Ian Baldwin

Nurses’ attitudes to a medical emergency team service in a teaching hospital

Background: Cultural barriers including allegiance to traditional models of ward care and fear of criticism may restrict use of a medical emergency team (MET) service, particularly by nursing staff. A 1-year preparation and education programme was undertaken before implementing the MET at the Austin Hospital, Melbourne, Australia. During the 4 years after introduction of the MET, the programme has continued to inform staff of the benefits of the MET and to overcome barriers restricting its use. Objective: To assess whether nurses value the MET service and to determine whether barriers to calling the MET exist in a 400-bed teaching hospital. Methods: Immediately before hand-over of ward nursing, we conducted a modified personal interview, using a 17-item Likert agreement scale questionnaire. Results: We created a sample of 351 ward nurses and obtained a 100% response rate. This represents 50.9% of the 689 ward nurses employed at the hospital. Most nurses felt that the MET prevented cardiac arrests (91%) and helped manage unwell patients (97%). Few nurses suggested that they restricted MET calls because they feared criticism of their patient care (2%) or criticism that the patient was not sufficiently unwell to need a MET call (10%). 19% of the respondents indicated that MET calls are required because medical management by the doctors has been inadequate; many ascribed this to junior doctors and a lack of knowledge and experience. Despite hospital MET protocol, 72% of nurses suggested that they would call the covering doctor before the MET for a sick ward patient. However, 81% indicated that they would activate the MET if they were unable to contact the covering doctor. In line with hospital MET protocol, 56% suggested that they would make a MET call for a patient they were worried about even if the patient’s vital signs were normal. Further, 62% indicated that they would call the MET for a patient who fulfilled MET physiological criteria but did not look unwell. Conclusions: Nurses in the Austin Hospital value the MET service and appreciate its potential benefits. The major barrier to calling the MET appears to be allegiance to the traditional approach of initially calling parent medical unit doctors, rather than fear of criticism for calling the MET service. A further barrier seems to be underestimation of the clinical significance of the physiological perturbations associated with the presence of MET call criteria.

Blood flow reductions during continuous renal replacement therapy and circuit life

ObjectiveReductions in blood flow rate may occur undetected during peristaltic pumping of blood through continuous renal replacement therapy circuits. We investigated whether undetected reductions in blood flow rate occur during continuous veno-venous haemofiltration, and whether they are correlated with filter life.PatientsTwelve patients receiving continuous veno-venous haemofiltration in the intensive care unit of a tertiary hospital.MethodsExtracorporeal circuit blood flow during haemofiltration was continuously monitored utilizing a miniature ultrasound Doppler device. Otherwise undetected blood flow reductions were identified at severity levels of between 20% and 100% less than the set diastolic flow rate (83xa0ml/min). Information on anticoagulation status was simultaneously obtained. The frequency and severity of blood flow reductions were recorded, and the correlation with filter life was determined.Measurements and resultsThe duration of filter life ranged from 1.5 to 53xa0h, with a mean functional life of 19.62±16.32xa0h. There were 314 episodes of blood flow reduction during the 525xa0h of monitoring (0.59 episodes/h). There was a significant inverse relationship between the number of medium-level blood flow reductions and filter life. This correlation was much stronger than that between APTT and filter life.ConclusionsUndetected blood flow reductions occur during continuous veno-venous haemofiltration. Such reductions are frequent, and when sufficiently severe appear to be correlated with filter life more strongly than the blood coagulation variables typically used to monitor adequacy of anticoagulation and promote filter longevity.

A questionnaire survey of critical care nurses' attitudes to delirium assessment before and after introduction of the CAM-ICU.

