons can be adversely impacted by practical and operational issues attributable to the time- and resource-intensive nature of this work. Some of these barriers include considerable travel times to prison, delays upon arrival at the prison and unexpected lockdown procedures.

Burnout and Resilience Among Nurses Practicing in High-Intensity Settings.

The high level of stress experienced by nurses leads to moral distress, burnout, and a host of detrimental effects. To support creation of healthy work environments and to design a 2-phase project to enhance nurses' resilience while improving retention and reducing turnover. In phase 1, a cross-sectional survey was used to characterize the experiences of a high-stress nursing cohort. A total of 114 nurses in 6 high-intensity units completed 6 survey tools to assess the nurses' characteristics as the context for burnout and to explore factors involved in burnout, moral distress, and resilience. Statistical analysis was used to determine associations between scale measures and to identify independent variables related to burnout. Moral distress was a significant predictor of all 3 aspects of burnout, and the association between burnout and resilience was strong. Greater resilience protected nurses from emotional exhaustion and contributed to personal accomplishment. Spiritual well-being reduced emotional exhaustion and depersonalization; physical well-being was associated with personal accomplishment. Meaning in patient care and hope were independent predictors of burnout. Higher levels of resilience were associated with increased hope and reduced stress. Resilience scores were relatively flat over years of experience. These findings provide the basis for an experimental intervention in phase 2, which is designed to help participants cultivate strategies and practices for renewal, including mindfulness practices and personal resilience plans.

Influence of Volumetric Shrinkage and Curing Light Intensity on Proximal Contact Tightness of Class II Resin Composite Restorations: In Vitro Study

Proximal contact tightness of class II resin composite restorations is influenced by a myriad of factors. Previous studies investigated the role of matrix band type and thickness, consistency of resin composite, and technique of placement. However, the effect of volumetric shrinkage of resin and intensity of curing light has yet to be determined. Thus, the aim of this study was to identify the influence of these factors on the proximal contact tightness when restoring class II cavity preparations in vitro. Sixty artificial molars were restored with either a low-shrinkage (Filtek Silorane, 3M ESPE) or a conventional (Z100, 3M ESPE) composite and polymerized with low-intensity (Smartlite IQ2, Dentsply) or high-intensity light curing units (Demi(TM), Kerr). Proximal contact tightness was measured using the Tooth Pressure Meter. Data were statistically analyzed using one-way analysis of variance and Tukey post hoc test. Use of low-shrinkage composite (Filtek Silorane) resulted in significantly tighter proximal contacts compared to the use of conventional composite (Z100) when cured with the same polymerization unit (p<0.001). Moreover, the low-intensity curing unit (IQ2) resulted in significantly tighter contacts than the high-intensity unit when material is constant (p<0.001). Low-shrinkage resin composite and low curing light intensity is associated with tighter proximal contact values.

UVR Emissions from Solaria in Australia and Implications for the Regulation Process

To assist in the development of the 2008 Australian/New Zealand standard on solaria and related regulations, Australian Radiation Protection and Nuclear Safety Agency scientists visited a number of tanning establishments during 2008 to measure the intensity and spectral distribution of the ultraviolet radiation (UVR) emissions from a range of solaria. The 2002 Australian/New Zealand Standard "Solaria for cosmetic purposes" (AS/NZS 2635) allowed a maximum UVR output from solaria of UV Index 60, a compromise between the solarium industry who wanted no upper limit and the health agencies who wanted to limit intensity. Of the 20 solaria examined in detail, only one had emissions of intensity less than UV Index 12, typical of mid-latitude summer sunlight, 15 units emitted more than UV Index 20, while three units emitted at intensities above UV Index 36, the maximum allowed by the new standard, AS/NZS 2635 (2008) and would thus not comply. UVA emissions ranged from 98W·m(-2) up to a maximum of 438W·m(-2) , more than six times the UVA content of mid-latitude summer sunshine. The results indicate that solaria users in Australia have access to solaria that are high intensity units with both significantly higher UVB and UVA emissions than sunlight, with implications for resultant adverse health effects.

