Scottish Intensive Care Units Research Articles

Prevalence of healthcare-associated infection in Scottish intensive care units

A national point prevalence survey of healthcare-associated infection (HCAI) in all acute hospitals, including intensive care units (ICUs), was carried out in Scotland from October 2005 to October 2006. The survey measured the prevalence of HCAIs to determine the burden on ICU resources. HCAI prevalence in ICUs was compared with HCAI prevalence in patients outside ICU. The prevalence of HCAI in ICU patients was 27.1%, significantly higher than HCAI prevalence in patients outside ICU, which was 9.3%. The prevalence of specific infections, namely pneumonia and lower respiratory tract, bloodstream and surgical site infections, was also significantly higher in ICU patients compared with non-ICU patients. These results highlight the burden on ICU resources from all HCAIs, regardless of site of infection. High HCAI prevalence in Scottish ICUs has major implications for patient safety and ICU resources and emphasises the need for continuing strong collaboration between intensivists and infection control teams.

End-of-Life Care in Scottish Intensive Care Units

We wished to assess practice, staff attitudes and desire for change in the way dying patients are cared for in intensive care units (ICUs) in Scotland. A questionnaire was distributed to all 23 general ICUs in Scotland, for medical and nursing staff of all grades to fill in. A dying patient was defined as one in whom a decision had been taken to withdraw or withhold intensive care in the expectation that the patient would die in less than 12 hours; respondents first answered questions about current practice in their ICU, immediately followed by questions concerning ideal practice. The response rate was 62% with the majority of staff being satisfied with current practice, although even the respondents who were satisfied overall would significantly change delivery of care in some areas. A small number (<1%) would not reduce or stop ventilatory, cardiovascular or renal support. In this survey, the withdrawal and limitation of life-sustaining treatment in Scottish ICUs was common, but variable in practice. In...

The Introduction of an Oral Surgical Service in an Intensive Care Unit Serving a Deprived Inner City Population

Much of the population of Glasgow has poor oral health. Poor oral hygiene is associated with the development of ventilator-associated pneumonia (VAP). In a survey of Scottish intensive care units (ICUs), none incorporated oral surgical review into their care. We evaluated the introduction of oral surgical review into our routine practice. An oral surgeon who was experienced in oral care provision in the critically ill reviewed patients who were expected to be mechanically ventilated for more than 48 hours. Oral health was assessed and interventions documented. One hundred patients were examined and forty-seven patients underwent oral surgical intervention. Thirteen patients required dental extraction. Of the patients not requiring additional oral care, 24/53 (45%) were edentulous. Our findings demonstrate that the oral care needs of this patient group were not being met by the current unit oral hygiene protocol. Further work is required to determine the optimal way to provide such a service cost effectively, and its impact on VAP prevention.

Extracorporeal membrane oxygenation in a Scottish intensive care unit

I reflected on the training I had on an extraordinary treatment for profound respiratory failure. The result of training enabled us to successfully treat a young female with the influenza A virus with extracorporeal membrane oxygenation (ECMO). I report the positive outcome that occurred, while continuing to run a busy general intensive care unit (ICU). She was the first of six patients who were all successfully treated with ECMO. Ten trained and experienced critical care nurses and two doctors attended the ECMO training course provided by the national centre in the UK. Five patients had already received ECMO therapy in the Scottish specialist unit (over the period of 8 years). As our Scottish specialist unit purchased exactly the same equipment as the national centre, it was easier for the multidisciplinary team to utilize their new-found knowledge and treat future patients with ECMO. With the predicted swine flu (H1N1) pandemic and the subsequent demand for critical care beds, funding was obtained to facilitate ECMO training. The potential need for increased provision of ECMO therapies was highlighted by recent events in Australia and New Zealand. Their most recent winter produced 68 patients requiring ECMO, whereas the previous year had manifested only three. Using our new equipment and adapted protocols from the national centre, we used these new skills to treat our first patient in October 2009. Johns' reflective practice tool was used to evaluate the care provided. Our patient was on ECMO for 9 days. She went on to make a remarkable recovery and was discharged from the ICU 1 week after ECMO was discontinued. She was discharged to the cardiothoracic high-dependency unit, where she was successfully rehabilitated. We were able to successfully treat a young lady, while providing the care for all other patients. This was a complex treatment, one that uses many resources including time and finance. Now that we have all the equipment, the necessary training and the knowledge, we can continue to deliver this service to the public in our locality.

