Annette Richardson

Nursing essential principles: continuous renal replacement therapy.

AIMS This article aims to guide critical care nurses with the care and management of patients on continuous renal replacement therapy (CRRT). BACKGROUND CRRT, a highly specialized therapy involving complex nursing care, is used widely in the intensive care unit to treat patients with acute kidney injury. METHODS A literature search was conducted using CINAHL, Medline from PubMed and BNI using the search terms CRRT or continuous veno-venous haemofiltration and nursing or nurses from 2000 onwards and limited to the English language. The appraised evidence and expert opinion is used in this article. RESULTS Four essential nursing principles for CRRT are reviewed (1) the importance of continuous assessment of the indications to influence the appropriate mode; (2) ensuring good vascular access; (3) the avoidance of unnecessary interruptions and (4) the prevention of complications. CONCLUSION The identified four essential nursing principles provide guidance on this complex aspects of nursing practice. Specific nursing research to guide the care and management of this therapy is limited so should be explored in the future. RELEVANCE TO CLINICAL PRACTICE Critical care nurses caring for and managing patients on CRRT require an understanding of how to deliver safe CRRT.

Reducing the incidence of pressure ulcers in critical care units: a 4-year quality improvement

Quality problem Critical care patients often have several risk factors for pressure ulceration and implementing prevention interventions have been shown to decrease risk. Initial assessment We identified a high incidence of pressure ulcers in the four adult critical care units in our organization. Therefore, avoiding pressure ulceration was an important quality priority. Choice of solution We undertook a quality improvement programme aimed at reducing the incidence of pressure ulceration using an evidence-based bundle approach. Implementation A bundle of technical and non-technical interventions were implemented supported by clinical leadership on each unit. Important components were evidence appraisals; changes to mattresses; focussed risk assessment alongside mandating patients at very high risk to be repositioned two hourly; and staff training to increase awareness of how to prevent pressure ulcers. Evaluation Pressure ulcer numbers, incidence and categories were collected continuously and monitored monthly by unit staff. Pressure ulcer rates reduced significantly from 8.08/100 patient admissions to 2.97/100 patient admissions, an overall relative rate reduction of 63% over 4 years. The greatest reduction was seen in the most severe category of pressure ulceration. The average estimated cost saving was £2.6 million (range £2.1-£3.1). Lessons learned A quality improvement programme including technical and non-technical interventions, data feedback to staff and clinical leadership was associated with a sustained reduction in the incidence of pressure ulceration in the critically ill. Strategies used in this programme may be transferable to other critical care units to bring more widespread patient benefit.

Falls in critical care: a local review to identify incidence and risk.

BACKGROUND Patient falls are the most common adverse event in hospitals, resulting in devastating physical, psychological and financial consequences. Therefore the emphasis on falls assessment and prevention is a key priority. Within hospitals those reported at greatest risk of falls are older patients with little known about the factors within critical care. At a local level, a practice development project was identified to review risk factors contributing to falls in critical care. AIMS To identify the incidence of falls within adult critical care and the risk factors most likely to contribute to a fall. METHODS Reported falls incidents were reviewed retrospectively using a local incident reporting system, over a 2-year period from four critical care units. FINDINGS Forty-two incidents were reviewed indicating a low rate of injury and low rate of occurrence (0·99 falls/1000 bed days). The median age of fallers was 58 years and the most common risk factor for falls was confusion or agitation, followed by patients attempting to mobilize against advice. DISCUSSION Critically ill patients were less likely to fall and were more likely to be younger than patients falling on an acute care ward. Neuroscience/trauma critically ill patients were more likely to fall than general critically ill patients; this was expected to be because of the increased presence of confusion or agitation in this group. The local system used to report falls produced difficulties in identifying risk factors in a consistent way. Although limitations exist, this review has enabled the development of more suitable local critical care falls risk factor assessment and interventions to minimize the risk of falling. CONCLUSIONS Fall rates, related injuries and circumstances of falls vary considerably among acute care and critical care specialities. Future work should concentrate on better falls reporting systems and further research should include validating risk factors for critical care falls.Background Patient falls are the most common adverse event in hospitals, resulting in devastating physical, psychological and financial consequences. Therefore the emphasis on falls assessment and prevention is a key priority. Within hospitals those reported at greatest risk of falls are older patients with little known about the factors within critical care. At a local level, a practice development project was identified to review risk factors contributing to falls in critical care. Aims To identify the incidence of falls within adult critical care and the risk factors most likely to contribute to a fall. Methods Reported falls incidents were reviewed retrospectively using a local incident reporting system, over a 2-year period from four critical care units. Findings Forty-two incidents were reviewed indicating a low rate of injury and low rate of occurrence (0·99 falls/1000 bed days). The median age of fallers was 58 years and the most common risk factor for falls was confusion or agitation, followed by patients attempting to mobilize against advice. Discussion Critically ill patients were less likely to fall and were more likely to be younger than patients falling on an acute care ward. Neuroscience/trauma critically ill patients were more likely to fall than general critically ill patients; this was expected to be because of the increased presence of confusion or agitation in this group. The local system used to report falls produced difficulties in identifying risk factors in a consistent way. Although limitations exist, this review has enabled the development of more suitable local critical care falls risk factor assessment and interventions to minimize the risk of falling. Conclusions Fall rates, related injuries and circumstances of falls vary considerably among acute care and critical care specialities. Future work should concentrate on better falls reporting systems and further research should include validating risk factors for critical care falls.

