The Effect of an algorithm based sedation guideline on the duration of mechanical ventilation for intensive care patients in an Australian intensive care unit

Patients who are cared for in intensive care units (ICUs) have life threatening illnesses and require intrusive interventions and monitoring, which may cause discomfort. They often require analgesic medications to relieve pain and sedative medications to reduce anxiety. Agitation and accidental self-harm may result from providing too little medication and the administration of too much may lead to the prolongation of mechanical ventilation. Sedation guidelines offer the potential to reduce these problems. The aim of this study was to examine the effect of an algorithm based sedation guideline on the duration of mechanical ventilation of patients in an Australian ICU. Secondary aims included the effect of the guideline on the: patients’ perspective of their recovery; length of stay in ICU; number of tracheostomies; number of self-extubations and reintubations; and the cost of intravenous sedative medications. The rate of adoption of the guideline and sedation scale was examined. The intervention was tested in a quasi-experimental preintervention and postintervention study (n= 322). The sample comprised 58% men and the median age was 61.1 years (range 19.7 to 91.8 years). Mean Acute Physiology and Chronic Health Evaluation II score was 21.8 points (range 3 to 45 points). Nineteen percent of patients were admitted post operatively and 81% were admitted for non-operative medical diagnoses. Mechanical ventilation was instigated for 225 (70%) patients prior to admission to the study ICU. There was a 22% mortality rate. The groups were equivalent at baseline. The mean duration of mechanical ventilation was 4.33 days for the preintervention group and 5.64 days for the postintervention group (p=0.02). There was no difference in the patients’ perspective of their recovery. There was no difference in length of stay in ICU and the number of tracheostomies. The number of self-extubations and reintubations were similar. The overall cost of intravenous sedative medications increased slightly in the postintervention phase. Sedation scale adoption was poor in the preintervention phase but increased in the postintervention phase. The sedation guideline was gradually adopted in the postintervention phase. Adoption data suggests that patients were more deeply sedated during the postintervention phase. In conclusion, the sedation scale and sedation guideline were well adopted by the nurses. Patients were more deeply sedated when the guideline was used and there was a mean increase in duration of ventilation of 1.31 days. Other secondary patient outcomes were not affected. The successful implementation of a clinical guideline was demonstrated but was not associated with improvements in patient outcomes in this setting

Emergency department presentations by older people for mental health or drug and alcohol conditions: A multicentre retrospective audit

© 2017 College of Emergency Nursing Australasia Purpose Emergency department presentations by older people associated with mental health and drug and alcohol related conditions are increasing. However, the characteristics of presentations by older people in Australia are largely unknown. The aim of this research was to explore the characteristics of older people presenting with mental health and drug and alcohol conditions. Procedures We used a retrospective electronic medical record audit to explore all emergency department presentations by older people 65 years and over for mental health and drug and alcohol related conditions over a 12 month period. Data were described using descriptive statistics. Finidngs There were 40,093 presentations; 2% (n = 900) were related to mental health or drug and alcohol related conditions. Presentations were mainly associated with primary mental or medical symptoms. The majority were female (n = 471; 53%). Predominate conditions were cognitive impairment (n = 234; 26%) and affective disorders (n = 233; 26.0%). Sixty-three percent of patients were admitted to a hospital ward. Over the study period 106 patients (242 episodes of care) represented. Principle conclusions Given the ageing population and increasing prevalence for mental health and drug and alcohol conditions, strategies are required to better recognise these conditions to reduce the burden on the health care system and improve health for older people

A pilot study of sound levels in an Australian adult general intensive care unit

High technology and activity levels in the intensive care unit (ICU) lead to elevated and disturbing sound levels. As noise has been shown to affect the ability of patients to rest and sleep, continuous sound levels are required during sleep investigations. The aim of this pilot study was to develop a robust protocol to measure continuous sound levels for a larger more substantive future study to improve sleep for the ICU patient. A review of published studies of sound levels in intensive care settings revealed sufficient information to develop a study protocol. The study protocol resulted in 10 usable recordings out of 11 attempts to collect pilot data. The mean recording time was 17.49 ± 4.5 h. Sound levels exceeded recommendations made by the World Health Organization (WHO) for hospitals. The mean equivalent sound level (LAeq) was 56.22 ± 1.65 dB and LA90 was 46.8 ± 2.46 dB. The data reveal the requirement for a noise reduction program within this ICU

