Intermediate Care Ward Research Articles

Learning and working on an interprofessional training ward in neonatology improves interprofessional competencies

IntroductionInterprofessional education (IPE) is essential for healthcare professionals to prepare them for future interprofessional collaboration (IPC). Interprofessional training wards (ITWs) have been set up for IPE and results have been published. There are no published studies on ITWs in neonatology. We have designed and established the Interprofessional Training Ward in Neonatology (IPANEO) for nursing trainees (NT) and medical students (MS) in a neonatological intermediate care (IMC) ward. We report on the concept and the results with regard to the interprofessional competencies of the participants, including parent satisfaction.MethodsSupervision by medical and nursing learning facilitators, 2week blocks each with 2 NT (n = 30) and 2 MS (n = 23) in their final year, ward-in-ward concept, 3 patients cared for. Evaluation of the participants (pre/post) with the Interprofessional Socialisation and Valuing Scale (ISVS), the Interprofessional Collaboration Scale (ICS) with questions on IP communication, accommodation and isolation as well as with an IPANEO-specific evaluation (IPQ), an external evaluation with the “Observational Questionnaire for Learning Facilitators” (OQLF) and a “Questionnaire on Parent Satisfaction” (PSQ) (n = 33).ResultsIPANEO participants showed significant increases in competencies in IP communication, accomodation and isolation (ICS), a better IP-collaboration and a higher role definition (IPANEO specific questionnaire). The ISVS 9A/B global scores increased. According to the self-assessment there were significant improvements in the external evaluation in all IP-categories (OQLF). The feedback from the parents was significantly positive (PSQ).ConclusionInterprofessional learning and working on IPANEO had a positive impact on interprofessional competencies with high parent satisfaction.

Workload reduction through automated documentation in intensive and intermediate care - a monocentric observational study.

The global coronavirus pandemic has placed an unprecedented and enormous burden on health systems worldwide. In addition to a shortage of resources, nurses were also confronted with high levels of sick leave and an increasing exodus from the profession. Automating documentation obligations is an effective way of reducing the burden on the workplace. The study was conducted at a tertiary university hospital. The time required for the manual documentation of administered medication and dose changes of syringe and infusion pumps was recorded using the patient data management system (PDMS) representing all intensive and intermediate care wards (n = 6). Subsequently, all medication administration - grouped into five classes - was evaluated from January 1st, 2019, until December 31st, 2022. A total of 1,373,340 drug applications were studied, treating 32,499 patients. Data were obtained from ICUs (68%) and IMC wards (32%). This corresponds to an overall time of 2,901 ± 233 hours per year. Based on publicly known national rates for intensive care nurses, an annual financial expenditure of approximately 83,300 € (~ USD 89,300) per year was estimated. A non-negligible part of the daily working time in the medical sector is spent on documentation duties. This aggravates the high workload, which has increased in recent years. Automated documentation systems can lead to considerable relief and the possibility of focusing primarily on the patient and on other core competencies and activities. This is even more important, as available staff will be a key resource in patient care for the foreseeable future.

Implementation of a shared oncologic intermediate and acute care unit in times of COVID. Has it come to stay?