An Evaluation of the Potential of High-Intensity Ultrasound for Improving the Microbial Safety of Poultry

The application of sonication and thermosonication (53 ± 1 °C) was investigated as potential methods for reducing numbers of Campylobacter, enterobacteriaceae and total viable counts (TVC) on raw poultry. Sonication equipment included a high-intensity unit (HI) and a low-intensity unit (LI), which produced 20,000 and 20 W/L, respectively. The susceptibility of ten Campylobacter isolates in liquid media to thermosonication treatment was also investigated to determine whether differences between isolates existed. All Campylobacter strains were susceptible to thermosonication in the HI unit with inactivations ranging from 2.97–4.15 log10 CFU/mL. Campylobacter jejuni was more susceptible to thermosonication than to thermal or sonication treatment with mean inactivations of 4.72, 1.45 and 3.17 log10 CFU/mL, respectively. Following 16 min thermal, sonication and thermosonication treatments of broiler skin pieces in the HI unit, no viable Campylobacter or enterobacteriaceae were detected and TVC were reduced by 1.93, 1.34 and 2.49 log10 CFU/g, respectively. Thermosonication treatment in the LI unit reduced enterobacteriaceae and TVC populations by 2.74 and 1.69 log10 CFU/g, respectively. Thermosonication treatment was generally more effective against Campylobacter in liquid matrices in comparison to inoculated poultry products.

Effects of High-Intensity Curing Lights on Microleakage under Bonded Lingual Retainers

To evaluate the effects of high-intensity light curing units (light-emitting diode [LED] and plasma arc curing [PAC]) on the microleakage of flexible spiral wire retainers (FSWRs) at the composite/enamel and composite/wire interfaces. Forty-five human mandibular incisor teeth were separated into three groups of 15 teeth. Multistranded PentaOne wire of .0215 inch diameter was bonded to enamel and was cured with three different light curing units: a quartz-tungsten-halogen (QTH) unit and two high-intensity units (ie, LED and PAC). A conventional halogen light served as the control. Samples were sealed with nail varnish, stained with 0.5% basic fuchsine, and sectioned. Transverse sections were evaluated under a stereomicroscope and were scored for microleakage for the composite/enamel and composite/wire interfaces. Statistical analysis was performed by Kruskal-Wallis and Mann-Whitney U-tests with Bonferroni correction. Little or no microleakage was detected at the composite/enamel interface of the FSWR cured with three different light sources. However, at the composite/wire interface, statistically significant differences were found between the QTH (mean, 1.10 +/- 1.05 mm) and high-intensity curing units. The PAC resulted in the greatest amount of microleakage (mean, 2.63 +/- 1.49 mm), whereas no statistically significant difference was noted between the PAC and the LED (mean, 2.35 +/- 1.28 mm). High-intensity light curing units show statistically significant microleakage at the composite/wire interface and therefore may not be safe for use in bonding FSWRs.

Pulp Chamber Temperature Rise during Curing of Resin-Based Composites with Different Light-Curing Units

Aims The purpose of the present study was to measure the intrapulpal temperature rise occurring during polymerisation of different shades of resin-based composites (RBCs), and two light-emitting diode (LED) units. Methods Seventy non-carious permanent molars, that had been extracted for orthodontic purposes and stored in 2% thymol for not more than four months, were selected. Patient age range was 11–18 years. Standard cavity preparation with standardised remaining dentine thickness and placement of thermocouples (TCs) was prepared using a novel split-tooth technique. Cavities were filled with one of two shades of RBC (A2 and C4, Filtek Z250, 3M ESPE, Seefeld, Germany), and cured with two LED high-intensity units (Elipar Freelight2, 3M ESPE, Seefeld, Germany; Bluephase, Ivoclar Vivadent, Schaan, Liechtenstein) and a conventional halogen light-curing unit (LCU) (Prismetics Lite 2, Dentsply, Weybridge, Surrey, UK) as a control. Results Pulp temperature rises during bonding [A2 results: H;2.67/0.48:E;5.24/1.32;B;5.99/1.61] were always greater than during RBC curing [A2 results: 2.44/0.63;E3.34/0.70;B3.38/0.60], and these were significant for both LED lights but not for the halogen control, irrespective of shade (Mann-Whitney test: 95% confidence limits). Temperature rises were at times in excess of the values normally quoted as causing irreversible pulp damage. Pulp temperature rises during bonding were higher with the LED lights than with the halogen control. There was no significant difference in temperature rise between the two LED lights when bonding but there was a significant difference between the two LED lights and the halogen control LCUs (Kruskal-Wallis Test: 95% confidence limits). Conclusions The results support the view that there is a potential risk for heat-induced pulpal injury when light-curing RBCs. The risk is greater during bonding and with high energy, as compared to low-energy output systems. As the extent of tolerable thermal trauma by the pulp tissues is unknown, care and consideration should be given to the choice of LCU and the exposure time when curing RBCs, and especially during bonding.

