Public Intensive Care Unit Research Articles

Assessing quality of critical care during an ongoing health emergency-a novel approach to evaluate quality of care at Lebanese public ICUs during COVID-19.

Quality of care has been systematically monitored in hospitals in high-income countries to ensure adequate care. However, in low- and middle-income countries, quality indicators are not readily measured. The primary aim of this study was to assess to what extent it was feasible to monitor the quality of intensive care in an ongoing health emergency, and the secondary aim was to assess a quality of care intervention (twinning project) focused on Intensive Care Unit (ICU) quality of care in public hospitals in Lebanon. We conducted a retrospective cohort study nested within an intervention implemented by the World Health Organization (WHO) together with partners. To assess the quality of care throughout the project, a monitoring system framed in the Donabedian model and included structure, process, and outcome indicators was developed and implemented. Data collection consisted of a checklist performed by external healthcare workers (HCWs) as well as collection of data from all admitted patients performed by each unit. The association between the number of activities within the interventional project and ICU mortality was evaluated. A total of 1679 patients were admitted to five COVID-19 ICUs during the study period. The project was conducted fully across four out of five hospitals. In these hospitals, a significant reduction in ICU mortality was found (OR: 0.83, P < 0.05, CI: 0.72-0.96). We present a feasible way to assess quality of care in ICUs and how it can be used in assessing a quality improvement project during ongoing crises in resource-limited settings. By implementing a quality of care intervention in Lebanon's public hospitals, we have shown that such initiatives might contribute to improvement of ICU care. The observed association between increased numbers of project activities and reduced ICU mortality underscores the potential of quality assurance interventions to improve outcomes for critically ill patients in resource-limited settings. Future research is needed to expand this model to be applicable in similar settings.

Physiotherapy services in intensive care. A workforce survey of Australia and New Zealand

BackgroundIn Australia and New Zealand, there are currently no recommendations to guide staffing levels for intensive care unit (ICU) physiotherapy services, and there is limited information about the current services provided. ObjectivesThe objective of this study was to document the profile of intensive care physiotherapy services currently offered in Australia and New Zealand. MethodsA binational survey was distributed to physiotherapists. The survey sought information on staffing and service profiles for weekday, weekend, and after-hour services including on-call and evening shifts. ResultsEighty-six sites completed the survey, with responses primarily from Level 3 (47/86, 55%) and public ICUs (74/86, 86%). For weekday services, the ratio of full-time equivalent physiotherapy staff allocated per bed was similar between all intensive care levels (0.11 [0.08–0.15], p = 0.421). Thirty respondents (35%) were satisfied with their staffing and reported higher levels of physiotherapy staff per bed (0.15 [0.1–0.2], p < 0.001). Most sites reported lower levels of staffing for weekend services (76/86, 88%), and many physiotherapists indicated that they were not satisfied with this service (55/86, 64%). Most Level 2, Level 3, and paediatric ICUs had a designated senior physiotherapist, with similar levels of senior physiotherapy staff allocated per bed between all ICU levels (0.05 [0.03–0.08], p = 0.844). Few sites reported dedicated staff attributed to intensive care education, research, tracheostomy service, or outreach roles. On-call physiotherapy services were available in 49 of 86 (57%) hospitals surveyed; however, utilisation of the service by ICUs was mainly reported to be less than once per month (19/49, 39%). ConclusionsPhysiotherapy staffing ratios were similar across different ICU levels. While weekend services are available for most ICUs, staffing levels are reduced. Higher staffing ratios were associated with higher levels of satisfaction to complete professional roles and responsibilities.

