The paediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU): Translation and cognitive debriefing for the German-speaking area

Purpose: To date there are only a few studies published, dealing with delirium in critically ill patients. The problem with these studies is that prevalence rates of delirium could only be estimated because of the lack of validated delirium assessment tools for the paediatric intensive care unit (PICU). The paediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU) was specifically developed and validated for the detection of delirium in PICU patients. The purpose of this study was the translation of the English pCAM-ICU into German according to international validated guidelines

Implementation of an evidence based, practically oriented Standard Operating Procedure regulating the testing for PCT and CRP in patients on a surgical intensiv care unit

Infektionen bzw. infektiöse Komplikationen kommen auf Intensivstationen bei 45% der Patienten vor und bedingen eine erhöhte Mortalität der betroffenen Patienten. Die Diagnosestellung kann gerade auf operativen Intensivstationen eine Herausforderung darstellen. Inflammationsmarker haben postoperativ zur Erkennung einer Infektion eine deutlich eingeschränkte Sensitivität und Spezifität, da sie von perioperativen non-infektiösen Inflammationsprozessen in der Regel nicht zu unterscheiden sind. Unnötige und schädliche Behandlungskonsequenzen können aufgrund nicht-evidenzbasierter Abnahmen der Inflammationsparameter Procalcitonin (PCT) und C-reaktivem Protein (CRP) resultieren. Daher war es primäres Ziel dieser Arbeit zu überprüfen, ob durch die Einführung eines evidenzbasierten praxisorientierten Standards in Form einer schriftlich festgelegten Standard Operating Procedure (SOP) zur Bestimmung von PCT und CRP deren Implementierungsrate auf ≥70% steigt. Sekundäres Ziel war eine Barrierenanalyse von Faktoren der Krankheitsschwere, welche klinisch tätige Ärzte möglicherweise von einer SOP-Einhaltung abgehalten haben. Es erfolgte eine retrospektive Datenerhebung aus dem zentralen Patientendatensystem (Medvision) und dem stationsinternen Patientendatenmanagement System (COPRA). Die Daten wurden auf den anästhesiologisch geleiteten Intensivstationen der Charité Campus Virchow- Klinikum und Campus Charité Mitte durchgeführt. Insgesamt wurden 602 Patienten evaluiert. Die SOPs waren in digitaler Form auf allen Stationen jederzeit verfügbar. Die Gruppeneinteilung erfolgte, in dem die Patienten bei einer SOP- Implementationsquote >70%, bezogen auf die Anzahl der SOP-konformen CRP- und PCT-Spiegelbestimmungen, der SOP-Gruppe, bei einer SOP-Implementierung ≤70% der NSOP-Gruppe zugeordnet wurden. Unterschiede zwischen der SOP- und der NSOP-Gruppe hinsichtlich der Krankheitsschwere sowie mehreren Outcomeparametern, wurden anhand der Aufnahme Scores ermittelt und sowohl univariat mittels Mann-Whitney U Test, als auch multivariat mit Hilfe der logistischen Regression nachgewiesen. Im Juni lag die Einhaltung der SOP bei 33,5%, im August bei 36,3% und im Januar bei 33.0%. Die Unterschiede zwischen den Monaten sind statistisch nicht signifikant (p= 0,759). Signifikante Unterschiede der beiden Gruppen fanden sich hinsichtlich der Scores SOFA, TISS und SAPS II. Die Unterschiede im APACHE II Score waren grenzwertig signifikant. Alle diese Scorewerte waren im Mittel bei der NSOP-Gruppe höher. Hochsignifikant waren Unterschiede in der Krankenhausverweildauer, der intensivstationären Behandlungsdauer  und der Beatmungsdauer, die bei der NSOP-Gruppe länger waren. In der multivariaten logistischen Regression verblieben der TISS und die Krankenhausverweildauer als Parameter, in denen sich die beiden Gruppen signifikant voneinander unterschieden. Nach Einführung einer evidenzbasierten SOP zur Bestimmung von CRP- und PCT-Spiegeln ist deren Implementationsrate nach einem und 6 Monaten nicht angestiegen. Als mögliche Ursachen für eine Nichteinhaltung der SOP könnte eine real oder subjektiv empfundene höhere Krankheitsschwere im Sinne einer persönlichen Barriere in Betracht kommen. Zusätzlich müssen weitere persönliche, strukturelle und umweltbedingte Barrieren als Ursache erwogen werden. Damit Patienten und die medizinische Versorgung als solche von der Erarbeitung und der Implementierung SOP-konformer Behandlung weiter profitieren können, sind zusätzliche Anstrengungen zur Identifikation von Barrieren erforderlich, um durch gezielte Interventionen die Anwendung von Evidenz im klinischen Alltag zu erreichen.Infections or infectious complications affect up to 45% of the patients on intensive care units and cause a raised mortality of the affected patients. The diagnosis can pose a challenge especially on surgical intensive care units. Markers of inflammation have postal-surgically to the recognition of an infection a clearly limited sensitivity and specificity, because they are not to be distinguished from perioperative non infectious inflammatory reactions. Unnecessary and injurious consequences of treatment can result on account of not evidence-based testing for the markers of inflammation Procalcitonin (PCT) and C-reactive protein (CRP). Hence, it was the primary aim of this work whether by the introduction of an evidence-based practically oriented standard in the form of an in writing agreed Standard Operating Procedure (SOP) regulating the testing for PCT and CRP enhances the implementing rate of above mentioned SOP to ≥70%. Secondary aim was a barrier analysis of factors of the illness severity which clinically active doctors have possibly held from a SOP observance. Data acquisition occurred retrospective from the central patient data management system (Medvision) and the station-internal patient data management system (COPRA). The data were collected the anesthesiologically led intensive care units of the Charité Campus Virchow and Campus Charité Mitte. All together 602 patients were evaluated. The SOPs were available in digital form on all wards any time. The group assignment occurred in which the patients with a SOP-implementationquota >70%, regarding the number of the SOP correspondent CRP and PCT testing in the individual patient, were assigned to the SOP group, those with a SOP implementationquota of ≤70% were assigned to the NSOP group. Differences between SOP-and the NSOP group concerning the illness severity measured with the admission scores as well as several further outcomeparameters, were analysed statistically univariate by means of the Mann-Whitney U test and multivariate using logistic regression. In June the observance of the SOP reached 33.5%, in August 36.3% and in January 33.0%. The differences between the months are not significant statistically (p = 0,759). Significant differences of both groups were found concerning the scores SOFA, TISS and SAPS II. The differences in the APACHE II scores were border-valued significant. All these score values were higher on average in the NSOP group. Length of hospital stay, the length of stay on ICU and hours of mechanical respiration were longer within the NSOP group and differences were highly significant. In the multivariate logistic regression length of stay in the hospital and TISS were parameters in which both groups differed significantly from each other. After introduction of an evidence-based SOP for the regulation of CRP-and PCT testing their rate of implementation has not risen after one and 6 months after introduction. As possible causes for a disregard of the SOP a higher illness severity subjectively or objectively could be considered as a personal barrier. In addition, other personal, structural barriers and environmental barriers must be considered. In order to further enhance medical care with the development and the implementiation of SOPs, additional efforts are necessary for the identification and overcoming of barriers by specific interventions to accomplish the use scientific evidence in the clinical everyday life

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used