Critical care delivery in the United States: Distribution of services and compliance with Leapfrog recommendations*

To describe the organization and distribution of intensive care unit (ICU) patients and services in the United States and to determine ICU physician staffing before the publication and dissemination of the Leapfrog Group ICU physician staffing recommendations. Stratified, weighted survey of ICU directors in the United States, performed as part of the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS) study. Using lenient definitions, we defined an ICU as "high intensity" if > or =80% of patients were cared for by a critical care physician (intensivist) and defined an ICU as compliant with Leapfrog if it was both high-intensity and providing some form of in-house physician coverage during all hours. Three hundred ninety-three ICU directors. None. We obtained a 33.5% response rate (393/1,173). We estimated there were 5,980 ICUs in the United States, caring for approximately 55,000 patients per day, with at least one ICU in all acute care hospitals. The predominant reasons for admission were respiratory insufficiency, postoperative care, and heart failure. Most ICUs were combined medical-surgical ICUs (n = 3,865; 65%), were located in nonteaching, community hospitals (n = 4,245; 71%), and were in hospitals of <300 beds (n = 3,710; 62%). One in four ICUs were high-intensity (n = 1,578; 26%), half had no intensivist coverage (n = 3,183; 53%), and the remainder had at least some intensivist presence (n = 1,219; 20%). High-intensity units were more common in larger hospitals (p = .001) and in teaching hospitals (p < .001) and more likely to be surgical (p < .001) or trauma ICUs (p < .001). Few ICUs had any in-house physician coverage outside weekday daylight hours (20% during weekend days, 12% during weeknights, and 10% during weekend nights). Only 4% (n = 255) of all adult ICUs in the United States appeared to meet the full Leapfrog standards (a high-intensity ICU staffing pattern plus dedicated attending coverage during daytime plus dedicated coverage by any physician during nighttime). ICU services are widely distributed but heterogeneously organized in the United States. Although high-intensity ICUs have been associated previously with improved outcomes, they were infrequent in our study, especially in smaller hospitals, and virtually no ICU met the Leapfrog standards before their dissemination. These findings highlight the considerable challenge to any efforts designed to promote either 24-hr physician coverage or high-intensity model organization.

Analysis of composite type and different sources of polymerization light on in vitro toothbrush/dentifrice abrasion resistance

Objectives: This study examined toothbrush/dentifrice abrasion of a photo-activated prosthetic composite (dentin and enamel variations) for the purpose of evaluating the influence of polymerization sources on abrasive wear. Methods: A photo-activated prosthetic composite material (Artglass) was assessed. Dentin and enamel variations were polymerized using a proprietary photo-curing unit with two xenon stroboscopic lamps (UniXS), and other enamel specimens were polymerized either with a laboratory photo-curing unit with three fluorescent tubes or with a high intensity unit with two metal halide lamps. All specimens were stored in water for 14 days and subjected to toothbrush/dentifrice abrasion (350 g vertical load) using an abrasive slurry (Colgate Fluoriguard) and a toothbrush (Oral-B 40). The amount of vertical loss and the surface roughness of the specimens after 20,000 strokes were determined by profilometer. Average values of groups of five specimens were compared using analysis of variance (ANOVA) and Sheffe's S intervals ( p<0.05). Results: When polymerizing with the proprietary unit, the abrasion and surface roughness of the enamel material required respective means of 34.08 μm (±3.66) and 1.00 μm (±0.08), and the those of the dentin material required means of 42.02 μm (±5.62) and 1.23 μm (±0.20). Both abrasion and surface roughness after toothbrushing of the enamel material were significantly smaller than were those of the dentin material. The abrasion of specimens polymerized with the metal halide unit required a mean of 23.89 μm (±6.17) and demonstrated minimal wear. Conclusions: The use of a high intensity metal halide photo-curing unit effectively enhanced the abrasion resistance of the composite. Surfaces of restorations should be covered with the enamel material in order to achieve smoothness and wear resistance.