The impact of language barriers & interpreters on critical care patient outcomes

BackgroundIn a multicultural society, the impact of language proficiency and interpreter use on critical care patient outcomes is unknown. ObjectiveTo investigate the relationship between English language preference, requirement for an interpreter and in-hospital mortality amongst non-elective intensive care unit (ICU) patients. MethodAdult patients admitted to all 23 public ICUs within the state of Victoria, Australia from July 2007 to June 2018, were extracted from The Australian New Zealand Intensive Care Society Adult Patient Database. De-identified patient data was matched using probabilistic methods and statistical linkage keys to the Victorian Admitted Episodes Database. Patients were classified into one of three groups: ‘English preferred’, ‘English not preferred’ and ‘Interpreter required’. Results126,891 ICU admissions were analysed, of whom 3394 (3%) were in the ‘English not preferred’ group and 6355 (5%) in the ‘Interpreter required’ group. Compared to the ‘English preferred’, both the ‘English not preferred’ and ‘Interpreter required’ groups were older, had more co-morbidities and higher severity of illness scores. In-hospital mortality was 13.1% in the ‘English preferred’ group, 19.6% in the ‘English not preferred’ group and 16.7% in the ‘Interpreter required’ group. However, after adjusting for sex, severity of illness and socio-economic status, the ‘English not preferred’ group remained with a higher risk adjusted mortality (OR 1.21, 95%CI 1.07–1.36, P = 0.002), whereas the ‘Interpreter required’ group had a lower adjusted risk of mortality (OR 0.81, 95%CI 0.74–0.89, P < 0.001). ConclusionBeing identified as having a requirement for an interpreter was associated with improved outcomes for adults admitted to public hospital ICUs in Victoria. Interpreter services should be more readily available in the hospital setting. It is recommended that patients, family members and clinicians actively use interpreter services when English is not the preferred language of an ICU patient.

Comparison of the predictive ability of clinical frailty scale and hospital frailty risk score to determine long-term survival in critically ill patients: a multicentre retrospective cohort study

BackgroundThe Clinical Frailty Scale (CFS) is the most commonly used frailty measure in intensive care unit (ICU) patients. The hospital frailty risk score (HFRS) was recently proposed for the quantification of frailty. We aimed to compare the HFRS with the CFS in critically ill patients in predicting long-term survival up to one year following ICU admission.MethodsIn this retrospective multicentre cohort study from 16 public ICUs in the state of Victoria, Australia between 1st January 2017 and 30th June 2018, ICU admission episodes listed in the Australian and New Zealand Intensive Care Society Adult Patient Database registry with a documented CFS, which had been linked with the Victorian Admitted Episode Dataset and the Victorian Death Index were examined. The HFRS was calculated for each patient using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes that represented pre-existing conditions at the time of index hospital admission. Descriptive methods, Cox proportional hazards and area under the receiver operating characteristic (AUROC) were used to investigate the association between each frailty score and long-term survival up to 1 year, after adjusting for confounders including sex and baseline severity of illness on admission to ICU (Australia New Zealand risk-of-death, ANZROD).Results7001 ICU patients with both frailty measures were analysed. The overall median (IQR) age was 63.7 (49.1–74.0) years; 59.5% (n = 4166) were male; the median (IQR) APACHE II score 14 (10–20). Almost half (46.7%, n = 3266) were mechanically ventilated. The hospital mortality was 9.5% (n = 642) and 1-year mortality was 14.4% (n = 1005). HFRS correlated weakly with CFS (Spearman’s rho 0.13 (95% CI 0.10–0.15) and had a poor agreement (kappa = 0.12, 95% CI 0.10–0.15). Both frailty measures predicted 1-year survival after adjusting for confounders, CFS (HR 1.26, 95% CI 1.21–1.31) and HFRS (HR 1.08, 95% CI 1.02–1.15). The CFS had better discrimination of 1-year mortality than HFRS (AUROC 0.66 vs 0.63 p < 0.0001).ConclusionBoth HFRS and CFS independently predicted up to 1-year survival following an ICU admission with moderate discrimination. The CFS was a better predictor of 1-year survival than the HFRS.

Preparation for airway management in Australia and New Zealand ICUs during the COVID -19 pandemic.