Improving the quality and quantity of sleep for the intensive care patient

University of Technology, Sydney. Faculty of Nursing, Midwifery and Health.Patients in intensive care units (ICUs) frequently experience sleep disruption. Few recent sleep studies using polysomnography (PSG) conducted in ICU are available. Interventional studies to improve sleep in ICU are rare and PSG is infrequently used to evaluate interventions designed to improve sleep in ICU. The primary aim of the study was to explore ICU patients’ quality and quantity of sleep, using 24-hour PSG recording, patient self-report and nurse nocturnal observation. Secondary aims included an assessment of 24-hour sound and illuminance levels; selfreported sleep quality on the Ward and at home two months after discharge from hospital; patients’ psychological well-being at home two months after discharge from hospital; and the effect of the introduction of a ‘rest and sleep’ guideline. An exploratory approach was taken in this quasi-experimental study. Thirty patients completed 24-hour PSG sleep recording before the introduction of the Guideline and 23 patients after. The Guideline was developed using a consultative approach in which research evidence and suggestions from ICU health care personnel were incorporated. Audits were conducted in the postintervention phase to assess guideline adoption. The sample comprised 70% men and the mean age was 58 years. Diagnoses were mainly nonoperative (66%). Fifty-four percent received mechanical ventilation during PSG recording. Median duration of mechanical ventilation was six days and median length of ICU stay was 12 days. Median total sleep time was five hours. The majority of sleep was stage 1 and 2. There was significant sleep fragmentation (median duration of sleep without waking: 3:15 min:sec). Forty-four per cent of sleep was during the day. There were concerns about the interrater reliability of the PSG data analysis using the Rechtshaffen and Kales criteria (Kappa values: 0.56 and 0.51). Patients’ self-reported sleep in ICU using the Richards Campbell Sleep Questionnaire was poor (mean: 51 mm). Nurses’ estimations of nocturnal sleep were higher than the PSG derived value. Sound levels exceeded international standards for hospitals. Night-time illuminance levels were appropriately low. The introduction of the Guideline did not appear to result in an improvement in sleep however Guideline uptake was limited. This investigation revealed the need for alternative methods of analysing ICU patients’ PSG data. The study protocol demonstrates the feasibility of conducting further extensive investigations into potential relationships between patients’ sleep disruption and outcomes. The method in which the Guideline was developed may be of interest to other clinicians wishing to develop guidelines when research evidence is limited

Suicide in older people, attitudes and knowledge of emergency nurses: A multi-centre study

© 2019 Introduction: Suicide in older people is a public health concern. Emergency nurses are ideally placed to identify suicide risk. Therefore, the aim of this research was to explore emergency nurses’ knowledge, confidence and attitudes about suicide in older people. Methods: This descriptive exploratory study was conducted in four emergency departments in Sydney, Australia. Data were collected using a 28-item survey from a convenience sample of emergency nurses. Descriptive quantitative statistics and conventional content analysis were performed. Ethics approval was provided. Results: The response rate was 58% (n = 136); the majority were female with an average of seven years emergency experience. The majority (n = 124, 91%) reported that they frequently managed suicidal behaviour and recognized suicide as a common event (80%). 51% (n = 69) recognized that suicide was a common event for older people. Only 16% (n = 22) reported receiving suicide prevention training with 11% feeling confident in managing suicidal behaviour. Conclusion: The findings contribute to the discourse on how suicide in older people is recognised by emergency nurses. Few nurses considered it a problem for older people and were not confident about their knowledge. There is a need for suicide prevention training as a priority particularly to identify risks in older people

Does pregnancy affect the metabolic equivalent at rest and during low intensity exercise?