Thromboprophylaxis in Intensive Care: A Nationwide, Multidisciplinary Quality Improvement Project

Patients admitted to intensive care units (ICUs) are at high risk of developing venous thromboemboli. Pharmacological thromboprophylaxis is efficacious in critically ill patients; however, prescription of such agents is often found to be suboptimal. The aim of this study was to assess the quality of pharmacoprophylaxis prescribing across Scottish ICUs, and to introduce measures to improve this. A point-prevalence survey of thromboprophylaxis was followed by a pharmacist-delivered intervention and a subsequent point-prevalence survey, in 22 Scottish ICUs. In the initial survey, 15% of eligible patients (n=94) were not receiving pharmacoprophylaxis, while 10% of ineligible patients had thromboprophylaxis prescribed. A quality improvement programme was instituted with pharmacist-delivered daily checks for thromboprophylaxis prescription, prompting of medical staff and local checklists. Following implementation of the intervention, a repeat survey of 130 patients revealed that the rate of eligible patients receiving thromboprophylaxis rose to 96%, (p=0.02, relative risk reduction 0.89). Additionally mechanoprophylaxis use increased and those receiving no prophylaxis fell to 8% (p=0.005 relative risk reduction 0.85). The rate of prescription of thromboprophylaxis to ineligible patients was 14% (p=0.65). A simple intervention led to significant improvements in the use of thromboprophylaxis in ICU, with an effect achievable on a national scale.

Observing the approaches to weaning of the long-term ventilated patients

The weaning process from mechanical ventilation is a complicated issue for patients with respiratory failure who require long-term respiratory support. Although the application of weaning protocols reduces weaning time, and enhances patient outcome, little is known about the actual approaches that clinicians use for the weaning of these patients. The purpose of this paper is to explore approaches to weaning of long-term ventilated patients in a Scottish Intensive Care Unit. The findings are part of a larger study on decision-making during the weaning of long-term ventilated patients. Data were collected through participant observation and follow-up interviews with the nursing staff. Twenty-four-hour chart and medical notes review and informal conversation with the bedside nurse were also used to collect information on the weaning process. Nine patients were recruited to the study. Two patients were extubated and three patients were extubated but then required a tracheostomy. A further four patients had a tracheostomy performed. Thematic analysis of the data showed that weaning was individualized, and physician led, regardless of the existence of the weaning protocol. Six different weaning approaches were identified. Nurses followed a conservative approach to weaning in comparison to doctors who appeared more aggressive. There are many varieties in the approaches clinicians use when weaning long-term ventilated patients, which acts on the continuity of their care. A shift of focus to identify ways of maintaining continuity of care and a combined 'wake and wean' approach needs to be considered.

Changes in Management of Septic Shock in Scottish Intensive Care Units after the Publication of the Surviving Sepsis Campaign Guidelines 2008

The 2004 guidelines of the Surviving Sepsis Campaign (SSC)1 for the management of severe sepsis and septic shock included recommendations about glucose control, the use of recombinant human activated protein C (rhAPC) and intravenous steroid replacement, based on original trials by van den Berghe and Annane in 2001 and Bernard (PROWESS) in 2002. In 2008, the SSC revised the international guidelines2 to reflect the results of recent trials (VISEP, CORTICUS, ADDRESS, RESOLVE). Some of these studies completely or partially contradicted results of the earlier trials. We conducted a questionnaire survey of all intensive care units (ICUs) in Scotland six months after publication of the 2008 SSC guidelines to assess current practice.