With aging population and improvement of cancer treatments, the growing number of complex cancer survivors’ challenge the delivery of quality and affordable care. Health care systems need innovate to improve care coordination, patients’ outcomes and experiences and to contain costs. The aim of this study was to evaluate the implementation of an oncology care unit shared between an acute and an intermediate care ward. The shared unit was launched as a response to the COVID-19 pandemic situation that overwhelmed hospital resources and put the quality of care for non-COVID pathologies at risk. The unit is formed by a multidisciplinary team, including oncologists, geriatricians, specialized nurses, therapists and social and psychological support. It is located in a ward with dedicated spaces and activities for oncologic patients. Patients are derived from the emergency ward of the acute hospital after triage or a short stay, when they need specialized oncologic care but without need of complex acute procedures. 
 We conducted a pre-post implementation evaluation using mixed-methods. We analyzed system-level longitudinal data from electronic health records before (historical controls) and during implementation. We performed quantitative and qualitative analysis of patients’ surveys, focus groups with professionals, and interviews with patients and caregivers.
 From January 2018 to June 2020 there were a mean of 160 discharges/month from the acute ward. Since the setup of the Unit in July 2020 until April 2022, approximately 45% (1551; 69 discharges/month) of patients were discharged from the subacute ward. Most patients (75.5%) were derived directly from the emergency unit of the acute care hospital or after a 1 day stay or less, thus avoiding acute hospitalization. During the implementation period patients attended in the subacute ward were older (67.9 vs 63.5), had higher comorbidity weight (GMA: 15.2 vs 13.5) and higher complexity (patients with complex chronic conditions due to health or social needs: 9.4 vs 7%; patients with advanced chronic conditions due to limited life expectancy or end of life situation: 20.7 vs 15%). Consequently, the number of complex patients in the acute ward decreased while the total capacity of the system increased.
 The focus group with professionals (n=15) revealed different arquetypes of patients: subacute care, symptoms control, end of life care and social problems; and caregivers: adjusted/unadjusted to the situation. Positive and negative aspects perceived by professionals were contrasted with those of patients. Professionals highlighted multidisciplinary and availability of adequate spaces and activities as positive values, patient valued the professionalism and humane treatment. Some improvement actions are taking place to improve the provision of information to patients.
 In conclusion, the shared intermediate oncology unit increases the total capacity of the oncologic care system and avoids acute hospitalization to complex patients due to age, comorbidity and social needs. Experiences of professionals, patients and caregivers are mostly positive. "

The Weaning Protocol of High Flow Nasal Cannula Reduce Duration of Weaning in Lower-Respiratory Tract Infection in Children Who Used High Flow Nasal Cannula: Single Center Experience in Thailand

Background: Use of high flow nasal cannula (HFNC) has been widely accepted as non-invasive respiratory support in children suffering from lower respiratory tract infections (LRI). Patients who use HFNC still need respiratory care from health personnel in ICU or intermediate care wards. Without the weaning protocol, the authors had noticed prolonged HFNC use, which affected the length of hospital stay (LOS). As such, a pediatric patient care team (PCT) created the weaning protocol and collected data whether the weaning protocol would shorten weaning time. Objective: To compare HFNC weaning times among children suffering from LRI, before and after using the weaning protocol. Materials and Methods: A pre- and post-intervention study of 1-month-old to 5-year-old children who received HFNC therapy for LRI at Panyananthaphikkhu Chonprathan Medical Center between August 2018 and July 2020, the one year before and after the protocol was implemented in August 2019, were carried out. Demographic data and severity of respiratory illness according to Respiratory Assessment Score (RAS) were recorded. Multivariate linear regression, adjusted for age, gender, weight, RR, HR, SpO₂, and RAS before using HFNC, was used to compare between the pre- and post-weaning protocol groups according to total HFNC time, duration of weaning time, and LOS. Results: There were 25 patients in each group. The mean age in the post-weaning protocol group was lower, but there was no difference in severity. Multivariate linear regression demonstrated that the post-weaning protocol group had a significantly shorter weaning time at 49.5±37.0 hours versus 84.2±62.8 hours (p=0.034). Moreover, total HFNC time was also significantly shorter in the post-weaning protocol group at 71.53±36.7 hours versus 119.6±78.2 hours (p=0.019). There was no difference in vital signs during weaning between the two groups. Conclusion: Implementing the weaning protocol reduce weaning time and total HFNC time, without affecting clinical outcomes. Keywords: High flow nasal cannula; Weaning protocol; Lower respiratory tract infection; Length of stay

Job demands at the patient’s bedside and their effects on stress and satisfaction of nurses

AimThe study aimed to assess job demands at the patient’s bedside and to evaluate the contribution of this central workplace to the stress and satisfaction of nurses.DesignIn this cross-sectional survey...

Psychiatric service delivery for older people in hospital and residential aged care: An updated systematic review.

