Intensive Care Unit Doctors Research Articles

Screening for ocular surface disease in the intensive care unit

Ventilated patients in the intensive care unit (ICU) often develop exposure keratopathy. This predisposes to the development of bacterial keratitis, which in ICU is often bilateral, with a high risk of perforation. As regular examinations of all ventilated patients by ophthalmologists would be impractical, the purpose of this study was to assess whether ICU staff can screen reliably for keratopathy. A prospective study was performed in a general adult ICU. Twice each week, two junior ICU doctors examined the lid position and ocular surface of all patients who had been continuously sedated for more than 24 h, using fluorescein and a pen torch with a blue filter. An ophthalmologist performed similar examinations using a portable slit lamp. A total of 48 ocular examinations were performed in 18 patients. Exposure keratopathy was found by the ophthalmologist in 37.5% of examinations and by ICU doctors in 31.3% of examinations. ICU doctors had a sensitivity of 77.8% and a specificity of 96.7% in detecting keratopathy, when compared with the findings of the ophthalmologist. All cases missed by ICU doctors had punctate erosions of less than 5% of the corneal surface. Keratopathy was significantly commoner in patients with incomplete lid closure than in patients with closed lids (70.0 vs 28.9%; two-tailed Fisher's exact test P=0.027). ICU staff can perform screening examinations for exposure keratopathy with reasonable sensitivity and specificity. Regular screening by ICU staff would facilitate appropriate treatment of exposure keratopathy and promote earlier identification of cases of keratitis.

Families' interactions with physicians in the intensive care unit: the impact on family's satisfaction

Purpose The objective of this study is to correlate the levels of satisfaction of family members, with their perception of the way information was offered and assistance delivered during the patient's stay in the intensive care unit (ICU). Materials and Methods This is a prospective study conducted in a 13-bed mixed ICU in a tertiary cancer. Family members were enrolled 2 days after admission if the patient remained in the ICU. Questions derived from a previous study assessed the quality of the information and support received ( Crit Care Med 1998; 26:1187). To generate the satisfaction criteria, families fulfilled a Portuguese version of the Critical Care Family Needs Inventory. Results One hundred sixty-four families were interviewed between May 2002 and May 2003. Insufficient information concerning the consequences of disease was a determinant of dissatisfaction (odds ratio [OR], 3.35; confidence interval [CI], 1.3-8.8), as well as insufficient information given by the ICU doctors (OR, 3.85; CI, 1.2-12.2). Accessibility of doctors was a major determinant of dissatisfaction when considered inadequate (OR, 6.92; CI, 2.3-20.6), and it was associated to a conflict regarding prognosis ( P = .017). Conclusion Family satisfaction and understanding in the ICU may improve if the doctors are more accessible to provide information and the staff strive to better explain the patient's condition.

Interdisciplinary communication in the intensive care unit

Patient safety research has shown poor communication among intensive care unit (ICU) nurses and doctors to be a common causal factor underlying critical incidents in intensive care. This study examines whether ICU doctors and nurses have a shared perception of interdisciplinary communication in the UK ICU. Cross-sectional survey of ICU nurses and doctors in four UK hospitals using a previously established measure of ICU interdisciplinary collaboration. A sample of 48 doctors and 136 nurses (47% response rate) from four ICUs responded to the survey. Nurses and doctors were found to have differing perceptions of interdisciplinary communication, with nurses reporting lower levels of communication openness between nurses and doctors. Compared with senior doctors, trainee doctors also reported lower levels of communication openness between doctors. A regression path analysis revealed that communication openness among ICU team members predicted the degree to which individuals reported understanding their patient care goals ((adj)R(2) = 0.17). It also showed that perceptions of the quality of unit leadership predicted open communication. Members of ICU teams have divergent perceptions of their communication with one another. Communication openness among team members is also associated with the degree to which they understand patient care goals. It is necessary to create an atmosphere where team members feel they can communicate openly without fear of reprisal or embarrassment.

