Benchmarking Intensive Care Physiotherapy Staffing in Australian Tertiary Hospitals

Physiotherapy is an important component in the management of patients in the Intensive Care Unit (ICU). Existing guidelines on ICU physiotherapy staffing represent European settings and are not contemporary. With no specific recommendations in Australia, medical and nursing staffing guidelines reflected the need to have designated physiotherapy services available and accessible 24 hours a day in ICU. Therefore, this study aimed to pinpoint a guideline for ICU physiotherapy staff allocation by examining the current physiotherapy staff levels in ICU of Australian tertiary hospitals and comparing it with staff levels desired by senior physiotherapy leaders

Role of the microbiome, probiotics, and 'dysbiosis therapy' in critical illness.

Purpose of reviewLoss of 'health-promoting' microbes and overgrowth of pathogenic bacteria (dysbiosis) in ICU is believed to contribute to nosocomial infections, sepsis, and organ failure (multiple organ dysfunction syndrome). This review discusses new understanding of ICU dysbiosis, new data for probiotics and fecal transplantation in ICU, and new data characterizing the ICU microbiome.Recent findingsICU dysbiosis results from many factors, including ubiquitous antibiotic use and overuse. Despite advances in antibiotic therapy, infections and mortality from often multidrug-resistant organisms (i.e., Clostridium difficile) are increasing. This raises the question of whether restoration of a healthy microbiome via probiotics or other 'dysbiosis therapies' would be an optimal alternative, or parallel treatment option, to antibiotics. Recent clinical data demonstrate probiotics can reduce ICU infections and probiotics or fecal microbial transplant (FMT) can treat Clostridium difficile. This contributes to recommendations that probiotics should be considered to prevent infection in ICU. Unfortunately, significant clinical variability limits the strength of current recommendations and further large clinical trials of probiotics and FMT are needed. Before larger trials of 'dysbiosis therapy' can be thoughtfully undertaken, further characterization of ICU dysbiosis is needed. To addressing this, we conducted an initial analysis demonstrating a rapid and marked change from a 'healthy' microbiome to an often pathogen-dominant microbiota (dysbiosis) in a broad ICU population.SummaryA growing body of evidence suggests critical illness and ubiquitous antibiotic use leads to ICU dysbiosis that is associated with increased ICU infection, sepsis, and multiple organ dysfunction syndrome. Probiotics and FMT show promise as ICU therapies for infection. We hope future-targeted therapies using microbiome signatures can be developed to correct 'illness-promoting' dysbiosis to restore a healthy microbiome post-ICU to improve patient outcomes

A novel computerized test for detecting and monitoring visual attentional deficits and delirium in the ICU

Objectives: Delirium in the ICU is associated with poor outcomes but is under-detected. Here we evaluated performance of a novel, graded test for objectively detecting inattention in delirium, implemented on a custom-built computerized device (Edinburgh Delirium Test Box–ICU). Design: A pilot study was conducted, followed by a prospective case-control study. Setting: Royal Infirmary of Edinburgh General ICU. Patients: A pilot study was conducted in an opportunistic sample of 20 patients. This was followed by a validation study in 30 selected patients with and without delirium (median age, 63 yr; range, 23–84) who were assessed with the Edinburgh Delirium Test Box–ICU on up to 5 separate days. Presence of delirium was assessed using the Confusion Assessment Method for the ICU. Measurements and Main Results: The Edinburgh Delirium Test Box–ICU involves a behavioral assessment and a computerized test of attention, requiring patients to count slowly presented lights. Thirty patients were assessed a total of 79 times (n = 31, 23, 15, 8, and 2 for subsequent assessments; 38% delirious). Edinburgh Delirium Test Box–ICU scores (range, 0–11) were lower for patients with delirium than those without at the first (median, 0 vs 9.5), second (median, 3.5 vs 9), and third (median, 0 vs 10.5) assessments (all p < 0.001). An Edinburgh Delirium Test Box–ICU score less than or equal to 5 was 100% sensitive and 92% specific to delirium across assessments. Longitudinally, participants’ Edinburgh Delirium Test Box–ICU performance was associated with delirium status. Conclusions: These findings suggest that the Edinburgh Delirium Test Box–ICU has diagnostic utility in detecting ICU delirium in patients with Richmond Agitation and Sedation Scale Score greater than –3. The Edinburgh Delirium Test Box–ICU has potential additional value in longitudinally tracking attentional deficits because it provides a range of scores and is sensitive to change