To review studies reporting on the effectiveness of psychiatry service delivery for older people and people with dementia in hospital and residential aged care. A systematic search of four databases was conducted to obtain peer-reviewed literature reporting original research published since June 2004 evaluating a psychiatry service for older people (aged 60 years and over) or people with dementia in inpatient or residential aged care settings. From the 38 included studies, there was consistent low-to-moderate quality evidence supporting the effectiveness of inpatient older persons' mental health wards (n = 14) on neuropsychiatric symptoms, mood, anxiety and quality of life. Inpatient consultation/liaison old age psychiatry services (n = 9) were not associated with improved depression, quality of life or mortality in high-quality randomised studies. However, low-quality evidence demonstrated improved patient satisfaction with care and reduced carer stress. The highest quality studies demonstrated no effect of psychiatric in-reach services to residential aged care (n = 9) on neuropsychiatric symptoms but a significant reduction in depressive symptoms among people with dementia. There was low-quality evidence that long-stay intermediate care wards (n = 6) were associated with reduced risk for dangerous behavioural incidents and reduced costs compared to residential aged care facilities. There was no effect of these units on neuropsychiatric symptoms or carer stress. The scarcity of high-quality studies examining the effectiveness of old age psychiatry services leaves providers and policy-makers to rely on low-quality evidence when designing services. Future research should consider carefully which outcomes to include, given that staff skill and confidence, length of stay, recommendation uptake, patient- and family-reported experiences, and negative outcomes (i.e. injuries, property damage) are as important as clinical outcomes.

Postoperative surveillance in cranial and spinal tumor neurosurgery: when is this warranted?

The outbreak of COVID-19 and the sudden increase in the number of patients requiring mechanical ventilation significantly affected the management of neurooncological patients. Hospitals were forced to reallocate already scarce human resources to maximize intensive care unit (ICU) capacities, resulting in a significant postponement of elective procedures for patients with brain and spinal tumors, who traditionally require elective postoperative surveillance on ICU or intermediate care wards. This study aimed to characterize those patients in whom postoperative monitoring is required by analyzing early postoperative complications and associated risk factors. All patients included in the analysis experienced benign or malignant cerebral or intradural tumors and underwent surgery between September 2017 and May 2019 at University Hospital Münster, Germany. Patient data were generated from a semiautomatic, prospectively designed database. The occurrence of adverse events within 24 hours and 30 days postoperatively-including unplanned reoperation, postoperative hemorrhage, CSF leakage, and pulmonary embolism-was chosen as the primary outcome measure. Furthermore, reasons and risk factors that led to a prolonged stay on the ICU were investigated. By performing multivariable logistic regression modeling, a risk score for early postoperative adverse events was calculated by assigning points based on beta coefficients. Eight hundred eleven patients were included in the study. Eleven patients (1.4%) had an early adverse event within 24 hours, which was either an unplanned reoperation (0.9%, n = 7) or a pulmonary embolism (0.5%, n = 4) within 24 hours. To predict the incidence of early postoperative complications, a score was developed including the number of secondary diagnoses, BMI, and incision closure time, termed the SOS score. According to this score, 0.3% of the patients were at low risk, 2.5% at intermediate risk, and 12% at high risk (p < 0.001). Postoperative surveillance in cranial and spinal tumor neurosurgery might only be required in a distinct patient collective. In this study, the authors present a new score allowing efficient prediction of the likelihood of early adverse events in patients undergoing neurooncological procedures, thus helping to stratify the necessity for ICU or intermediate care unit beds. Nevertheless, validation of the score in a multicenter prospective setting is needed.

First 18 months as certified ERAS® center for colorectal cancer : Lessons learned and results of the first 261 patients

Enhanced recovery after surgery (ERAS®) describes amultimodal, interdisciplinary and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures. The aim of this article is to present the experiences of our center certified by the ERAS® Society for colorectal resections 18months after successful implementation. Since the beginning of the certification 261 patients have been treated in our clinic according to the specifications of the ERAS® concept. As acomparison group the last 50patients prior to implementation were evaluated in terms of compliance with ERAS® requirements, length of hospital stay and readmission rate, the need for care in an intensive or intermediate care ward, the number of necessary reoperations and the complication rate. Compliance increased from 39.3% preERAS® to 81.1% after ERAS® implementation (p < 0.001). At the same time the length of stay of ERAS® patients was reduced from 7days to 5days (p = 0.001). While the rate of surgical complications was the same between the two groups (p = 0.236), nonsurgical complications occurred significantly less frequently in the ERAS® cohort (p = 0.018). There are well-known stumbling blocks in implementing and maintaining an ERAS® concept; however, it is worthwhile for the patient to circumnavigate this and establish ERAS® as the standard treatment path.

