Deteriorating Patients and Risk Assessment among Nurses and Junior Doctors: A Review

The presence of nurses and junior doctors in the ward environment are crucial, especially in detecting deteriorating patients. However, there is consistent evidence that warning signs may not always be identified or acted upon. This paper aimed to analyse the incidence of deteriorating patients, and the concept of risk assessment of these patients by nurses and junior doctors in general ward, through a review on relevant literature. An extensive literature search was conducted through online research databases, i.e. CINAHL, MEDLINE (Ovid), Science Direct and ProQuest. Professional journals were hand searched for relevant literature based on reference lists and citations made in key publications, and attempts were also made to obtain any relevant grey literature (unpublished materials). A total of eleven papers which focused on patient’s assessment, response to deteriorating patients and knowledge in medication, and a guideline were reviewed. Most of the studies were carried out in the United Kingdom (n=4), followed by Australia (n=2), Sweden (n=2), the Netherlands (n=1) and Taiwan (n=1). Meanwhile, among these studies, the chosen research designs include, qualitative (n=6), quantitative (n=3) and systematic review (n=1). This review concluded that nurses and junior doctors in general ward have a lack of knowledge in risk assessment of deteriorating patients

Derivation of A New Bioscore for Predicting Mortality in Sepsis

Introduction: Currently, there is a lack of clinically feasible and reliable method for discriminating outcome in sepsis. We aimed to derive a new bioscore for predicting mortality in critically ill patients with sepsis using a combination of biomarkers and clinical indexes. Materials and Methods: This was a secondary analysis from a prospective study involving 159 patients with sepsis admitted to an intensive care unit (ICU). Data for key variables considered for possible inclusion in the score were collected, which included: age, sex, source of admission, comorbidities, microorganism, bacteraemia, site of infection, septic shock status, baseline Simplified Acute Physiological Score II, Sequential Organ Failure Assessment (SOFA) score (total and organ sub-scores), C-reactive protein, procalcitonin and interleukin-6 (IL-6). Approximate quintiles of each variable were given points as per the strength of their association with 30-day mortality. Results: In accordance with the statistical significance in the logistic regression analysis, the final score utilised candidate variables of age, central nervous system and liver SOFA sub-scores and IL-6. The bioscore predicted 30-day mortality with a very good performance [area under the receiver operating characteristic curve 0.814 (95% confidence interval 0.745-0.871, p< 0.0001)] in our sepsis cohort. A bioscore greater than 4 predicted 30-day mortality with 80.4% sensitivity, 69.9% specificity, 2.67 positive likelihood ratio and 0.28 negative likelihood ratio. As the score increased, so did mortality rate. Conclusion: A new bioscore combining age, central nervous system and liver SOFA sub-scores and IL-6 measured on ICU admission potentially improves prediction of mortality in sepsis. Further study is warranted to prospectively validate the clinical utility of this bioscore in risk-stratifying patients with suspected sepsis

Medical and Islamic Perspectives on Human Immunodeficiency Virus Infection and its Prevention

Human Immunodeficiency Virus (HIV) that causes Acquired Immune Deficiency Syndrome (AIDS) is one of the world’s most serious health and nation-state destructions. It creates long-term economic and psychosocial impact on the lives of individuals, families and communities. Since the first reported case of HIV/AIDS in Malaysia in 1986, its prevalence has escalated significantly. As of December 2017, there are over 115,263 reported cases of HIV infections in the country and over 40,000 people died from HIV/AIDS.1 Although many religious people regarded HIV infection as a divine punishment for their sins of sexual promiscuity, Islamic teaching emphasises the prevention of the disease and care for people living with HIV or AIDS. It is imperative to discuss the Islamic perspectives in providing ways to prevent the spread of HIV and support to people living with HIV (PLHIV). This article focuses on epidemiological data; highlight the burden of HIV infection/AIDS in Malaysia and its impact on the society, HIV infection from medical perspective and its preventive measures from Islamic viewpoints. A good teamwork among healthcare providers and religious leaders is compulsory as it may improve the preventive strategies to curb the disease in the country

Stochastic integrated model-based protocol for volume-controlled ventilation setting