BackgroundThis paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM).Methods and findingsProspective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE “spotters” (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%).ConclusionThere was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines.

Nurses' Knowledge on Sepsis Related to Mechanical Ventilation: An Intervention Study.

Sepsis is a leading cause of mortality and morbidity worldwide. South African adult public critical care units experience incidences of sepsis on an ongoing basis. Nurses caring for mechanically ventilated adult patients in intensive care units (ICUs) need to base their nursing care on "surviving sepsis campaign" (SSC) guidelines to properly manage sepsis. Adequate knowledge on sepsis guidelines remains crucially indicated for nurses as they endeavor to maintain asepsis in critically ill patients. This study was conducted to assess the effect of an educational intervention on nurses' knowledge and practices of sepsis in mechanically ventilated adult patients in public ICUs. An intervention study, with quasi-intervention two-group, pretest-posttest design, was used to collect data using a self-administered, structured, pretest and posttest questionnaire designed to measure nurses' knowledge and practices on sepsis related to mechanical ventilation. The study was conducted between June and October 2018. An educational intervention was developed and validated. Five purposively selected public ICUs in the Eastern Cape, South Africa, were selected and assigned to three groups: Intervention Group 1 (ICUs 1 and 2), which received the full intervention (containing a 20-minute PowerPoint presentation, printed materials based on sections of the SSC guidelines, and monitoring visits bimonthly for 3 months); Intervention Group 2 (ICUs 3 and 4; receiving the same as Intervention Group 1 but with no monitoring visits); and the control group (ICU 5; receiving no intervention). One hundred seventeen nurses completed the questionnaires at pretest, and 94 completed the questionnaires at posttest, producing a response rate of 79% and 80%, respectively. The results revealed a significant knowledge score increase between pretest and posttest for both Intervention Group 2 (53.28 ± 14.39 and 62.18 ± 13.60, respectively; p = .004) and the control group (56.72 ± 13.72 and 70.05 ± 12.40, respectively; p = .001). Similarly, a recommended practice score increase was shown for Intervention Group 2 (58.8 ± 9.63 and 62.80 ± 9.52, respectively), and a significant increase was shown for the control group (56.72 ± 7.54 and 63.29 ± 5.89, respectively; p = .002). Intervention Group 1 showed a detectable but not significant decline in knowledge (57.72 ± 13.99 and 54.61 ± 12.15, respectively) and recommended practice (61.22 ± 8.66 and 60.33 ± 7.83, respectively) scores. The availability of SSC guidelines was found to have increased knowledge on sepsis related to mechanical ventilation, although including monitoring visits as part of the educational intervention was not found to have a positive effect on increasing knowledge and practices. Further studies are required to explore factors contributing to improving knowledge and practices on sepsis related to mechanical ventilation and the effect that various educational interventions have in this context.

Impact of language barriers and interpreter requirement on non-elective intensive care patient outcomes

Background: In a multicultural society, limited data is available on the impact of language proficiency and utilisation of interpreters on critical care patient outcomes. Objective To investigate the relationship between hospital outcomes of non-elective intensive care unit (ICU) patients with language barriers and interpreter requirement. Methodology: Patients admitted to 23 adult public ICUs within the state of Victoria, Australia from July 2007 to June 2018, were extracted from The Australian New Zealand Intensive Care Society Adult Patient Database. De-identified patient data was matched using probabilistic methods and statistical linkage keys to the Victorian Admitted Episodes Database. Patients were classified into one of three groups; English as preferred language (EPL), English not-preferred language (ENPL), and English not-preferred language, interpreter required (ENPL-IR). Results: ICU admissions (n=126,891) were analysed of whom 6,355 (5%) were in the ENPL-IR group and 3,394 (3%) in the ENPL group. Compared to EPL, both groups of ENPL were older, had more co-morbidities and higher severity of illness scores. In-hospital mortality was 13.1% in EPL, 16.7% in the ENPL-IR group and 19.6% in the ENPL group. However, after adjusting for age, severity of illness and socio-economic status, the ENPL group remained with a higher risk adjusted mortality (OR 1.21, 95%CI 1.07-1.36, P = 0.002), whereas ENPL-IR group had a lower risk adjusted mortality (OR 0.81, 95%CI 0.74-0.89, P<0.001). Conclusion: The requirement for an interpreter is strongly associated with improved hospital outcomes for non-elective ICU patients with English as a non-preferred language. In view of these results, it is recommended that patients, family members and clinicians utilise interpreter services when English is not the preferred language of an ICU patient.