Seasonal burden of severe influenza virus infection in the critically ill patients, using the Assistance Publique-H\xf4pitaux de Paris clinical data warehouse: a pilot study

PurposeAt the critical care level, the flu surveillance system is limited in France, with heterogeneous regional modalities of implementation.Materials, patients and methodsWe aimed at assessing the relevance of the Assistance Publique-Hôpitaux de Paris (AP-HP) clinical data warehouse for estimating the burden of the influenza epidemic on medical adult critical care units of the AP-HP, and outcome of patients during the flu season 2017–2018. This exploratory multi-site epidemiological study comprised all consecutive adult stays (n = 320) in 18 medical intensive care units (ICU) or intermediate care wards (ICW) for probable or confirmed Influenza virus infection during the 2017–2018 flu season.ResultsPatients admitted to ICU/ICW had low vaccination coverage (21%), required life support in 60% of cases, stayed in the ICU for a median of 8 days, and had high 28-day mortality rate (19.7%; 95% confidence interval 15.5–24.5). Early prognostic factors included age, core temperature, the acute organ failures score, and the early administration of antiviral therapy.ConclusionsData directly extracted from the electronic medical records stored in the data warehouse provide detailed clinical, care pathway and prognosis information. The real-time availability should enable to detect and assess the burden of the most severe cases. By a firmer and more acute monitoring and adjustment of care and patient management, hospitals could generate more ICU/ICW capacities, sensitize their emergency department and contribute to the recommendations from health authorities. This pilot study is of particular relevance in the context of emerging epidemics of severe acute respiratory diseases.

The practice of rheumatology during the covid-19 pandemic

The COVID-19 pandemic has imposed many challenges that have ranged from migrating to new technologies to returning to an ICU or intermediate care ward. In the Pan-American Day of Rheumatology framework, we look at the challenges faced and at what is to come regarding patient care in this specialty.

Effects of the first lockdown of the COVID-19 pandemic on the trauma surgery clinic of a German Level I Trauma Center

PurposeThe effects of the first pandemic wave on a German Level I Trauma Center should be evaluated to find ways to redistribute structural, personnel, and financial resources in a targeted manner in preparation for the assumed second pandemic wave.MethodsWe examined the repercussions of the first wave of the pandemic on the trauma surgery clinic of a Level I Trauma Center and compared the data with data from 58 other trauma clinics. The results could aid in orientating the distribution of structural, financial, and human resources (HR) during the second wave. The period between March 16 and April 30, 2020 was compared with the data over the same period during 2019. Information was collected from the HR department, central revenue management, and internal documentation.ResultsThe proportion of trauma surgical patients in the emergency room decreased by 22%. The number of polytrauma cases increased by 53%. Hospital days of trauma surgery patients in the intensive and intermediate care wards increased by 90%. The number of operations decreased by 15%, although the operating time outside of normal working hours increased by 44%. Clinics with more than 600 beds recorded a decrease in cases and emergencies by 8 and 9%, respectively, while the Trauma Center showed an increase of 19 and 12%. The results reflect the importance of level I trauma centers in the lockdown phase.ConclusionTo reduce the risk of an increased burden on the healthcare infrastructure, it suggests the care of trauma and COVID-19 patients should be separated locally, when possible.

Knowledge gained from a 31-h power outage in Berlin Köpenick-medical problems and challenges

Am 19.02.2019 kam es nach Durchtrennung eines 110-kV-Kabels zu einem großflächigen Stromausfall im Berliner Bezirk Treptow-Köpenick. Nachfolgend waren ca. 30.000 Haushalte ohne Strom; betroffen waren ca. 70.000 Menschen. Der Stromausfall dauerte mehr als 24 h an und stellte alle Beteiligten vor eine Vielzahl von Herausforderungen. Es wurde der Führungsstab (operativ-taktisch) einberufen, in dem auch medizinische Schwerpunkte fortlaufend identifiziert und reevaluiert werden mussten. Hierbei handelte es sich mitunter um die Identifikation von besonders gefährdeten Patienten wie beispielsweise heimbeatmeten Patienten oder Patienten mit Kunstherz. Weiterhin mussten einzelne Pflegeheime evakuiert werden. Im Verlauf war es notwendig, aufgrund des Ausfalls der Stromversorgung im Schadensgebiet, eine Intensivstation bzw. „Intermediate-care“-Station mit 23 Patienten zu evakuieren. Krankenhäuser müssen sich im Rahmen von Vorplanungen auf derartige Szenarien einstellen. Weiterhin müssen seitens der zuständigen Behörden Vorplanungen erfolgen, die die besonderen Bedürfnisse von vulnerablen Gruppen beinhalten.