Empiric Antibiotic Therapy in the Treatment of Community-acquired Pneumonia in a General Hospital in Saudi Arabia

Background: Guideline-based empiric antimicrobial therapy is recommended for the treatment of community-acquired pneumonia (CAP). In this study, we evaluate the pattern of empiric antibiotics of CAP patients. Materials and Methods: Patients with CAP were retrieved from the health information unit using the International Classification of Diseases, Ninth Revision. The electronic pharmacy database was used to retrieve prescribed antibiotics and the duration of therapy for each antibiotic. Results: A total of 1672 adult patients were included in the study and 868 (52%) were male. Of all the patients, 47 (2.8%) were admitted to the intensive care unit (ICU). The most frequently used antibiotics were levofloxacin (68.12%), ceftriaxone (37.7%), imipenem-cilastatin (32.5%), and azithromycin (20.6%). The mean days of therapy of each of these antibiotics were 3.2, 2.8, 4.4, and 2.9, respectively. A combination therapy of levofloxacin and imipenem-cilastatin was prescribed for 355 (21.8%) of non-ICU patients versus 20 (60.6%) of ICU patients (P = 0.0007). Imipenem-cilastatin was prescribed for 518 (31.8%) of non-ICU patients versus 25 (56.8%) of ICU patients (P = 0.0009). Levofloxacin was prescribed for 1106 (68%) of non-ICU patients versus 33 (75%) of ICU patients (P = 0.412). Ceftriaxone use decreased significantly from 40.9% in 2013 to 25.9% in 2016 (P = 0.034). In addition, levofloxacin use increased from 63.7% to 75% (P = 0.63). Conclusion: The most commonly used antibiotics were levofloxacin, ceftriaxone, imipenem-cilastatin, and azithromycin. The data call for further refinement and prospective audit of antibiotic use in CAP, especially in non-ICU settings

The effect of adding comorbidities to current centers for disease control and prevention central-line–associated bloodstream infection risk-adjustment methodology

BACKGROUNDRisk adjustment is needed to fairly compare central-line–associated bloodstream infection (CLABSI) rates between hospitals. Until 2017, the Centers for Disease Control and Prevention (CDC) methodology adjusted CLABSI rates only by type of intensive care unit (ICU). The 2017 CDC models also adjust for hospital size and medical school affiliation. We hypothesized that risk adjustment would be improved by including patient demographics and comorbidities from electronically available hospital discharge codes.METHODSUsing a cohort design across 22 hospitals, we analyzed data from ICU patients admitted between January 2012 and December 2013. Demographics and International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) discharge codes were obtained for each patient, and CLABSIs were identified by trained infection preventionists. Models adjusting only for ICU type and for ICU type plus patient case mix were built and compared using discrimination and standardized infection ratio (SIR). Hospitals were ranked by SIR for each model to examine and compare the changes in rank.RESULTSOverall, 85,849 ICU patients were analyzed and 162 (0.2%) developed CLABSI. The significant variables added to the ICU model were coagulopathy, paralysis, renal failure, malnutrition, and age. The C statistics were 0.55 (95% CI, 0.51–0.59) for the ICU-type model and 0.64 (95% CI, 0.60–0.69) for the ICU-type plus patient case-mix model. When the hospitals were ranked by adjusted SIRs, 10 hospitals (45%) changed rank when comorbidity was added to the ICU-type model.CONCLUSIONSOur risk-adjustment model for CLABSI using electronically available comorbidities demonstrated better discrimination than did the CDC model. The CDC should strongly consider comorbidity-based risk adjustment to more accurately compare CLABSI rates across hospitals.Infect Control Hosp Epidemiol 2017;38:1019–1024</jats:sec