Adherence to international recommendations of physiotherapy in Chilean adult intensive care units

International recommendations propose the presence of physiotherapists with specialized training in critical patients, available 24 hours a day and 7 days a week (24/7-PT) in the Intensive Care Unit (ICU), with a standardized physiotherapist/patient ratio of 1 per 5 beds in high complexity units. It is unknown if the organizational characteristics of the ICUs are related to the adherence with these recommendations. Objective: To determine the relationship between the organizational characteristics and the adherence of international recommendations of physiotherapy care, in adult ICUs at a national level. Methods: Secondary database analysis, with information from 86% of adult Chilean ICUs. The organizational characteristics (origin of the ICU, number of beds, level of complexity and technical-administrative dependency of the physiotherapist) were related to 24/7-PT availability, physiotherapist/patient ratio of 1 per 5 beds and presence of physiotherapy specialists. Results: Out of 64 adult ICUs, a 70% (n=45) have 24/7-PT availability. Physiotherapist/patient ratio was observed during weekdays in half of the private centers during day shifts. Presence of physiotherapy specialists was detected in 31% of the private sector. Significant differences were found between the number of beds and the probability to accomplish 24/7-PT availability and physiotherapist/patient ratio (p<0.001 and p=0.34 respectively). The probability that a unit complies 24/7-PT availability differs significantly depending on the technical-administrative dependency (p<0.001). No significant relationship was found between the level of complexity and the adherence to the international recommendations. A greater adherence to 24/7-PT availability in public ICUs (OR 5.21, 95%CI 1.37-19.81) and when physiotherapist-dependence became the Critical Patients Unit (OR 6.59, 95%CI 1.41-30.80) was evidenced. Conclusions: The origin of the ICU and the technical-administrative dependence seem to be relevant for the compliance of 24/7-PT availability. Future studies should be aimed at identifying the causes of this relationship, in order to optimize the human resources in the ICU.

The effect of the Greek financial crisis on the operation of public intensive care units

SUMMARYThe National Healthcare System in Greece has taken a serious blow by the financial crisis the country has been experiencing for the past 9 years. The operation of the Intensive Care Units (ICUs) in public hospitals could not remain unaffected, since the largest part of their funding comes from the state’s budget.Objective: To investigate the effect of the financial crisis on the operation of public ICUs in Greek hospitals.Method: Narrative literature review including Greek and English language articles in medical databases such as PUBMED, CINAHL, and in websites of Greek newspapers and other media.Results: During the crisis years, a clear shift of healthcare users from the private sector to public hospitals, together with a significant reduction of functional beds in the ICUs of public hospitals have created significant ICU bed shortages and rendered Greek ICUs clearly incapable of meeting nationwide needs. The doctors and nurses employed in public ICUs are not sufficient, and, subsequently, a decline in the quality of the healthcare provided to the critically ill has been noted.Conclusions: The situation in Greek public ICUs is critical. Without sufficient state funding, staff and ICU-bed shortages increase the likelihood that the care provided within Greek ICUs will deviate from international standards.

A comparison of private and public sector intensive care unit infrastructure in South Africa.

