Quiet Time for Mechanically Ventilated Patients in The Medical Intensive Care Unit

Objective: Sleep disruption occurs frequently in critically ill patients. The primary aim of this study was to examine the effect of quiet time (QT) on patient sedation frequency, sedation and delirium scores; and to determine if consecutive QTs influenced physiologic measures (heart rate, mean arterial blood pressure and respiratory rate). Method: A prospective study of a quiet time protocol was conducted with 72 adult patients on mechanical ventilation. Setting: A Medical Intensive Care Unit (MICU) in the Midwest region of the United States. Results: Sedation was given less frequently after QT (p = 0.045). Those who were agitated prior to QT were more likely to be at goal sedation after QT (p \u3c 0.001). Although not statistically significant, the majority of patients who were negative on the Confusion Assessment Method (CAM-ICU) prior to QT remained delirium free after QT. Repeated measures analysis of variance (ANOVA) for three consecutive QTs showed a significant difference for respiratory rate (p = 0.035). Conclusion: QT may influence sedation administration and promote patient rest. Future studies are required to further understand the influence of QT on mechanically ventilated patients in the intensive care unit

Influence of Sedation Level and Ventilation Status on the Diagnostic Validity of Delirium Screening Tools in the ICU—An International, Prospective, Bi-Center Observational Study (IDeAS)

Background and objectives: The use of delirium screening instruments (DSIs) is recommended in critical care practice for a timely detection of delirium. We hypothesize that the patient-related factors "level of sedation" and "mechanical ventilation" impact test validity of DSIs. Materials and Methods: This is a prospective, bi-center observational study (clinicaltrials.gov: NCT01720914). Critically ill patients were screened for delirium daily for up to seven days after enrollment using the Nursing Delirium Screening Scale (Nu-DESC), Intensive Care Delirium Screening Checklist (ICDSC), and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference standard for delirium diagnosis was the neuropsychiatric examination using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Immediately before delirium assessment, ventilation status and sedation levels were documented. Results: 160 patients were enrolled and 151 patients went into final analysis. Delirium incidence was 23.2%. Nu-DESC showed a sensitivity and specificity of 88.5%, a positive predictive value (PPV) of 71.9%, and a negative predictive value (NPV) of 95.8%. ICDSC had a sensitivity of 62.5%, a specificity of 92.4%, a PPV of 71.4%, and a NPV of 89.0%. CAM-ICU showed a sensitivity of 75.0%, a specificity of 94.7%, a PPV of 85.7%, and a NPV of 90.0%. For Nu-DESC and ICDSC, test validity was significantly better for non-sedated patients (Richmond Agitation Sedation Scale (RASS) 0/-1), whereas test validity for CAM-ICU in a severity scale version showed no significant differences for different sedation levels. No DSI showed a significant difference in test validity between noninvasively and invasively ventilated patients. Conclusions: Test validities of DSIs were comparable to previous studies. The observational scores ICDSC and Nu-DESC showed a significantly better performance in awake and drowsy patients (RASS 0/-1) when compared with other sedation levels. Physicians should refrain from sedation whenever possible to avoid suboptimal performance of DSIs

Ethics-in-practice in fragile contexts: research in education for displaced persons, refugees and asylum seekers

The rising numbers of forcibly displaced peoples on the move globally, and the challenges with providing access to education, reflects the shifting and complex times that we live in. Even though there has been a proliferation in educational research in the context of forced migration, in line with the increasing number of forced migrants, there has not been a commensurate focus on unpicking the increasingly complex ethical conditions within which researchers and participants operate. To examine this issue, the article provides three narrated accounts by researchers in this field and explores the interaction of researcher and researcher-author voice to critically appraise their research experience and identify critical reflections of understanding of ethics-in-practice in fragile contexts. These narratives are framed by the CERD ethical appraisal framework which explores ethical thinking through four ethical lenses – Consequential, Ecological, Relational and Deontological. The article contributes to a deeper understanding of ethics-in-practice as a central dimension in educational research. The implications of this work show how one-size-fits-all approach to ethical appraisal is inappropriate for a socially just educational research. This work also illustrates the importance of attending to relationships and voice of the forcibly displaced, both of which are often lacking in educational research in fragile contexts

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

Purpose Recalibration and determining discriminative power, internationally, of the existing delirium prediction model (PRE-DELIRIC) for intensive care patients. Methods A prospective multicenter cohort study was performed in eight intensive care units (ICUs) in six countries. The ten predictors (age, APACHE-II, urgent and admission category, infection, coma, sedation, morphine use, urea level, metabolic acidosis) were collected within 24 h after ICU admission. The confusion assessment method for the intensive care unit (CAM-ICU) was used to identify ICU delirium. CAM-ICU screening compliance and inter-rater reliability measurements were used to secure the quality of the data. Results A total of 2,852 adult ICU patients were screened of which 1,824 (64 %) were eligible for the study. Main reasons for exclusion were length of stay <1 day (19.1 %) and sustained coma (4.1 %). CAM-ICU compliance was mean (SD) 82 ± 16 % and inter-rater reliability 0.87 ± 0.17. The median delirium incidence was 22.5 % (IQR 12.8–36.6 %). Although the incidence of all ten predictors differed significantly between centers, the area under the receiver operating characteristic (AUROC) curve of the eight participating centers remained good: 0.77 (95 % CI 0.74–0.79). The linear predictor and intercept of the prediction rule were adjusted and resulted in improved re-calibration of the PRE-DELIRIC model. Conclusions In this multinational study, we recalibrated the PRE-DELIRIC model. Despite differences in the incidence of predictors between the centers in the different countries, the performance of the PRE-DELIRIC-model remained good. Following validation of the PRE-DELIRIC model, it may facilitate implementation of strategies to prevent delirium and aid improvements in delirium management of ICU patients