Epidemiology of intensive care unit-acquired sepsis in Italy: results of the SPIN-UTI network

BACKGROUND: Sepsis is the major cause of mortality from any infectious disease worldwide. Sepsis may be the result of a healthcare associated infection (HAI): the most frequent adverse events during care delivery especially in Intensive Care Units (ICUs). The main aim of the present study was to describe the epidemiology of ICU-acquired sepsis and related outcomes among patients enrolled in the framework of the Italian Nosocomial Infections Surveillance in ICUs - SPIN-UTI project. STUDY DESIGN: Prospective multicenter study. METHODS: The SPIN-UTI network adopted the European protocols for patient-based HAI surveillance. RESULTS: During the five editions of the SPIN-UTI project, from 2008 to 2017, 47.0% of HAIs has led to sepsis in 832 patients. Overall, 57.0% episodes were classified as sepsis, 20.5% as severe sepsis and 22.5% as septic shock. The most common isolated microorganisms from sepsis episodes were Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa. The case fatality rate increased with the severity of sepsis and the mean length of ICU-stay was significantly higher in patients with ICU-acquired sepsis than in patients without. CONCLUSION: Our study provides evidence that ICU-acquired sepsis occurs frequently in Italian ICU patients and is associated with a high case fatality rate and increased length of stay. However, in order to explain these findings further analyses are needed in this population of ICU patient

Characteristics and outcome of patients with newly diagnosed advanced or metastatic lung cancer admitted to intensive care units (ICUs)

BACKGROUND: Although patients with advanced or metastatic lung cancer have poor prognosis, admission to the ICU for management of life-threatening complications has increased over the years. Patients with newly diagnosed lung cancer appear as good candidates for ICU admission, but more robust information to assist decisions is lacking. The aim of our study was to evaluate the prognosis of newly diagnosed unresectable lung cancer patients. METHODS: A retrospective multicentric study analyzed the outcome of patients admitted to the ICU with a newly diagnosed lung cancer (diagnosis within the month) between 2010 and 2013. RESULTS: Out of the 100 patients, 30 had small cell lung cancer (SCLC) and 70 had non-small cell lung cancer. (Thirty patients had already been treated with oncologic treatments.) Mechanical ventilation (MV) was performed for 81 patients. Seventeen patients received emergency chemotherapy during their ICU stay. ICU, hospital, 3- and 6-month mortality were, respectively, 47, 60, 67 and 71%. Hospital mortality was 60% when invasive MV was used alone, 71% when MV and vasopressors were needed and 83% when MV, vasopressors and hemodialysis were required. In multivariate analysis, hospital mortality was associated with metastatic disease (OR 4.22 [1.4-12.4]; p = 0.008), need for invasive MV (OR 4.20 [1.11-16.2]; p = 0.030), while chemotherapy in ICU was associated with survival (OR 0.23, [0.07-0.81]; p = 0.020). CONCLUSION: This study shows that ICU management can be appropriate for selected newly diagnosed patients with advanced lung cancer, and chemotherapy might improve outcome for patients with SCLC admitted for cancer-related complications. Nevertheless, tumors' characteristics, numbers and types of organ dysfunction should be taken into account in the decisional process before admitting these patients in ICU.Peer reviewe

Exploration of the Association Between Professional Interactions and Emotional Distress of Intensive Care Unit Nursing Personnel