Empirical Antibiotic Therapy Assessment of Patients diagnosed with Sepsis in Intermediate Care Ward of Internal Medicine Department of Dr. Soetomo General Hospital according to Gyssens Method

Rational empirical antimicrobial therapy is an important component of sepsis patient management. This study aimed to assess the rationality of empirical antimicrobial therapy in patients diagnosed with sepsis admitted in intermediate care ward of internal medicine department (RPI) of Dr. Soetomo General Hospital from January 2016 to July 2017. Medical records of 91 patients diagnosed with sepsis were collected and studied retrospectively in period from July 2017 to November 2017. 91 (85.05%) medical records from 107 sepsis patients were evaluated. Cultures and antimicrobial sensitivity tests were carried out in 21 (23.07%) patients. 14 patients yielded positive culture results, 9 of which were MDRO positive with ESBL as resistant marker. Empirical antibiotic therapies for these patients were reviewed according to Gyssens method.73 (80.2%) of 91 patients were deemed receiving appropriate empirical antibiotic therapies. Ceftriaxone IV injection as monotherapy or combination therapy were the most common empirical antibiotic therapies (82 in 91 patients, 90.1%), despite local microbiologic flora and antibiogram show most pathogens were resistant to ceftriaxone. Mortality rate in this study was high, 92.3% (84 patients died) despite rational empirical antibiotic therapies were high.This study concluded that empirical antibiotic therapies in sepsis patients according to guidelines adopted in Soetomo General Hospital, albeit deemed rational, was no longer appropriate according to local antibiogram issued by microbiological department of Soetomo General Hospital.

Palliative sedation : Development and consensus of aGerman language documentation template

Palliative sedation (PS) serves as atherapeutic option in cases of otherwise intractable suffering. As the use of sedative and hypnotic medication in many diverse situations is acore competency of anesthesiology, anesthesiologists are confronted with questions of sedative therapy at the end of life in institutions for specialized palliative care, in intensive care units and intermediate care wards. In recent years anumber of guidelines have been published internationally but so far no official guidelines exist in Germany. The most recognized document is the European Association for Palliative Care (EAPC) framework on PS. This project aims to develop aGerman language template for the preparation, application, documentation and evaluation of PS according to the current frameworks, especially the EAPC framework on PS. Afirst draft of the template was generated by the project team using the EAPC framework and individual templates of various institutions, which had been collected during aprevious project. Professionals (n = 136) from inpatient and outpatient specialist palliative and hospice care were invited to assess all items of the draft regarding "relevance", "wording" and "feasibility" in an online Delphi survey (Unipark®, Questback, Cologne, Germany). After the second Delphi round an expert panel was asked to reflect the results and generate afinal draft. Approval was granted if acceptance exceeded 75% of participants. The 3rounds of the Delphi process were completed by 64, 46 and 41participants, respectively. The Delphi process as well as the expert panel led to significant changes of the template. The indications for PS had to be clarified. The significance of documentation of vital parameters, such as oxygen saturation, blood pressure or respiratory rate during PS was intensively discussed. In many teams, predominantly hospice or outpatient palliative care teams, it seems to be difficult to measure these parameters or it is regarded as inappropriate in apalliative care setting. In contrast, the EAPC framework recommends monitoring of vital parameters in cases of intermittent or respite sedation. Finally, asolution was found to support documentation of additional data without the explicit mentioning of specific parameters. After the third Delphi round, all 16items of the documentation template reached consensus with respect to relevance (82.9-100%), clarity of wording (80.5-100%), and feasibility in practice (78-100%). This article provides an empirically based, multiprofessional consented documentation template for PS. Core elements of the documentation of PS are the indications and the decision process towards PS. During the treatment, at least the level of sedation and the symptom burden have to be recorded. The documentation of vital signs during PS remains ahighly disputed topic. The presented data suggest that especially in outpatient settings and in hospices measuring and documentation of vital parameters is uncommon and therefore is often regarded as not feasible. This template can help to support the medically and ethically sound use of PS and facilitate research. The template can be accessed at http://www.palliativmedizin.uk-erlangen.de/forschung/downloads/ .