Hand hygiene compliance: universally better post-contact than pre-contact in healthcare workers in the UK and Australia

Objective: To establish whether post-patient contact hand hygiene practice is universally higher than pre-patient contact in two highly resourced countries. Methods: Observations of medical and nursing staffs' hand hygiene compliance were made by the same observers in two different hospitals in Sydney and Birmingham, in both intensive care units (ICU) and surgical wards, using a standardised data collection tool. Results: Hand hygiene rates pre- and post-patient contact were low for both nurses and doctors in Sydney and Birmingham, with the exception of Sydney ICU doctors (pre-contact 74.8% and post-contact 75.7%, p=0.868). Post-contact compliance was low but significantly better than pre-contact in Sydney ICU nurses (41.3% versus 59.6% p<0.0001), surgical ward nurses (14.9% versus 29.6%, p=0.0019) and Sydney surgeons (10.2% versus 30.2%, p<0.0001). Post-contact compliance rates were low but higher than pre-contact in Birmingham ICU nurses (33.1% versus 52.2%, p=0.0011) and doctors (29.3% versus 70.1%, p<0.0001) but not in the Birmingham surgical ward (nurses: 42.6% versus 43.4%, p=0.89; surgeons: 39.6% versus 48.4%, p=0.187). Handwashing on removal of gloves was extremely low (1.7% to 16.6%), regardless of city, specialties or clinical staff. Conclusion: The pattern of post-contact compliance and non-compliance associated with glove use strongly suggests hand hygiene practice in both countries is primarily self-protective rather than a patient safety centred practice.

“Futile” care: Do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses

Purpose To qualitatively explore the process of the provision of futile care in Canadian intensive care units (ICUs). Materials and Methods A mailed, semistructured survey was sent to medical and nursing unit directors of all Canadian ICUs, asking them to estimate the frequency of provision of futile care, when care becomes “futile,” the reasons such care is provided, and the resources that are available to help make end-of-life decisions. Nurse/physician agreement was assessed by χ 2 analysis or Fisher exact test. Content analysis to identify common themes was carried out by 4 raters using a Delphi process. Results The response rate was 72%. The majority reported futile therapy had been provided in their ICU over the last year (nurses, “N” = 95%, physicians, “P” = 87%, P = .02). The most commonly stated reasons for providing futile care were family request (N = 91%, P = 91%, P = NS) and attending physician request (N = 91%, P = 87% P = NS). Physicians were cited to provide futile care because of prognostic uncertainty (N = 73%, P = 84%, P = .047) and legal pressures (N = 84%, P = 75%, P = NS). Comment review revealed 8 main reasons why futile care was provided, the most common of which were that “death was perceived as treatment failure,” and poor provider-family communication. Few providers were aware of societal (N = 26%, P = 51%) or local (22%, all) guidelines relating to the provision of futile care, but of those who were aware, the majority found these useful (range, 73%-74%). Twenty-seven percent expressed the need for someone to discuss difficult ethical issues, such an individual with ethics training specifically assigned to the ICU. Conclusions Caregivers voice the opinion that provision of futile care occurs, for multiple reasons, not the least of which is provider-driven. Nurses and physicians of Canadian ICUs perceive the need for increased availability of more ICU-directed and ethically trained resources to help them in providing end-of-life care.