Intensive care units (ICUs) are designed to care for patients who are often at increased risk of acquiring healthcare-associated infections. The structure of ICUs should be optimally designed to facilitate the care of these critically ill patients, and minimise their risk of infection. National regulations (R158) were developed to govern the building and registration of private hospitals, and until recently equivalent regulations were not available for public hospitals. To assess and compare the compliance of ICUs in the private and public sectors with the R158 regulations. A cross-sectional study design was used to assess the infrastructure of 25 private sector and 6 public sector ICUs in eThekwini Health District, KwaZulu-Natal Province, South Africa. We used the R158 checklist, which was developed by the KwaZulu-Natal Department of Health Private Licensing Unit and Infection Prevention and Control Unit. The aspects covered in the R158 checklist were categorised into the design, general safety and patient services of the ICUs. Most of the ICUs in both sectors met the general safety requirements. There were varying levels of compliance with the design criteria. Only 7 (28.0%) and 1 (16.7%) of the private and public ICUs, respectively, had sufficient space around the beds. Twenty-two private ICUs (88.0%) and 4 public ICUs (66.7%) had isolation rooms, but only some of these isolation rooms (15 private and 2 public) had appropriate mechanical ventilation. None of the ICUs had clinical hand-wash basins in the nurse stations and dirty utility rooms. The majority of the ICUs had the required number of oxygen and electric outlets at the bedside. None of the public ICUs met the light intensity requirement over the bed area. Adequate spacing in ICUs is an issue in many cases. Interventions need to be put in place to ensure that ICUs meet the relevant design standards. There is an urgent need to revise the R158 regulations to reflect current best practices, particularly with regard to infection control. The same standards should be applied to ICUs in the private and public health sectors to maintain quality of care to patients.

Predicting Mortality in Low-Income Country ICUs: The Rwanda Mortality Probability Model (R-MPM).

IntroductionIntensive Care Unit (ICU) risk prediction models are used to compare outcomes for quality improvement initiatives, benchmarking, and research. While such models provide robust tools in high-income countries, an ICU risk prediction model has not been validated in a low-income country where ICU population characteristics are different from those in high-income countries, and where laboratory-based patient data are often unavailable. We sought to validate the Mortality Probability Admission Model, version III (MPM0-III) in two public ICUs in Rwanda and to develop a new Rwanda Mortality Probability Model (R-MPM) for use in low-income countries.MethodsWe prospectively collected data on all adult patients admitted to Rwanda’s two public ICUs between August 19, 2013 and October 6, 2014. We described demographic and presenting characteristics and outcomes. We assessed the discrimination and calibration of the MPM0-III model. Using stepwise selection, we developed a new logistic model for risk prediction, the R-MPM, and used bootstrapping techniques to test for optimism in the model.ResultsAmong 427 consecutive adults, the median age was 34 (IQR 25–47) years and mortality was 48.7%. Mechanical ventilation was initiated for 85.3%, and 41.9% received vasopressors. The MPM0-III predicted mortality with area under the receiver operating characteristic curve of 0.72 and Hosmer-Lemeshow chi-square statistic p = 0.024. We developed a new model using five variables: age, suspected or confirmed infection within 24 hours of ICU admission, hypotension or shock as a reason for ICU admission, Glasgow Coma Scale score at ICU admission, and heart rate at ICU admission. Using these five variables, the R-MPM predicted outcomes with area under the ROC curve of 0.81 with 95% confidence interval of (0.77, 0.86), and Hosmer-Lemeshow chi-square statistic p = 0.154.ConclusionsThe MPM0-III has modest ability to predict mortality in a population of Rwandan ICU patients. The R-MPM is an alternative risk prediction model with fewer variables and better predictive power. If validated in other critically ill patients in a broad range of settings, the model has the potential to improve the reliability of comparisons used for critical care research and quality improvement initiatives in low-income countries.