A psychiatric intensive care unit for older adults: an interval comparison of admissions

Published information on psychiatric intensive care provision and requirements of older adults is limited. This audit aims to describe and compare demographic data, clinical characteristics and outcomes of patients admitted to a Scottish regional psychiatric intensive care unit (PICU) for older adults during two 18-month periods five years apart. Data on all patients admitted to the PICU for older adults during the two sample periods, commencing 2001 and 2006 respectively, were collected prospectively by the clinical care team, and included information on previous psychiatric contact and detentions under mental health legislation, diagnoses, cognitive ratings, reasons for transfer to the PICU, treatments and outcomes. Continuous variables were subject to statistical analyses. Twenty-one and 20 male patients were admitted during the 2001 and 2006 cohorts respectively, with equivalent mean ages of 72.9 years. The majority of patients were married, diagnosed with dementia, with similar levels of previous psychiatric admissions and detentions under mental health legislation. The commonest reason for transfer to the PICU was physical aggression. The 2006 cohort exhibited shorter inpatient stays prior to transfer to, and shorter durations of stay in, the PICU. The PICU for older adults provides a function similar to the PICU for general adults. The cohorts were similar on most recorded variables, with noted differences possibly reflecting increased awareness and acceptance of the service, reduced tolerance by staff of aggressive behaviors by patients, and enhanced community services in the region. These perceptions warrant further study and clarification.

The Influence of the Corticus Study on Steroid Use for Septic Shock in Scottish Intensive Care Units

The publication of the CORTICUS study in January 2008 suggested that the use of low-dose steroids in patients with septic shock did not improve survival or reversal of shock. This result contradicted results from the original trial by Annane in 2002. We carried out a telephone survey of all the intensive care units in Scotland eight weeks following the publication of the CORTICUS study, with the aim of assessing any change in practice since its publication. Prior to CORTICUS, 62% of Scottish intensive care units prescribed steroids routinely in all patients with septic shock requiring vasopressors. Eight weeks following the publication of CORTICUS, only six (25%) units had changed or planned to change their practice. Despite this relatively small change, 50% of the medical staff we questioned claimed that the CORTICUS study had affected their own individual practice.

Uptake of therapeutic hypothermia following out‐of‐hospital cardiac arrest in Scottish Intensive Care Units

Uptake of therapeutic hypothermia following out‐of‐hospital cardiac arrest in Scottish Intensive Care Units

The Outcome of Haematological Malignancy in Scottish Intensive Care Units

To study the prognostic indicators and outcome in patients with haematological malignancy requiring intensive care, we identified 714 adult patients and analysed their clinical audit data. Mean APACHE II score was 24. Main admitting diagnoses were acute lymphoma (43%) and acute leukaemia (28%). There was a high requirement for acute organ support. Intensive care unit (ICU) mortality was 39% and hospital mortality 55%, with a standardised mortality rate of 1.05 (0.98–1.13). Factors predictive of outcome after multivariate analysis were: cardiopulmonary resuscitation (CPR) in the 24-hours before ICU admission, inotropic support in the first 24-hours, APACHE II score and requirement for ventilatory support immediately prior to, or at admission to the ICU. Neutropaenia was not an independent predictor. Patients with neutropaenic septic shock and multiorgan failure left hospital. Hospital mortality for this group is comparable to that of non-cancer patients admitted with multi-organ system failure. The reluctance to admit such patients to ICU may be unjustified.

Nutritional Practices in Scottish Intensive Care Units: Results of a 2006 Survey

Nutritional practices in Scottish ICUs vary widely, according to a survey carried out in 2006. Most striking is the variation in the use of parenteral nutrition and naso-jejunal feeding. Nutrition teams have been recommended for all acute hospitals and may aid in the management of difficult cases. Evidence-based guidelines for critical care nutrition are available and delivery of nutrition may be improved by the use of these guidelines. Regular audit of nutritional delivery is suggested to ensure optimal feeding of intensive care patients.