Background and objective: Mechanical ventilation (MV) is the primary form of care for respiratory failure patients. MV settings are based on general clinical guidelines, intuition, and experience. This approach is not patient-specific and patients may thus experience suboptimal, potentially harmful MV care. This study presents the Stochastic integrated VENT (SiVENT) protocol which combines model-based approaches of the VENT protocol from previous works, with stochastic modelling to take the variation of patient respiratory elastance over time into consideration. Methods: A stochastic model of Ers is integrated into the VENT protocol from previous works to develop the SiVENT protocol, to account for both intra- and inter-patient variability. A cohort of 20 virtual MV patients based on retrospective patient data are used to validate the performance of this method for volume-controlled (VC) ventilation. A performance evaluation was conducted where the SiVENT and VENT protocols were implemented in 1080 instances each to compare the two protocols and evaluate the difference in reduction of possible MV settings achieved by each. Results: From an initial number of 189,000 possible MV setting combinations, the VENT protocol reduced this number to a median of 10,612, achieving a reduction of 94.4% across the cohort. With the integration of the stochastic model component, the SiVENT protocol reduced this number from 189,000 to a median of 9329, achieving a reduction of 95.1% across the cohort. The SiVENT protocol reduces the number of possible combinations provided to the user by more than 1000 combinations as compared to the VENT protocol. Conclusions: Adding a stochastic model component into a model-based approach to selecting MV settings improves the ability of a decision support system to recommend patient-specific MV settings. It specifically considers inter- and intra-patient variability in respiratory elastance and eliminates potentially harmful settings based on clinically recommended pressure thresholds. Clinical input and local protocols can further reduce the number of safe setting combinations. The results for the SiVENT protocol justify further investigation of its prediction accuracy and clinical validation trials

Model-based insulin-nutrition administration for glycemic control in Malaysian critical care: First pilot trial

© 2018, Springer Science+Business Media Singapore. Stress-induced hyperglycemia is prevalent in critical care, even in patients with no history of diabetes. Control of blood glucose level with tight insulin therapy has been shown to reduce incidences of hyperglycemia leading to reduced mortality and improved clinical outcomes. STAR is a tablet-based glucose control protocol with a specialized user interface into which insulin and nutrition information can be entered and predicted. This research describes the first clinical pilot trial of STAR approach in International Islamic University Hospital, Kuantan, Malaysia. The clinically specified target for blood glucose level is between 4.4 and 8.0 mmol/L. Seven episodes (of 359 h) were recruited based on the need for glucose control. Overall, 43.93% of measurement are in the range of 4.4–8.0 mmol/L band. The blood glucose median is 8.30 [6.32–10.00] mmol/L with only 1 patient having below than 2.22 mmol/L which is the guaranteed minimum risk level. This pilot study shows that STAR protocol is a patient specific approach that provides a good glycemic control in critically ill patients. Nevertheless, its implementation in Malaysian intensive care environments requires modifications and improvements in certain areas

Protocol and statistical analysis plan for the mega randomised registry trial comparing conservative vs. liberal oxygenation targets in adults with nonhypoxic ischaemic acute brain injuries and conditions in the intensive care unit (Mega-ROX Brains)

Background: The effect of conservative vs. liberal oxygen therapy on 90-day in-hospital mortality in adults who have nonhypoxic ischaemic encephalopathy acute brain injuries and conditions and are receiving invasive mechanical ventilation in the intensive care unit (ICU) is uncertain. Objective: The objective of this study was to summarise the protocol and statistical analysis plan for the Mega-ROX Brains trial. Design, setting, and participants: Mega-ROX Brains is an international randomised clinical trial, which will be conducted within an overarching 40,000-participant, registry-embedded clinical trial comparing conservative and liberal ICU oxygen therapy regimens. We expect to enrol between 7500 and 9500 participants with nonhypoxic ischaemic encephalopathy acute brain injuries and conditions who are receiving unplanned invasive mechanical ventilation in the ICU. Main outcome measures: The primary outcome is in-hospital all-cause mortality up to 90 d from the date of randomisation. Secondary outcomes include duration of survival, duration of mechanical ventilation, ICU length of stay, hospital length of stay, and the proportion of participants discharged home. Results and conclusions: Mega-ROX Brains will compare the effect of conservative vs. liberal oxygen therapy regimens on 90-day in-hospital mortality in adults in the ICU with acute brain injuries and conditions. The protocol and planned analyses are reported here to mitigate analysis bias. Trial Registration: Australian and New Zealand Clinical Trials Registry (ACTRN 12620000391976)

Deteriorating Patients and Risk Assessment among Nurses and Junior Doctors: A Review

The presence of nurses and junior doctors in the ward environment are crucial, especially in detecting deteriorating patients. However, there is consistent evidence that warning signs may not always be identified or acted upon. This paper aimed to analyse the incidence of deteriorating patients, and the concept of risk assessment of these patients by nurses and junior doctors in general ward, through a review on relevant literature. An extensive literature search was conducted through online research databases, i.e. CINAHL, MEDLINE (Ovid), Science Direct and ProQuest. Professional journals were hand searched for relevant literature based on reference lists and citations made in key publications, and attempts were also made to obtain any relevant grey literature (unpublished materials). A total of eleven papers which focused on patient’s assessment, response to deteriorating patients and knowledge in medication, and a guideline were reviewed. Most of the studies were carried out in the United Kingdom (n=4), followed by Australia (n=2), Sweden (n=2), the Netherlands (n=1) and Taiwan (n=1). Meanwhile, among these studies, the chosen research designs include, qualitative (n=6), quantitative (n=3) and systematic review (n=1). This review concluded that nurses and junior doctors in general ward have a lack of knowledge in risk assessment of deteriorating patients.</jats:p

