Adherence to guidelines for the management of donors after brain death

Purpose: Guideline adherence for the management of a donor after brain death (DBD) is largely unknown. This study aimed to perform an importance-performance analysis of prioritized key interventions (KIs) by linking guideline adherence rates to expert consensus ratings for the management of a DBD. Materials and methods: This observational, cross-sectional multicenter study was performed in 21 Belgian ICUs. A retrospective review of patient records of adult utilized DBDs between 2013 and 2016 used 67 KIs to describe adherence to guidelines. Results: A total of 296 patients were included. Thirty-five of 67 KIs had a high level of adherence congruent to a high expert panel rating of importance. Nineteen of 67 KIs had a low level of adherence in spite of a high level of importance according to expert consensus. However, inadequate documentation proved an important issue, hampering true guideline adherence assessment. Adherence ranged between 3 and 100% for single KI items and on average, patients received 72% of the integrated expert panel recommended care set. Conclusions: Guideline adherence to an expert panel predefined care set in DBD donor management proved moderate leaving substantial room for improvement. An importance-performance analysis can be used to improve implementation and documentation of guidelines

Clinical and Hemodynamic Effects of Percutaneous Edge-to-Edge Mitral Valve Repair in Atrial Versus Ventricular Functional Mitral Regurgitation.

The present study aims to assess the clinical and hemodynamic impact of percutaneous edge-to-edge mitral valve repair with MitraClip in patients with atrial functional mitral regurgitation (A-FMR) compared with ventricular functional mitral regurgitation (V-FMR). Mitral regurgitation (MR) grade, functional status (New York Heart Association class), and major adverse cardiac events (MACE; all-cause mortality or hospitalization for heart failure) were evaluated in 52 patients with A-FMR and in 307 patients with V-FMR. In 56 patients, hemodynamic assessment during exercise echocardiography was performed before and 6 months after intervention. MR reduction after MitraClip implantation was noninferior in A-FMR compared with V-FMR (MR grade ≤2 at 6 months in 94% vs 82%, respectively, p <0.001 for noninferiority) and was associated with improvement of functional status (New York Heart Association class ≤2 at 6 months in 90% vs 80%, respectively, p = 0.2). Hemodynamic assessment revealed that cardiac output at 6 months was higher in A-FMR at rest (5.1 ± 1.5 L/min vs 3.8 ± 1.5 L/min, p = 0.002) and during peak exercise (7.9 ± 2.4 L/min vs 6.1 ± 2.1 L/min, p = 0.02). In addition, the reduction in systolic pulmonary artery pressure at rest was more pronounced in A-FMR: Δ SPAP -13.1 ± 15.1 mm Hg versus -2.2 ± 13.3 mm Hg (p = 0.03). MACE rate at follow-up was significantly lower in A-FMR versus V-FMR, with an adjusted odds ratio of 0.46 (95% confidence interval 0.24 to 0.88), which was caused by a reduction in hospitalization for heart failure. In conclusion, percutaneous edge-to-edge mitral valve repair with MitraClip is at least as effective in A-FMR as in V-FMR in reducing MR. However, the hemodynamic improvement and reduction of MACE were significantly better in A-FMR

Recommendations on basic requirements for intensive care units: structural and organizational aspects

OBJECTIVE: To provide guidance and recommendations for the planning or renovation of intensive care units (ICUs) with respect to the specific characteristics relevant to organizational and structural aspects of intensive care medicine. METHODOLOGY: The Working Group on Quality Improvement (WGQI) of the European Society of Intensive Care Medicine (ESICM) identified the basic requirements for ICUs by a comprehensive literature search and an iterative process with several rounds of consensus finding with the participation of 47 intensive care physicians from 23 countries. The starting point of this process was an ESICM recommendation published in 1997 with the need for an updated version. RESULTS: The document consists of operational guidelines and design recommendations for ICUs. In the first part it covers the definition and objectives of an ICU, functional criteria, activity criteria, and the management of equipment. The second part deals with recommendations with respect to the planning process, floorplan and connections, accommodation, fire safety, central services, and the necessary communication systems. CONCLUSION: This document provides a detailed framework for the planning or renovation of ICUs based on a multinational consensus within the ESIC

Reasons for the higher incidence of unplanned extubation in medical ICUs than in surgical ICUs: reply to the letter by F. Kapadia

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Self-extubation risk assessment tool (SERAT): predictive validity in a real-life setting