Antibiotic Use in Scottish Intensive Care Units

Antibiotic Use in Scottish Intensive Care Units

Tight Glycaemic Control in Scottish Intensive Care Units

Tight Glycaemic Control in Scottish Intensive Care Units

Serum Thyroid Hormones in Preterm Infants: Associations with Postnatal Illnesses and Drug Usage

Transient hypothyroxinemia is common in infants less than 30 wk gestation and is associated with neurodevelopmental deficits. Reductions in T4 and T3 levels with TSH unchanged are the key features of severe illness using surrogate indices of overall severity of illness, but these do not inform the impact of individual disease conditions or drug use. Our objective was to investigate the contribution of postnatal factors to the variations in serum levels of iodothyronines, thyroid-binding globulin, and TSH. We recruited a cohort of infants (23-34 wk gestation; n = 780) between January 1998 and September 2001. The study involved 11 level III Scottish neonatal intensive care units and included cohorts of infants delivered at 23-34 wk gestation. We assessed serum levels of iodothyronines, thyroid-binding globulin, and TSH at 7, 14, and 28 d adjusted for the potentially significant postnatal influences (n = 31). Serum levels of TSH, free T4, T3, and T4 are variably but significantly associated with bacteremia, endotracheal bacterial cultures, persistent ductus arteriosus, necrotizing enterocolitis, cerebral ultrasonography changes, oxygen dependence at 28 d, and the use of aminophylline, caffeine, dexamethasone, diamorphine, and dopamine. There are many more associations of postnatal factors with transient hypothyroxinemia than had previously been considered in preterm infants. Alternative strategies should be considered for correction of hypothyroxinemia rather than sole reliance on the direct therapy of hormone replacement. A more oblique preventative approach may be necessary through reduction in the incidence or severity of individual illness(es). Similarly, alternatives to those drugs that interfere with the hypothalamic-pituitary-thyroid axis should be evaluated (e.g. other inotropics instead of dopamine).

Prevalence of ischaemic heart disease at admission to intensive care and its influence on red cell transfusion thresholds: multicentre Scottish Study

Restrictive transfusion triggers are safe for most critically ill patients, but doubts exist for patients with ischaemic heart disease (IHD). We investigated the prevalence of reported IHD at admission to the intensive care unit (ICU) and investigated how this influenced red cell transfusion triggers. We also compared observed practice with the clinicians' responses to clinical scenarios.We studied 1023 sequential ICU admissions over 100 days to 10 Scottish ICUs. Daily haemoglobin, red cell transfusion, and haemorrhage data were available for 99.4% of 5638 ICU patient days. We recorded if IHD was recorded in clinical records at ICU admission. We grouped admissions as having a non-cardiac primary ICU diagnosis and no documentary evidence of IHD (Group 1, n=697), a non-cardiac primary ICU diagnosis with evidence of IHD (Group 2, n=213), or a cardiac primary ICU admission diagnosis (Group 3, n=113). We examined pre-transfusion haemoglobin concentration (Hb) for transfusion episodes not associated with haemorrhage. Clinical transfusion scenarios were sent to intensivists in the ICUs after data collection, which were designed to explore the clinicians' attitude to transfusion triggers in patients with IHD.Previous myocardial infarction was documented in 159 (16%), cardiac failure in 142 (14%), and angina in 167 (16%). Overall, 28.8% of admissions had >/=1 of these documented. The adjusted mean (se) pre-transfusion Hb concentrations varied across the groups. These were 74 (2.2) g litre(-1) in Group 1, 77 (2.3) g litre(-1) in Group 2, and 79 (3.1) g litre(-1) in Group 3 (P=0.003 across the groups). There was concordance between observed practice and responses to the scenario similar to Group 1, but discordance for patients with IHD (Groups 2 and 3). In scenario responses, intensivists stated these patients should have significantly higher transfusion triggers than were actually observed (median [IQR] response for both groups: 90 [80-100] g litre(-1)).About 29% of patients admitted to Scottish ICUs had documented IHD, which was associated with small adjustments to Hb transfusion triggers. In response to scenarios, clinicians believe that patients with IHD require higher transfusion triggers than are observed in practice.