ROZWÓJ SŁUCHU U DZIECI Z ODDZIAŁÓW INTENSYWNEJ TERAPII I POŚREDNIEJ OPIEKI ZDROWOTNEJ W BRAZYLII

BackgroundUnidentified hearing loss at birth can badly affect the linguistic, social, and educational development of children. National and international committees on infant hearing emphasize the importance of early identification of hearing loss, with follow-up and early intervention. The aim of this study was to analyze data on hearing development from a program following up exits from the Neonatal Intensive Care Unit (NICU) and from neonatal intermediate care wards in Prof. Dr. Jose Aristodemo Pinotti Women’s Hospital in the Brazilian State of Sao Paulo.Material and MethodsThis was a retrospective study based on records from a follow-up program. Data came from records collected from 2012 to 2015 on 88 subjects, and included the results of behavioral hearing tests, visual reinforcement audiometry and tympanometry. The data were descriptively and statistically analyzed.ResultsChanges in the development of hearing abilities over the first two years of life in children that stayed at the NICU or the intermediate care ward for more than 48 hours were significant. However, late-onset or progressive hearing losses were not observed. There was no correlation between hearing development and specific risk indicators or with tympanometry.ConclusionsFor the analyzed program, progressive or late-onset losses were not found, but there were major delays in the development of hearing abilities in the first two years of life for children from NICU and neonatal intermediate care wards.

Independent Risk Factors for Fast-Track Failure Using a Predefined Fast-Track Protocol in Preselected Cardiac Surgery Patients.

The purpose of this study was to identify the independent risk factors for fast-track failure (FTF) in cardiac surgery patients. A retrospective analysis. A university-affiliated heart center. In a 2-year period, 1,704 consecutive preselected patients undergoing elective cardiac surgery were treated according to the local fast-track protocol in the postanesthetic care unit (PACU), bypassing the intensive care unit (ICU). Independent risk factors for FTF in the univariate regression analysis were tested in a multivariate regression analysis. FTF was defined as any transfer of the preselected patient to the ICU. FTF was primary when the patient was transferred directly from the postanesthetic care unit to the ICU and secondary when the patient was transferred from the intermediate care unit or ward to the ICU. FTF rate was 11.6% for primary and 5.6% for secondary FTF. In the multivariate regression analysis, age>70 years, female sex, prolonged surgery, and prolonged cross-clamp time could be defined as independent risk factors for FTF. In a preselected patient population, fast-track treatment could be done with a low FTF rate. Independent risk factors for FTF are age, female sex, prolonged surgery, and prolonged cross-clamp time.

The characterization of noise levels in a neonatal intensive care unit and the implications for noise management

The effects of noise are particularly harmful for the newborns, and therefore this study assesses and characterizes noise levels in a neonatal intensive care unit (NICU) in a medium-size hospital in the city of Huelva with the aim of optimizing the management and quality of care for newborns. The equivalent continuous sound level was recorded as A-weighting curves using Type I sound level meters with levels measured during 100 milliseconds along to 15-day period in the both critical (in and out of incubators), and intermediate care units from a medium-size hospital. These devices were attached to a central beam 80 cm below the ceiling and into one of the incubators. The maximum noise levels measured for critical (C-in), C(out) and intermediate (I) were: 88.8 dBA, 97.2 dBA and 92.4 dBA, respectively, while for the equivalent noise levels for the total measuring period (15 d) were 57.0 dBA, 63.7 dBA, and 59.7 dBA, respectively. The Fourier frequency analysis has demonstrated several typical periods related to both work activities and family visit, which were: 7 days, 24 h, 12 h, and 3 h. The statistical analysis revealed a clear correlation between the noise level, the kind of care room, and the time of the day. The results show that the values recommended by international bodies and agencies (AAP, WHO) are surpassed by a large margin, thus making it crucial that certain norms are followed in order to reduce the noise level in the NICU, by means of physical alterations to the layout, and raising awareness of health care personnel and visitors in order to encourage noise prevention in the daily care work and conversation. And finally, has been demonstrated that by applying the t-Student test the mean noise values in both wards are significantly different, which leads us to state that the noise level for the critical wards are higher than in the intermediate care ward.