AIM: To evaluate the predictive validity of the self-extubation risk assessment tool (SERAT) in intensive care patients. BACKGROUND: Unplanned extubation is an important complication in intensive care units (ICUs). Physicians and nurses working in the ICU would benefit by having access to a tool that could reliably identify patients at risk for unplanned extubation. The SERAT is a risk stratification scheme developed to identify patients at risk for deliberate self-extubation. DESIGN: A prospective, diagnostic study. METHODS: Over a 3-month period, 256 patients who were admitted in one of five ICUs in four hospitals in Flanders (Belgium) were studied. The Glasgow Coma Scale and the Bloomsbury Sedation Score were completed by nurses at the start of each shift, i.e. three times per day. Independent nurse researchers collected data on planned or unplanned extubation and placed the data in the SERAT classification scheme. RESULTS: Five self-extubations and three accidental extubations occurred during the 3-month study period, yielding an incidence of 4.47% that corresponded to 0.56 unplanned extubations per 100 ventilation days. Using the highest accuracy model, we determined that the SERAT had a sensitivity of 100%, specificity of 90%, negative predictive value of 100%, positive predictive value of 1.2% and accuracy of 90%. CONCLUSIONS: Although the SERAT can correctly identify patients at risk for deliberate self-extubation, its use also produces a high number of false-positive identifications. Further research is necessary to evaluate how the false-positive rate can be reduced, and subsequently, the predictive validity of the SERAT can be improved. RELEVANCE TO CLINICAL PRACTICE: Because of the high number of false positives, the use of the SERAT in clinical practice to date is not advocated. The positive predictive value has to be improved to avoid the implementation of intensive interventions in patients who are not at risk.status: publishe

Balancing Cost and Efficiency in Screening Potential Organ Donors With Whole Body CT

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Beliefs and attitudes of intensive care nurses toward visits and open visiting policy

OBJECTIVE: To describe the beliefs and attitudes of intensive care unit (ICU) nurses toward visiting, visiting hours, and open visiting policies in critical care settings. DESIGN: A descriptive, cross-sectional, multicenter survey. SETTING: Seventeen hospitals in Flanders (Dutch-speaking Belgium), including 30 ICUs. Sixteen mixed adult medical/surgical ICUs, three medical ICUs, five surgical ICUs, three coronary care units, two post-cardiac surgery ICUs, and one burn unit. PARTICIPANTS: A total of 531 intensive care nurses. MEASUREMENTS AND RESULTS: We devised a questionnaire comprising 20 items assessing beliefs and 14 items assessing attitudes. Nurses indicated their level of agreement for each statement on a five-point rating scale. Nurses believed that open visiting hampers planning of adequate nursing care (75.2%), interferes with direct nursing care (73.8%), and causes nurses to spend more time in providing information to the patients' families (82.3%). The presumed effects of visits on the patients and families were contradictory. Most nurses (75.3%) did not want to liberalize the visiting policy of their unit. CONCLUSIONS: ICU nurses have rather skeptical beliefs and attitudes toward visiting and open visiting policy. This suggests that the culture at Flemish ICUs is not ready for a drastic liberalization of the visiting policy.status: publishe

Care pathways for organ donation after brain death : guidance from available literature?

Aims. A discussion of the literature concerning the impact of care pathways in the complex and by definition multidisciplinary process of organ donation following brain death. Background. Enhancing the quality and safety of organs for transplantation has become a central concern for governmental and professional organizations. At the local hospital level, a donor coordinator can use a range of interventions to improve the donation and procurement process. Care pathways have been proven to represent an effective intervention in several settings for optimizing processes and outcomes. Design. A discussion paper. Data sources. A systematic review of the Medline, CINAHL, EMBASE and The Cochrane Library databases was conducted for articles published until June 2015, using the keywords donation after brain death and care pathways. Each paper was reviewed to investigate the effects of existing care pathways for donation after brain death. An additional search for unpublished information was conducted. Discussion. Although literature supports care pathways as an effective intervention in several settings, few studies have explored its use and effectiveness for complex care processes such as donation after brain death. Implications for nursing. Nurses should be aware of their role in the donation process. Care pathways have the potential to support them, but their effectiveness has been insufficiently explored. Conclusion. Further research should focus on the development and standardization of the clinical content of a care pathway for donation after brain death and the identification of quality indicators. These should be used in a prospective effectiveness assessment of the proposed pathway

EGFR in melanoma : clinical significance and potential therapeutic target

Background: The role of epidermal growth factor receptor (EGFR) has been established in a range of neoplasms. In melanoma, data on EGFR protein expression are conflicting. Fluorescence in situ hybridization ( FISH) analysis for EGFR gene expression in melanoma showed EGFR gene amplification to be linked with worse prognosis. Cetuximab has been shown to suppress the formation of metastasis in Methods: EGFR protein expression and gene copy number status were evaluated by means of immunohistochemistry and FISH in melanoma samples of patients with known clinicopathological data. Associations between EGFR expression and prognostic parameters were investigated. The effect of different cetuximab concentrations on the BLM melanoma cell line was evaluated by means of methyl tetrazolium (MTT), sulforhodamine B (SRB) and Matrigel invasion assays. Results: EGFR protein expression was more frequently observed in patients with a positive sentinel lymph node. However, EGFR immunostaining has no predictive value. The presence of EGFR polysomy was associated with thicker tumors. Treatment of the BLM melanoma cell line with different concentrations of cetuximab reduced the invasive capacity of the cells, but did not alter cell viability or growth. Conclusion: EGFR appears to be involved in progression and metastasis of a subset of melanomas. Targeting EGFR could therefore represent a therapeutic option for these melanomas