Background: One metabolic equivalent (MET) is the amount of oxygen consumed while sitting at rest and is equal to 3.5 ml O2·kg-1·min-1. METs are often used to provide simple, practical, and easily understood values that reflect the energy cost of physical activity. It is plausible that the increase in body mass and absolute submaximal oxygen uptake during gestation has the potential to affect the MET of pregnant women. Objective: The aim of this study was to measure the MET during the second trimester of pregnancy and to compare this with non-pregnant women. In addition, the measured MET values were compared to those proposed by the Compendium of Physical Activities (CPA). Design: Ten pregnant and ten non-pregnant women participated in this study. Ventilatory variables and heart rate (HR) were measured during four conditions on two different days: Condition 1 - sitting, Condition 2 - lying, Condition 3 - treadmill walking and Condition 4 - cycling. The women performed two conditions on each testing day; one resting condition followed by one exercising condition. The data were analysed using a two-way ANOVA with repeated measures. Bonferroni’s tests were used when significant differences were detected. Results: The MET was not significantly different between pregnant and non-pregnant women either at rest or during exercise (p > 0.05). While cycling, the MET obtained by indirect calorimetry (IC) was significantly higher than the CPA predicted MET, regardless of group (pregnant cycling p = 0.002 and non-pregnant cycling p 0.05). In general, (combined pregnant and non-pregnant data), VE and HR were significantly higher during seated rest, when compared with supine rest and all ventilatory variables, HR and ratings of perceived exertion (RPE) were significantly higher during cycling, when compared with walking (p > 0.05). Conclusion: METs were unaffected by pregnancy at rest or when undertaking either walking or cycling exercise during the second trimester of pregnancy. The MET of cycling was significantly underestimated by the CPA, when compared to IC, in both groups

Antimicrobial prescription patterns and ventilator associated pneumonia: Findings from a 10-site prospective audit

© 2018 The Author(s). Objective: To examine anti-microbial prescribing practices associated with ventilator-associated pneumonia from data gathered during an audit of practice and outcomes in intensive care units (ICUs) in a previously published study. Results: The patient sample of 169 was 65% male with an average age of 59.7 years, a mean APACHE II score of 20.6, and a median ICU stay of 11 days. While ventilator-associated pneumonia was identified using a specific 4-item checklist in 29 patients, agreement between the checklist and independent physician diagnosis was only 17%. Sputum microbe culture reporting was sparse. Approximately 75% of the sample was administered an antimicrobial (main indications: lung infection [54%] and prophylaxis [11%]). No clinical justification was documented for 20% of prescriptions. Piperacillin/tazobactam was most frequently prescribed (1/3rd of all antimicrobial prescriptions) with about half of those for prophylaxis. Variations in prescribing practices were identified, including apparent gaps in antimicrobial stewardship; particularly in relation to prescribing for prophylaxis and therapy de-escalation. Sputum microbe culture reports for VAP did not appear to contribute to prescribing decisions but physician suspicion of lung infection and empiric therapy rather than ventilator-associated pneumonia criteria and guideline concordance

Exploring modularity in biological networks

Network theoretical approaches have shaped our understanding of many different kinds of biological modularity. This essay makes the case that to capture these contributions, it is useful to think about the role of network models in exploratory research. The overall point is that it is possible to provide a systematic analysis of the exploratory functions of network models in bioscientific research. Using two examples from molecular and developmental biology, I argue that often the same modelling approach can perform one or more exploratory functions, such as introducing new directions of research, offering a complementary set of concepts, methods and algorithms for individuating important features of natural phenomena, generating proofs of principle demonstrations and potential explanations for phenomena of interest and enlarging the scope of certain research agendas. This article is part of the theme issue 'Unifying the essential concepts of biological networks: biological insights and philosophical foundations'

Effect of maternal Schistosoma mansoni infection and praziquantel treatment during pregnancy on Schistosoma mansoni infection and immune responsiveness among offspring at age five years.