Mini Nutritional Assessment as a Useful Method of Predicting the Development of Pressure Ulcers in Elderly Inpatients

To determine the usefulness of the Mini Nutritional Assessment (MNA) and plasma amino acid analysis in predicting the formation of pressure ulcers (PUs) in inpatients. Prospective, observational cohort study with a mean observation period of 62.2 ± 86.4 days. Intermediate and acute care wards of a hospital in rural Japan. Inpatients with an average age of 85.0 ± 7.6 (N = 422). Mini Nutritional Assessment, Subjective Global Assessment (SGA), Braden Scale (PU prognostic score), PU formation, and biochemical analysis including plasma amino acid concentrations. PUs developed in 7.1% of participants. A MNA score of less than 8 was more sensitive than a rating of moderate or severe malnourishment on the SGA combined with a Braden Scale score of less than 15 in predicting future PUs. The area under the receiver operating characteristic curve (AUC) of the MNA was superior to that of the Braden Scale. The Braden Scale nutrition subscore had the lowest AUC of the six Braden Scale subscores. Individuals who developed PUs had significantly lower plasma arginine concentrations than those who did not. Mini Nutritional Assessment was able to predict the development of PUs. A MNA score of less than 8 performed better than the SGA, Braden Scale, and plasma arginine levels in predicting PU development. Although lower plasma arginine concentration at time of admission was associated with PU development, the AUC for arginine was not significantly different from 0.50. The findings from this prospective study support the use of nutritional assessment in inpatients to predict PU risk and target appropriate interventions.

High proportion of healthcare-associated urinary tract infection in the absence of prior exposure to urinary catheter: a cross-sectional study

BackgroundExposure to urinary catheters is considered the most important risk factor for healthcare-associated urinary tract infection (UTI) and is associated with significant morbidity and substantial extra-costs. In this study, we assessed the impact of urinary catheterisation (UC) on symptomatic healthcare-associated UTI among hospitalized patients.MethodsA nationwide period prevalence survey of healthcare-associated infections was conducted during 1 May to 30 June 2004 in 49 Swiss hospitals and included 8169 adult patients (4313 female; 52.8%) hospitalised in medical, surgical, intermediate, and intensive care wards. Additional data were collected on exposure to UC to investigate factors associated with UTI among hospitalised adult patients exposed and non-exposed to UC.Results1917 (23.5%) patients were exposed to UC within the week prior to survey day; 126 (126/8169; 1.5%) developed UTI. Exposure to UC preceded UTI only in 73 cases (58%). By multivariate logistic regression analysis, UTI was independently associated with exposure to UC (odds ratio [OR], 3.9 [95% CI, 2.6-5.9]), female gender (OR, 2.1 [95% CI, 1.4-3.1]), an American Society of Anesthesiologists’ score > 2 points (OR, 3.2 [95% CI, 1.1-9.4], and prolonged hospital stay >20 days (OR, 1.9 [95% CI, 1.4-3.2]. Further analysis showed that the only significant factor for UTI with exposure to UC use was prolonged hospital stay >40 days (OR, 2.9 [95% CI, 1.3-6.1], while female gender only showed a tendency (OR, 1.6 [95% CI, 1.0-2.7]. In the absence of exposure to UC, the only significant risk factor for UTI was female gender (OR, 3.3 [95% CI, 1.7-6.5]).ConclusionsExposure to UC was the most important risk factor for symptomatic healthcare-associated UTI, but only concerned about half of all patients with UTI. Further investigation is warranted to improve overall infection control strategies for UTI.

Die positive T-Welle in V1 als Hinweis auf eine signifikante KHK

The 56-year-old man came to our emergency department because of heartburn, chest tightness and sweating. Cardiovascular risk factors were obesity and hypertension. Clinical examination revealed no significant abnormalities. Laboratory results showed no pathologies except a slightly elevated creatinine (1,19 ng/dl). Troponin I ultra sensitive was negative (< 0,006 ng/ml), CK and CK-MB not elevated. The 12-channel-ECG revealed sinus rhythm with a heart rate of 68/min, a non-significant ST-elevation in V2 as well as elevated T-waves in V1 and V2. The T-wave in V1 was positive (> 0,15 mV) and bigger than the T-wave in V6. The patient was monitored at our intermediate-care ward. The troponin level was checked again after about four hours and showed a troponin of 1,519 ng/ml (norm: 0,02 - 0,06 ng/ml). NSTEMI was diagnosed and coronary angiography was performed next morning, demonstrating coronary three vessel disease with 95 % occlusion of the left anterior descending (LAD). An upright T-wave in V1 can be an indicator for coronary artery disease (CAD). A bigger T-wave in V1 than in V6 can indicate CAD with LAD involvement. Therefore, in patients with thoracic pain and a positive T-wave in V1 cardiac ischemia should be considered.