Becoming an advanced practitioner in neonatal nursing: a psycho‐social study of the relationship between educational preparation and role development

The aims of this research were to identify (a) the educational and working experiences and (b) subsequent training needs of graduates of one ANNP course in the UK. The objectives were (a) to assess the medium to long-term impact of the training programme on the professional development of the respondents; (b) identify potential areas of excellence and (c) areas for improvement in this and other training programmes for ANNPs. Neonatal intensive care continues to be a rapidly changing area of work. Nurses and doctors in neonatal intensive care units (NICUs) have to be skilled equally in interpersonal communications and technical expertise. The Advanced Neonatal Nurse Practitioner (ANNP) training programme was introduced in 1992 in the UK in the broader political context of extending nursing roles in a range of specialties. The role of the neonatal intensive care nurse had expanded elsewhere previously, particularly in North America as a response to medical staffing crises where the practice and the training/education programmes were expanded during the 1970s/1980s and continued to evolve to encompass an advanced role for the neonatal nurse practitioner. This was a study of five cohorts of graduates from one university course training programme for advanced neonatal practitioners (ANNPs) to explore their experiences of their role as ANNPs in the context of changes and developments in the British National Health Service and their own personal and professional development. This study employs mixed methods (interviews, focus groups and a survey) and forms of data analysis (qualitative and quantitative) to explore the experiences of the transition to becoming an advanced practitioner. Data were collected from a sample of five cohorts; members of the current course team and the nursing and medical staff at one NICU which employs many of these graduates. Most graduates value their course experience and the ANNP role and the findings suggest that confidence about practice develops naturally with postcourse experience. However, the more experienced and confident ANNPs frequently reported increased inter-professional role confusion/conflict with junior doctors, and some consultants particularly where there are only one or two ANNPs overall in the team. There are personal and professional benefits to individual nurses who have had this training. However more attention needs to be paid to ongoing professional development particularly the management of professional role relationships among all nurses and between nurses and doctors. A focus on professional role relationships and more effective communication in the clinical setting would be of benefit to all members of multi-disciplinary teams. A greater level of day-to-day support is required for ANNPs, other neonatal nurses and junior doctors if this is to be achieved, especially in clinical settings where there are few ANNPs or the addition of these clinical specialists is relatively new.

Stress in U.K. Intensive Care Unit Doctors

Stress in U.K. Intensive Care Unit Doctors

Trauma care systems in Spain

Trauma care systems in Spain are provided by the Nacional Health Service in a decentralized way by the seventeen autonomous communities whose process of decentralization was completed in January 2002. Its organisation is similar in all of them. Public sector companies of sanitary emergencies look after the health of citizens in relation to medical and trauma emergencies with a wide range of up to date resources both technical and human. In the following piece there is a description of the emergency response teams divided into ground and air that are responsible for the on site care of the patients in coordination with other public services. They also elaborate the prehospital clinical history that is going to be a valuable piece of information for the teams that receive the patient in the Emergency Hospital Unit (EHU). From 1980 to 1996 the mortality rate per 10.000 vehicles and the deaths per 1.000 accidents dropped significantly: in 1980 6.4 and 96.19% and in 1996, 2.8 and 64.06% respectively. In the intrahospital organisation there are two differentiated areas to receive trauma patients the casualty department and the EHU. In the EHU the severe and multiple injured patients are treated by the emergency hospital doctors; first in the triage or resuscitation areas and after when stabilised they are passed too the observation area or to the Intensive Care Unit (ICU) and from there the EHU or ICU doctors call the appropriate specialists. There is a close collaboration and coordination between the orthopaedic surgeon the EHU doctors and the other specialists surgeons in order to comply with treatment prioritization protocols. Once the patient has been transferred an entire process of assistance continuity is developed based on interdisciplinary teams formed in the hospital from the services areas involved in trauma assistance and usually coordinated by the ICU doctors. There is also mentioned the assistance registry of trauma patients, the ICU professional training in the ATLS and the future guidelines for trauma care in the ICU based on epidemiological studies carried out in both the North Spanish Group and the Southern one to promote development and improvement in several areas.