Several studies provide evidence for the association between the quality of collaboration among intensive care unit (ICU) professionals and patients' outcomes, as well as nurses' moral distress and professional satisfaction. However, potential associations between collaboration and nurses' mental health indices have not been explored. The aim of this descriptive correlational study was to investigate the degree of satisfaction from interaction among ICU nursing personnel, as well as between ICU nursing personnel and physicians, and potential associations with ICU nursing personnel's anxiety symptoms. The sample consisted of ICU nursing personnel from 11 adult general hospitals in Greece (n = 229). Hamilton's Anxiety scale was applied for the quantitative assessment of anxiety symptoms and Stamps' Index of Work Satisfaction for the appraisal of nursing personnel's satisfaction from professional interactions. Demographic, vocational, and educational data were also recorded. Descriptive statistics were explored, and group comparisons, correlation, and regression analysis were used. The average satisfaction score from interaction among nursing personnel was moderate to high (5.3 [SD, 1.0]) and from nurse-to-physician interaction was moderate (4.0 [SD, 1.4]) (scale range, 1-7). The score of satisfaction from nurse-to-physician interaction was negatively mildly correlated with participants' (a) total anxiety score ( = ?0.160, P = .001), (b) tension ( = ?0.125, P = .015), and (c) depressive symptoms ( = ?0.148, P = .005). Weak negative correlations were detected between satisfaction from interaction among nursing personnel and participants' (a) total anxiety state ( = ?0.139, P = .003), (b) tension ( = ?0.137, P = .008), and (c) sleep disturbances ( = ? 0.150, P = .003). Overall, female respondents had higher levels of anxiety symptoms than male respondents (Mann-Whitney U, P = .007). Satisfaction from professional interaction was not a strong predictor of anxiety symptoms among ICU nursing personnel (R2 = 0.046, ?0.15). Nursing personnel in Greek ICUs seem to be satisfied with the quality of relationships among them, as well as with physicians. Despite that anxiety symptoms associate with the degree of satisfaction from professional interaction, the latter may not be a significant indicator of ICU nurses' well-being. Further qualitative research is needed to identify mediating factor

Bench-to-bedside review: Dealing with increased intensive care unit staff turnover: a leadership challenge

Critical care leaders frequently must face challenging situations requiring specific leadership and management skills for which they are, not uncommonly, poorly prepared. Such a fictitious scenario was discussed at a Canadian interdisciplinary critical care leadership meeting, whereby increasing intensive care unit (ICU) staff turnover had led to problems with staff recruitment. Participants discussed and proposed solutions to the scenario in a structured format. The results of the discussion are presented. In situations such as this, the ICU leader should first define the core problem, its complexity, its duration and its potential for reversibility. These factors often reside within workload and staff support issues. Some examples of core problems discussed that are frequently associated with poor retention and recruitment are a lack of a positive team culture, a lack of a favorable ICU image, a lack of good working relationships between staff and disciplines, and a lack of specific supportive resources. Several tools or individuals (typically outside the ICU environment) are available to help determine the core problem. Once the core problem is identified, specific solutions can be developed. Such solutions often require originality and flexibility, and must be planned, with specific short-term, medium-term and long-term goals. The ICU leader will need to develop an implementation strategy for these solutions, in which partners who can assist are identified from within the ICU and from outside the ICU. It is important that the leader communicates to all stakeholders frequently as the process moves forward

Haemodialysis and peritoneal dialysis patients admitted to intensive care units.

Hutchison and colleagues report a 10-year experience of dialysis patients admitted to intensive care units (ICUs) in the UK excluding Scotland. Their study is the largest published so far and raises issues of interest to both ICU physicians and nephrologists. Overall, the dialysis patients, although sicker on admission and having pre-existing co-morbidities, do as well as other ICU patients. Their clinical progress after leaving the ICU, however, is less good than for other ICU patients, raising the possibility that the patients might be leaving too early, or perhaps that dialysis patients should be discharged to a high-dependency unit rather than go direct to a renal ward. All in all, the paper by Hutchison and colleagues provides a useful foundation for planning the critical care management of dialysis patients in the UK and elsewhere