Derivation of A New Bioscore for Predicting Mortality in Sepsis

Introduction: Currently, there is a lack of clinically feasible and reliable method for discriminating outcome in sepsis. We aimed to derive a new bioscore for predicting mortality in critically ill patients with sepsis using a combination of biomarkers and clinical indexes. Materials and Methods: This was a secondary analysis from a prospective study involving 159 patients with sepsis admitted to an intensive care unit (ICU). Data for key variables considered for possible inclusion in the score were collected, which included: age, sex, source of admission, comorbidities, microorganism, bacteraemia, site of infection, septic shock status, baseline Simplified Acute Physiological Score II, Sequential Organ Failure Assessment (SOFA) score (total and organ sub-scores), C-reactive protein, procalcitonin and interleukin-6 (IL-6). Approximate quintiles of each variable were given points as per the strength of their association with 30-day mortality. Results: In accordance with the statistical significance in the logistic regression analysis, the final score utilised candidate variables of age, central nervous system and liver SOFA sub-scores and IL-6. The bioscore predicted 30-day mortality with a very good performance [area under the receiver operating characteristic curve 0.814 (95% confidence interval 0.745-0.871, p&lt; 0.0001)] in our sepsis cohort. A bioscore greater than 4 predicted 30-day mortality with 80.4% sensitivity, 69.9% specificity, 2.67 positive likelihood ratio and 0.28 negative likelihood ratio. As the score increased, so did mortality rate. Conclusion: A new bioscore combining age, central nervous system and liver SOFA sub-scores and IL-6 measured on ICU admission potentially improves prediction of mortality in sepsis. Further study is warranted to prospectively validate the clinical utility of this bioscore in risk-stratifying patients with suspected sepsis.</jats:p

Medical and Islamic Perspectives on Human Immunodeficiency Virus Infection and its Prevention

Human Immunodeficiency Virus (HIV) that causes Acquired Immune Deficiency Syndrome (AIDS) is one of the world’s most serious health and nation-state destructions. It creates long-term economic and psychosocial impact on the lives of individuals, families and communities. Since the first reported case of HIV/AIDS in Malaysia in 1986, its prevalence has escalated significantly. As of December 2017, there are over 115,263 reported cases of HIV infections in the country and over 40,000 people died from HIV/AIDS.1 Although many religious people regarded HIV infection as a divine punishment for their sins of sexual promiscuity, Islamic teaching emphasises the prevention of the disease and care for people living with HIV or AIDS. It is imperative to discuss the Islamic perspectives in providing ways to prevent the spread of HIV and support to people living with HIV (PLHIV). This article focuses on epidemiological data; highlight the burden of HIV infection/AIDS in Malaysia and its impact on the society, HIV infection from medical perspective and its preventive measures from Islamic viewpoints. A good teamwork among healthcare providers and religious leaders is compulsory as it may improve the preventive strategies to curb the disease in the country.</jats:p

Model-based glycemic control in a Malaysian intensive care unit: performance and safety study.

Background: Stress-induced hyperglycemia is common in critically ill patients. A few forms of model-based glycemic control have been introduced to reduce this phenomena and among them is the automated STAR protocol which has been used in the Christchurch and Gyulá hospitals' intensive care units (ICUs) since 2010. Methods: This article presents the pilot trial assessment of STAR protocol which has been implemented in the International Islamic University Malaysia Medical Centre (IIUMMC) Hospital ICU since December 2017. One hundred and forty-two patients who received STAR treatment for more than 20 hours were used in the assessment. The initial results are presented to discuss the ability to adopt and adapt the model-based control framework in a Malaysian environment by analyzing its performance and safety. Results: Overall, 60.7% of blood glucose measurements were in the target band. Only 0.78% and 0.02% of cohort measurements were below 4.0 mmol/L and 2.2 mmol/L (the limitsfor mild and severe hypoglycemia, respectively). Treatment preference-wise, the clinical staff were favorable of longer intervention options when available. However, 1 hourly treatments were still used in 73.7% of cases. Conclusion: The protocol succeeded in achieving patient-specific glycemic control while maintaining safety and was trusted by nurses to reduce workload. Its lower performance results, however, give the indication for modification in some of the control settings to better fit the Malaysian environment