INTRODUCTION: Offspring of Schistosoma mansoni-infected women in schistosomiasis-endemic areas may be sensitised in-utero. This may influence their immune responsiveness to schistosome infection and schistosomiasis-associated morbidity. Effects of praziquantel treatment of S. mansoni during pregnancy on risk of S. mansoni infection among offspring, and on their immune responsiveness when they become exposed to S. mansoni, are unknown. Here we examined effects of praziquantel treatment of S. mansoni during pregnancy on prevalence of S. mansoni and immune responsiveness among offspring at age five years. METHODS: In a trial in Uganda (ISRCTN32849447, http://www.controlled-trials.com/ISRCTN32849447/elliott), offspring of women treated with praziquantel or placebo during pregnancy were examined for S. mansoni infection and for cytokine and antibody responses to SWA and SEA, as well as for T cell expression of FoxP3, at age five years. RESULTS: Of the 1343 children examined, 32 (2.4%) had S. mansoni infection at age five years based on a single stool sample. Infection prevalence did not differ between children of treated or untreated mothers. Cytokine (IFNγ, IL-5, IL-10 and IL-13) and antibody (IgG1, Ig4 and IgE) responses to SWA and SEA, and FoxP3 expression, were higher among infected than uninfected children. Praziquantel treatment of S. mansoni during pregnancy had no effect on immune responses, with the exception of IL-10 responses to SWA, which was higher in offspring of women that received praziquantel during pregnancy than those who did not. CONCLUSION: We found no evidence that maternal S. mansoni infection and its treatment during pregnancy influence prevalence and intensity of S. mansoni infection or effector immune response to S. mansoni infection among offspring at age five years, but the observed effects on IL-10 responses to SWA suggest that maternal S. mansoni and its treatment during pregnancy may affect immunoregulatory responsiveness in childhood schistosomiasis. This might have implications for pathogenesis of the disease

The impact of prenatal exposure to parasitic infections and to anthelminthic treatment on antibody responses to routine immunisations given in infancy: Secondary analysis of a randomised controlled trial.

BACKGROUND: Chronic parasitic infections are associated with active immunomodulation which may include by-stander effects on unrelated antigens. It has been suggested that pre-natal exposure to parasitic infections in the mother impacts immunological development in the fetus and hence the offspring's response to vaccines, and that control of parasitic infection among pregnant women will therefore be beneficial. METHODOLOGY/PRINCIPAL FINDINGS: We used new data from the Entebbe Mother and Baby Study, a trial of anthelminthic treatment during pregnancy conducted in Uganda, to further investigate this hypothesis. 2705 mothers were investigated for parasitic infections and then randomised to albendazole (400mg) versus placebo and praziquantel (40mg/kg) during pregnancy in a factorial design. All mothers received sulfadoxine/pyrimethamine for presumptive treatment of malaria. Offspring received Expanded Programme on Immunisation vaccines at birth, six, 10 and 14 weeks. New data on antibody levels to diphtheria toxin, three pertussis antigens, Haemophilus influenzae type B (HiB) and Hepatitis B, measured at one year (April 2004 -May 2007) from 1379 infants were analysed for this report. Additional observational analyses relating maternal infections to infant vaccine responses were also conducted. Helminth infections were highly prevalent amongst mothers (hookworm 43.1%, Mansonella 20.9%, Schistosoma mansoni 17.3%, Strongyloides 11.7%, Trichuris 8.1%) and 9.4% had malaria at enrolment. In the trial analysis we found no overall effect of either anthelminthic intervention on the measured infant vaccine responses. In observational analyses, no species was associated with suppressed responses. Strongyloidiasis was associated with enhanced responses to pertussis toxin, HiB and Hep B vaccine antigens. CONCLUSIONS/SIGNIFICANCE: Our results do not support the hypothesis that routine anthelminthic treatment during pregnancy has a benefit for the infant's vaccine response, or that maternal helminth infection has a net suppressive effect on the offspring's response to vaccines. TRIAL REGISTRATION: ISRCTN.com ISRCTN32849447