BACKGROUNDnNurses are usually the first to identify delirium in ICU patients. We aimed to assess the attitudes of Australian critical care nurses when we introduced the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).nnnMETHODSnWe surveyed all 174 nurses in our ICU using two questionnaires: first after a one-month period of mandated but unstructured delirium assessments, and then following one month of CAM-ICU assessments. We also quantified antipsychotic medication usage by inspecting pharmacy records.nnnFINDINGSnThe first survey response rate was 65/174 (37%). Most nurses (73%) thought active delirium assessment was important, and 93% thought their assessments were worth the time required. These assessments were largely unstructured, as only 20% knew a formal delirium test, and only 7% sometimes used one. The second survey response rate was 45/174 (26%). Most (89%) still thought delirium assessment was important, but only 75% thought the CAM-ICU worth the time required (p=0.01 compared to unstructured assessments). Similar proportions (75% and 73%) were confident in the accuracy of their assessments. Many (33%) found the CAM-ICU quite or very hard to perform, but despite this, 82% wanted to continue to use it. Free-text answers suggested this was because medical staff paid more attention to the CAM-ICU. Supporting this, prescriptions of antipsychotic medications increased significantly in the CAM-ICU period.nnnCONCLUSIONnCritical care nurses in our Australian ICU who responded to our survey think delirium assessment is important. Although they find unstructured assessments easier to perform, they wanted to persist with the CAM-ICU, in part because it facilitated more appropriate pharmacological treatment of delirium for their patients. We recommend the CAM-ICU as a tool to improve communication between nurses and physicians in the management of delirium.

A pilot randomized controlled comparison of extended daily dialysis with filtration and continuous veno-venous hemofiltration: fluid removal and hemodynamics.

Objectives Extended intermittent dialytic techniques are increasingly being reported in the treatment of ARF in the ICU but few randomized controlled trials exist. We compared one such technique to a technique of continuous renal replacement therapy with regard to fluid removal and hemodynamics. Methods Sixteen critically ill patients with ARF were enrolled in a randomized controlled trial at the ICU of a tertiary hospital. We randomized eight patients to three consecutive days of treatment with either Extended Daily Dialysis with filtration (EDDf) or Continuous Veno-Venous Hemofiltration (CVVH) and compared fluid removal and hemodynamics during treatment. Results A total of 16.6 liters of fluid were removed during EDDf (830 mL/day over 20 treatment days) compared with 15.4 liters (700 ml/day over 22 treatment days) during CVVH. Median fluid removal per day was 1837 mL in the EDDf group compared with 1410 mL per day in the CVVH group, p=0.674. Median hourly fluid removal rate was 252 mL for EDDf and 128 mL for CVVH (p<0.01). Mean arterial pressure in the EDDf group was lower at two hours after starting treatment (76 mmHg vs. 94 mmHg) in the CVVH group; p= 0.031. There was no significant difference between groups for heart rate, CVP and noradrenaline dose at all time intervals measured. Conclusions Adequate prescribed fluid removal was achieved with both techniques. However, as expected, fluid was removed at a faster rate during EDDf. This was initially associated with a lower blood pressure than during CVVH where blood pressure increased.

Role of Technology for the Management of AKI in Critically Ill Patients: From Adoptive Technology to Precision Continuous Renal Replacement Therapy

This paper reports on the continuous renal replacement therapy (CRRT) technology group recommendations and research proposals developed during the 17th Acute Dialysis Quality Initiative Meeting in Asiago, Italy. The group was tasked to address questions related to the impact of technology on acute kidney injury management. We discuss technological aspects of the decision to initiate CRRT and the components of the treatment prescription and delivery, the integration of information technology (IT) on overall patient management, the incorporation of CRRT into other ‘non-renal extracorporeal technologies such as ECMO and ECCO2R and the use of sorbents in sepsis and propose new areas for future research. Instead of reviewing current knowledge, the group focused on developing a renovated research agenda that reflects current and future technological advances, centered on innovations in new equipment, membranes and IT that will permit the integration of patient care and decision-making processes for years to come.