Multinational development and validation of an early prediction model for delirium in ICU patients

Rationale Delirium incidence in intensive care unit (ICU) patients is high and associated with poor outcome. Identification of high-risk patients may facilitate its prevention. Purpose To develop and validate a model based on data available at ICU admission to predict delirium development during a patient’s complete ICU stay and to determine the predictive value of this model in relation to the time of delirium development. Methods Prospective cohort study in 13 ICUs from seven countries. Multiple logistic regression analysis was used to develop the early prediction (E-PRE-DELIRIC) model on data of the first two-thirds and validated on data of the last one-third of the patients from every participating ICU. Results In total, 2914 patients were included. Delirium incidence was 23.6 %. The E-PRE-DELIRIC model consists of nine predictors assessed at ICU admission: age, history of cognitive impairment, history of alcohol abuse, blood urea nitrogen, admission category, urgent admission, mean arterial blood pressure, use of corticosteroids, and respiratory failure. The area under the receiver operating characteristic curve (AUROC) was 0.76 [95 % confidence interval (CI) 0.73–0.77] in the development dataset and 0.75 (95 % CI 0.71–0.79) in the validation dataset. The model was well calibrated. AUROC increased from 0.70 (95 % CI 0.67–0.74), for delirium that developed 6 days. Conclusion Patients’ delirium risk for the complete ICU length of stay can be predicted at admission using the E-PRE-DELIRIC model, allowing early preventive interventions aimed to reduce incidence and severity of ICU delirium

Community Gardening: Integrating Social Responsibility and Sustainability in a Higher Education Setting—A Case Study from Australia

Community gardening (CG) has been the subject of growing interest, both within and without the realm of academia. The reasons for this increase in interest are straightforward, given that CG typically offers benefits in at least three areas: (1) fostering a sense of community among contributing stakeholders; (2) promoting a sense of social responsibility; and (3) heightening awareness in areas of sustainability. As such CG is typically recognised as having the capacity to conjointly meet core human needs. This paper presents a case study that describes the inception and progressive implementation of a community garden project (“campus greening”), set within the university context of a private higher education (HE) provider in Brisbane, Australia. The paper charts progress made to date, highlights hurdles that have had to be overcome, distils relevant lessons learned, and extrapolates success factors for future similar projects. Capitalising on ‘right timing’ emerges as a critical success factor for incentivising, progressing and implementing CG projects. The case study analysis also culminates in a shortlist of tentative recommendations for different stakeholders: (1) soliciting input from alternative leaders; (2) building supportive interdepartmental coalitions; (3) building a broad stakeholder base; and (4) building momentum and support through unconventional means. Experiences and lessons gathered in this paper will be useful for education stakeholders who are interested to use CG to promote community, social responsibility, and sustainability

Intercultural Education for Intercultural Competence: A New Kind of Literacy for Sustainable Development

The concept of culture is subject to many different interpretations. For the present purpose, the wide-ranging definition of Pederson (2000), as summarized by Corey et al. (2011), would appear suitable. In this definition culture was conceptualized as including “demographic variables such as age, gender, and place of residence; status variables such as social, educational and economic background; formal and informal affiliations; and the ethnographic variables of nationality, ethnicity, language, and religion” (p.115) ..

The European rescue of the Washington Consensus? EU and IMF lending to Central and Eastern European countries

The latest global financial crisis has allowed the International Monetary Fund (IMF) a spectacular comeback. But despite its notorious reputation as a staunch advocate of restrictive economic policies, the Fund has displayed less preference for austerity in recent crisis lending. Though widely welcomed as overdue, the IMF’s shift away from what John Williamson coined the ‘Washington Consensus’ was met with resistance from the European Union (EU) where it concerned Central and Eastern European (CEE) countries. The situation of hard-hit Hungary, Latvia, and Romania propelled unprecedented cooperation between the IMF and the EU, in which the EU has very actively promoted orthodox measures in return for loans. We argue that this represents a European rescue of the Washington Consensus. The case of Latvia is paradigmatic for the profound disagreements between an austerity-demanding EU and a less austere IMF. The IMF’s stance contradicts conventional wisdom about the organization as the guardian of economic orthodoxy. To solve this puzzle, we shed light on three complementary factors of (non)learning that have shaped the EU’s relations vis-à-vis CEE borrowing countries in comparison to the IMF’s: (1) a disadvantageous institutional setting; (2) vociferous creditor coalitions; (3) the precarious eurozone project