Safety climate in 5 intensive care units: A nationwide hospital survey using the Greek-Cypriot version of the Safety Attitudes Questionnaire

BackgroundPatient safety is considered an antecedent of quality of hospital care. The explicit need to focus on quality of care underpins the aim of the study to evaluate the safety culture and teamwork climate in the public intensive care units (ICUs) of the 5 regional public hospitals in Cyprus as measured by a validated safety attitudes tool. MethodsA questionnaire that included the Greek version of the generic version of the Safety Attitudes Questionnaire has been used in all public ICUs across Cyprus. ResultsThere were 132 (76.7%) fully completed questionnaires of 172 registered nurses who are currently positioned in Cyprus ICUs. The mean age of the participants was 33.09 ± 08.16 years. The mean of the total working years as a nurse was 10.82 ± 8.47 years, whereas the mean of the total work experience in the ICU units was 6.05 ± 5.16 years. The sample's age strongly correlated with teamwork, nurses with more years of experience rated higher teamwork (P = .02), and their perceptions of management were better than those of the inexperienced nurses. ConclusionsConsiderable safety climate variations between the ICUs of the regional hospitals of Cyprus have been verified. Age, infrastructure, the severity of cases, and the nurse skill mix are variables that affect the patient safety culture in an ICU environment.

Withholding and Withdrawal of Therapy in New Zealand Intensive Care Units (ICUs): A Survey of Clinical Directors

Withdrawing and withholding life-support therapy in patients who are unlikely to survive despite treatment are common practices in intensive care units (ICUs). The literature suggests there is a large variation in practice between different ICUs in different parts of the world. We conducted a postal survey among all public ICUs in New Zealand to investigate the pattern of practice in withholding and withdrawal of therapy. Nineteen ICUs responded to this survey and they represented 74% of all the public ICU beds and 83% of the annual ICU admissions. The percentage of ICU admissions with therapy withdrawn or withheld was less than 10% in most ICUs. Only a small percentage (21%) of ICUs had a formal policy in withholding and withdrawal of therapy. The timing of making the decision to withhold or withdraw therapy was very variable. The patient and/or the family, the primary medical team consultant, two or more ICU consultants, and ICU nurses were usually involved in the decision making process. ICU nurses were more commonly involved in the decision making process in smaller ICUs (5 beds vs 10 beds, P = 0.03). The patient's pre-ICU quality of life, medical comorbidities, predicted mortality, predicted post-ICU quality of life, and the family's wishes were important factors in deciding whether ICU therapy would be withheld or withdrawn. Hospice ward or the patient's home was the preferred place for palliative care in 32% of the responses.

Standing with assistance of a tilt table in intensive care: A survey of Australian physiotherapy practice

Although tilt tables are used by physiotherapists to reintroduce patients to the vertical position, no quantitative evidence is available regarding their use within intensive care units (ICUs) of Australian hospitals. The purpose of this study was to evaluate the use of tilt tables in physiotherapy management of patients in ICUs across Australia. Ninety-nine physiotherapists working in Australian public ICUs were contacted via mail and asked to complete a questionnaire regarding their use of tilt tables in practice. Reasons for the use of the tilt table, contraindications, commonly used adjuncts, monitoring, and outcome measures were also investigated. Eighty-six questionnaires were returned (87% response). The tilt table was used by 58 physiotherapists (67.4%). The most common reasons for inclusion of tilt table treatment were to: facilitate weight bearing (94.8% of those who tilt); prevent muscle contractures (86%); improve lower limb strength (81%); and increase arousal (70%). The tilt table was most frequently applied to patients with neurological conditions (63.8%) and during long-term ICU stay (43.1%). Techniques often combined with tilt table treatment included upper limb exercises (93.1%) and breathing exercises (86.2%). Standing with assistance of the tilt table is used by the majority of physiotherapists working in Australian ICUs. A moderate level of agreement is demonstrated by physiotherapists regarding indications to commence tilt table treatment and adjunct modalities combined with standing with assistance of the tilt table.