Utility of a Scottish regional intensive psychiatric care unit for demented elders

Utility of a Scottish regional intensive psychiatric care unit for demented elders

Acute respiratory distress syndrome: an audit of incidence and outcome in Scottish intensive care units

This prospective audit of incidence and outcome of the acute respiratory distress syndrome was conducted as part of the national audit of intensive care practice in Scotland. All patients with acute respiratory distress syndrome in 23 adult intensive care units were identified using the diagnostic criteria defined by the American-European Consensus Conference. Daily data collection was continued until death or intensive care unit discharge. Three hundred and sixty-nine patients were diagnosed with acute respiratory distress syndrome over the 8-month study period. The frequency of acute respiratory distress syndrome in the intensive care unit population was 8.1%; the incidence in the Scottish population was estimated at 16.0 cases.100,000(-1).year(-1). Intensive care unit mortality for acute respiratory distress syndrome was 53.1%, with a hospital mortality of 60.9%. In our national unselected population of critically ill patients, the overall outcome is comparable with published series (Acute Physiology and Chronic Health Evaluation II standardised mortality ratio = 0.99). However, mortality from acute respiratory distress syndrome in Scotland is substantially higher than in recent other series suggesting an improvement in outcome in this condition.

User customisation of medical devices: the reality and the possibilities

While studies of office environments have treated the customisation of technology by users as a positive response to the situated nature of work, customisation of devices in the medical domain, and other safety-critical domains, when acknowledged, has been treated understandably as a violation and a threat to safety. This paper looks at the customisation of medical devices by nursing staff, based on an observational study carried out in three Scottish intensive care units. Drawing on the insights of ethnomethodology, this paper proposes an alternative approach to the study of user customisation and its organisation. An attempt has been made to go beyond the simple categorisation of types of customisation to explicate the detail of how customisation is carried out. Drawing on concerns in human-computer interaction and arguments in medicine surrounding the use of protocols, the potential for supporting customisation in the medical domain is discussed.

Red cell transfusion practice following the transfusion requirements in critical care (TRICC) study: prospective observational cohort study in a large UK intensive care unit.

The Transfusion Requirements In Critical Care (TRICC) study found that critically ill patients tolerate a restrictive haemoglobin transfusion threshold. We investigated red-cell transfusion practice since publication of the TRICC study in a large Scottish teaching hospital intensive care unit (ICU). We prospectively collected daily data for a 6-month period on haemoglobin concentrations, red-cell transfusions and indications for transfusions, throughout ICU stay for all patients who stayed for longer than 24 h in the ICU. A total of 176 patients were studied, who utilized 1237 ICU days. Of these 176 patients, 52% received red-cell transfusions. A haemoglobin concentration of < or = 9 g/dl was measured in 55% of patients; this occurred by day 1 and day 2 in 52% and 77% of these cases, respectively. Overall the haemoglobin concentration was < or = 9 g/dl for 45% of all patient days. Total red-cell use was 3.1 units per admission (0.47 units per patient day). Only 18% of transfusion episodes were required as a result of haemorrhage. For 'non-haemorrhage' transfusion episodes, the median pretransfusion haemoglobin concentration was 7.8 g/dl (interquartile range: 7.4-8.4 g/dl), and 64% of transfusion episodes were for 2 units. Clinicians in our centre were conservative, in keeping with recent transfusion guidelines, but deviated from the TRICC protocol by transfusing at haemoglobin concentrations of between 7 and 9 g/dl, rather than below 7 g/dl, and by prescribing 2 unit transfusions. Significant numbers of red-cell units are still used in the critically ill.