Stress in UK intensive care unit doctors

Doctors have long been considered at risk of occupational stress. A postal survey of all members of the Intensive Care Society using validated instruments. Eight-five per cent of members returned questionnaires and 70% were eligible for the study. Twenty-nine per cent were suffering General Health Questionnaire-12 (GHQ-12) identified distress and 12% Symptom Checklist-Depression (SCL-D) defined depression. There were no significant age or sex differences between staff suffering distress or depression and those who did not. Dissatisfaction with career correlated highly with both distress and depression (P<0.01). Twenty doctors (3%) were bothered by suicidal thoughts. The most stressful aspects of work were bed allocation, being over-stretched, effect of hours of work and stress on personal/family life, and compromising standards when resources are short. Logistic regression revealed mental health problems were predicted by five stressors: 'lack of recognition of one's own contribution by others'; 'too much responsibility at times'; 'effect of stress on personal/family life'; 'keeping up to date with knowledge'; and 'making the right decision alone'. Nearly one in three ICU doctors appeared distressed (GHQ), and one in 10 depressed (SCL-D); this is no greater than that reported in other specialities. Perceived stressors reveal some key areas of concern for the employer and the specialty.

Strategies for increasing transplantation: the Saudi experience

THE STRATEGIES adopted in the Kingdom of Saudi Arabia for increasing organ transplantation are in general terms similar to those adopted elsewhere, ie, increasing awareness among public and doctors, establishing a central body to coordinate transplantation activities (ie, the Saudi Centre for Organ Transplantation), and obtaining the support of the government. However, relatively unique in this experience are the religious dimensions and the fact that advanced medical application is relatively recent in the Kingdom. The people of Saudi Arabia are devout Moslems. Their daily actions are governed by Islamic teachings, even in mundane matters. To accept organ donation, be it in life or after death, the Islamic view had to be ascertained. To fulfill this objective one of our early strategies was to urge our Islamic scholars to discuss this subject. Religious opinions (fatwas) were obtained permitting both living related and cadaveric donation as well as approving the concept of brain death. Until now, for wide consent for organ donation to be successful, the religious aspect of permission to donate must be stressed and fatwas must be cited to the relatives of the deceased. The advanced and state-of-the-art medical facilities existing in the Kingdom are relatively recent, as compared to the West. The populace and our practicing doctors were not familiar with brain stem death, transplantation, etc, when we started transplantation. This necessitated a sustained and persistent education process. Until 30 years ago, many patients were admitted to the hospital in a terminal status and died. The people did not trust doctors very much and this lack of trust then made it difficult to convince the people that “we know what we are doing,” a difficult task initially. As within any other country, increasing public awareness is an integral part of the strategy. This was undertaken through a sustained media campaign. News of transplantation activities are projected continually. Television programmes are devised including live question and answer sessions with religious scholars as panelists. Public debates are organised, usually in association with scientific conferences. Supportive newspaper columnists write on the topic usually from humanitarian point of view. Financial donation campaigns are organised, including marathons. For establishing awareness among medical personnel, regular meetings are held for intensive care unit (ICU) doctors, coordinators, hospital managers and nurses. A total of 80 such meetings were held for 2010 attendees. The topics discussed are tailored to the group involved, but generally cover religious and ethical aspects, diagnosis of brain death, method of reporting, methodology of obtaining consent, methods of increasing organ donation, and preservation of organs. Pamphlets are published on these and other topics. Sometimes ICU doctors are reluctant to get involved. Support is provided for them at all stages of organ donation (diagnosis, reporting, preservation, harvesting). The hospitals involvement is also encouraged by the policy of giving priority to patients for transplantation from the donor hospitals. For all these activities to be effective, a central coordinating body had to be established with full goodwill of the policy makers. By this support, the National Kidney Foundation was established in 1985, which was later renamed the Saudi Centre for Organ Transplantation (SCOT) in 1993, as the need for a multiorgan programme became evident. This body acts to coordinate and establish all activities related to transplantation. Policies are made by committees comprising experienced physicians and others in the Kingdom. It follows up organ donation from the stage of reporting to transplantation. The airborne Medivac system of the Ministry of Defence lends its support for transportation of the retrieved organs as the Kingdom has a vast area (2.5 million km). Recently, SCOT started coordination with the countries of the Gulf Cooperation Council (Oman, United Arab Emirates, Qatar, Bahrain, and Kuwait). Organs are now being exchanged through this programme. Saudi Arabia is the leading Islamic country in organ donation. The number of organs harvested so far are 950 kidneys, 165 hearts, and 163 livers, and patient and graft survival rates are excellent.