Central venous catheter dressing durability: an evaluation

Background: Skin organisms at the insertion site are frequently implicated in central venous catheter blood stream infections (CVC BSIs) yet few studies have compared the durability of CVC dressings in critically ill patients. Aims: To undertake an evaluation of the durability and associated costs of different CVC dressings. Methods: Dressing duration was captured prospectively using a pro forma on four different dressings on five critical care units over a 12-month period. Staff received training on CVC dressing evidence-based practices and a ‘how to guide’ was implemented. Findings: A total of 1229 CVC dressings were observed from 590 CVCs. One dressing had a median (IQR) duration of 68.5 h (range, 32–105 h) compared to a median duration of 43.5, 46.0 and 40.5 h for the other dressings (P <0.001). The mean time to change a CVC dressing was 13.5 min and the cost of a dressing change was in the range of £1.97–4.97. During the 12-month study period we observed a downward trend in CVC BSIs. Discussion: Despite few dressings remaining adherent for 7 days, the low rates of CVC BSI observed suggests good dressing practices. Conclusions: One dressing appeared more durable than the others, although it was still below the recommended standard and more expensive.

BACCN's contribution to National Critical Care Developments

CRITICAL CARE LEADERSHIP FORUM This group promotes UK-wide high-quality care for patients with, or at risk of, critical illness through integrating the energies and skills of its participating organizations. The forum acts as a single point of reference for accessing specialist advice for national policy initiatives, commissioning, research, audit, education, professional standards and clinical practice. BACCN is represented on this Forum. The activities have included a critical care non-medical workforce survey to assist in the planning of the future critical care workforce.

Quality and patient safety: the bedrock for future critical care nursing

Quality and safety are increasingly positioned together as the most important priorities in the provision of health care services worldwide, and this is no different within critical care. Looking at the definitions of both, quality care is often defined as the ‘degree of excellence’ (The Health Foundation, 2013) and patient safety as the ‘prevention of harm associated with the process of healthcare’ (Vincent, 2010). Similarities are evident, although quality is an umbrella term and patient safety is more focussed on preventing harm. A more detailed review of the key components of quality care reveals patient safety as only one of the six characteristics of high quality care, the others being: effective, person-centred, timely, efficient and equitable (Institute of Medicine, 2001). A more recent and refined definition of high quality care reduces these characteristics to three: patient safety, a positive patient experience and care that is clinically effective (NHS, 2015). No matter how quality is considered, patient safety is only one of the important pillars of quality. Critical care nurses may therefore wonder why ‘patient safety’ has been recently displayed alongside quality as two key priorities, and thus receiving heightened attention. My own perception is that it is not because the other characteristics are unimportant, it is due to the recognition of current level of patient harm occurring within health care service provision. The level of harm in the world of patient safety is a figure of 1 in 10 patients (Shojania and Panesar, 2014) and points to an urgent requirement to improve this to a safer level. Critical care is no different, the level of harm measured in a prospective intensive care study found adverse events occurring in 20% of intensive care admissions, with 45% of these adverse events preventable (Rothschild et al., 2005). This further highlights the requirement for critical care nurses to play an important role in developing safer care. During my 25 years of working as a critical care nurse in many different types of specialist and general critical care units with a variety of critical care teams, the vision of placing quality as the number one priority is certainly not new. Indeed it has always been an integral part of nurse education and training and is at the heart of professional nursing practice. Delivering the highest possible quality of care has always been a notable part of the culture I have observed from these teams. One would think that this positive position for providing high quality care, would make the task of making health care safer easy, but unfortunately this is not always the case. The vast majority of staff, including nurses, would not wish harm on any patient under their care. In fact, nurses are usually horrified when they are informed that avoidable harm has occurred, particularly when patient stories indicate that the system they work in has adversely contributed to the patient’s condition. Despite this, changing practice and introducing new systems to improve patient safety should not be underestimated and presents substantial challenges for everyone. Overcoming the challenges to make improvements and ensure care is safer must be a fundamental focus for all critical care nurses. The challenges associated with changing practice should start with raising awareness of the exact types and levels of harm within the critical care area, accompanied by an understanding of the consequences that harm and adverse events have on patients and their families. As we know, because many patients in critical care often have complex problems including multi-organ failure, their care is focussed on supporting life and recovery from illness. Consequently, associated harms such as infections, pressure ulcers, falls and medication incidents are often viewed as a consequence of being critically unwell. Changing this view to one which puts the prevention of patient harm alongside the treatment of critical illness is paramount. A further component helping to influence practice and drive forward safer care is the implementation of quality improvement interventions. It is reassuring that these improvement interventions and techniques are gaining momentum and the evidence-base is growing (Bion et al., 2012; Wachter, 2012). These techniques focus on the contribution of human factors, described as those factors that can influence people and their behaviour such as the environment and individual characteristics, which influence behaviour at work (Clinical Human Factor Group, 2015). Other techniques include, measuring improvement, creating a positive patient safety culture, learning from errors and sharing lessons, working in complex environments, being open and transparent with patients, and education and training. These are by no means the whole solution, but all offer important elements for consideration by critical care nurses to make patient care safer in the future.