Do we know the costs of what we prescribe? A study on awareness of the cost of drugs and devices among ICU staff.

To evaluate the level of cost awareness of drugs and devices among intensive care unit (ICU) doctors with variable levels of experience (senior intensivists, junior intensivists, residents). Interview-questionnaire. ICU of the University of Rome "La Sapienza". 60 ICU doctors (40 specialists in anaesthesia and intensive care, 20 residents). The estimated prices of drugs and devices were compared with the correct prices; responses within a range +/- 20% of the true price were arbitrarily considered correct; all the subgroups of doctors made inaccurate estimates of the prices, showing an absence of any impact of professional experience of cost awareness. The doctors in the study showed a high level of inaccurate cost awareness of drugs and devices.

Kidney donation by the elderly--an emergency solution?

In 1994 the number of kidney donors once again decreased in Germany. On the other hand, more and more old people are being considered for renal transplantation; thus the shortage of transplants is becoming more severe. The kidneys of elderly donors might improve this situation. The results available are inconsistent. There is no doubt that kidney function declines with age, but the individual aging process depends mainly on concomitant disease, especially arterial hypertension. Transplantation of kidney from an elderly person requires appropriate selection of donors as well as good perioperative management. Doctors in medical intensive care units should contact transplant centres more often to evaluate potential elderly kidney donors. More open-minded assessment of certain situations is necessary in conservative medical disciplines.

Organ donation from intensive care units in England.

To audit all deaths in intensive care units (excepting coronary care only and neonatal intensive care units) in England to assess potential for organ procurement. An audit in which 14 regional health authorities and London special health authorities each designated a regional liaison officer to identify intensive care units and liaise with Department of Health and the Medical Research Council's biostatistics unit in distribution, return, and checking of audit forms. Audit took place from 1 January to 31 March 1989 and will continue to 31 December 1990. 278 Intensive care units in England. Colleagues in intensive care units (doctors, nurses, coordinators, and others), who completed serially numbered audit forms for all patients who died in intensive care. The estimated number of deaths in intensive care units was 3085, and validated audit forms were received for 2853 deaths (92%). Brain stem death was a possible diagnosis in only 407 (14%) patients (about 1700 cases a year) and was confirmed in 282 (10%) patients (an estimated 1200 cases a year). Half the patients (95% confidence interval 45% to 57%) in whom brain stem death was confirmed became actual donors of solid organs. Tests for brain stem death were not performed in 106 (26%) of 407 patients with brain stem death as a possible diagnosis, and general medical contraindication to organ donation was recorded for 48 (17%) of 282 patients who fulfilled brain stem death criteria before cessation of heart beat. The criteria were fulfilled before cessation of heart beat and in the absence of any general medical contraindication to organ donation in 234 patients, 8% of those dying in intensive care (an estimated 1000 cases a year). Consent for organ donation was given in 152 (70%) of 218 cases (64% to 76%) when the possibility of organ donation was suggested to relatives. In only 14 out of 232 families (6%; 3% to 9%) was there no discussion of organ donation with relatives. Corneal suitability was recorded as "not known" in a high proportion (1271; 45%) of all deaths and intensive care units reported only 123 corneal donors (4% of all audited deaths). When brain stem death is a possible diagnosis tests should always be carried out for confirmation. Early referral to the transplant team or coordinator should occur in all cases of brain stem death to check contraindications to organ donation. There should be increased use of asystolic kidney donation, and patients should be routinely assessed for suitability for corneal donation. Finally, more publicity and education are necessary to promote consent.