Nursing for Renal Replacement Therapies in the Intensive Care Unit: Historical, Educational, and Protocol Review

Nurses have made a significant contribution to the development and application of dialysis in the 1950s and continuous renal replacement therapies (CRRT) in the Intensive Care Unit (ICU) setting from the 1980s. Any treatment requires patient and machine-circuit preparation, connection of the extracorporeal circuit (EC) to the patient vascular access catheter and regular tasks to maintain a treatment in progress. During treatment, nurses prepare fluids, adjust fluid settings to provide fluid balance, prepare electrolyte additives, monitor acid base and electrolyte levels, monitor patient and machine ‘vital signs’, and then when necessary diagnose circuit clotting and perform a disconnection of the EC from the patient. All of these aspects of CRRT nursing are essential to a suitable nursing policy or protocol. This paper provides a clinical review for this every day sequence when using CRRT in the ICU setting.

Design and implementation of a virtual world training simulation of ICU first hour handover processes.

Nursing training for an Intensive Care Unit (ICU) is a resource intensive process. High demands are made on staff, students and physical resources. Interactive, 3D computer simulations, known as virtual worlds, are increasingly being used to supplement training regimes in the health sciences; especially in areas such as complex hospital ward processes. Such worlds have been found to be very useful in maximising the utilisation of training resources. Our aim is to design and develop a novel virtual world application for teaching and training Intensive Care nurses in the approach and method for shift handover, to provide an independent, but rigorous approach to teaching these important skills. In this paper we present a virtual world simulator for students to practice key steps in handing over the 24/7 care requirements of intensive care patients during the commencing first hour of a shift. We describe the modelling process to provide a convincing interactive simulation of the handover steps involved. The virtual world provides a practice tool for students to test their analytical skills with scenarios previously provided by simple physical simulations, and live on the job training. Additional educational benefits include facilitation of remote learning, high flexibility in study hours and the automatic recording of a reviewable log from the session. To the best of our knowledge, we believe this is a novel and original application of virtual worlds to an ICU handover process. The major outcome of the work was a virtual world environment for training nurses in the shift handover process, designed and developed for use by postgraduate nurses in training.

Critical care nurses' opinion and self-reported practice of oxygen therapy: a survey.

BACKGROUNDnCritical care nurses frequently and independently manage oxygen therapy. Despite the importance of oxygen therapy, there is limited evidence to inform or support critical care nurses oxygen therapy practices.nnnAIMnTo establish if there is variability in oxygen therapy practices of critical care nurses and examine the degree of variability.nnnMETHODnOn-line questionnaire of ACCCN members between April and June 2010.nnnRESULTSnThe response rate was 36% (542/1523 critical care nurses). Overall, 378 (70%) respondents practiced in metropolitan critical care units; 278 (51%) had ≥14 years of specialty practice. In response to falling SpO(2), 8.9% of nurses would never escalate oxygen therapy without a doctors request, and 51% of nurses would not routinely escalate oxygen therapy in the absence of medical orders. Only 56% of nurses reported always increasing FiO(2) prior to endotracheal suctioning. In mechanically ventilated patients, 33% of nurses believed oxygen toxicity was a greater threat to lung injury than barotrauma. More than >60% of respondents reported a tolerance for a stable SpO(2) of 90%. Nurses in rural critical care units were less likely to independently titrate oxygen to their own target SpO(2), but more likely to independently treat a falling SpO(2) with higher FiO(2).nnnCONCLUSIONnCritical care nurses varied in their self-reported oxygen therapy practices justifying observational and interventional studies aimed at improving oxygen therapy for critically ill patients.

Clinical nursing for the application of continuous renal replacement therapy in the intensive care unit.

Treatment of critically ill patients with continuous renal replacement therapy (CRRT) requires a set of new skills and knowledge base for the intensive care unit (ICU) nurse. After a decision to treat is made, nurses effectively manage the technique by following a series of steps in sequence. These sequential steps include patient and machine circuit preparation, connection of the extracorporeal circuit (EC) to the patient’s vascular access, and nursing management of a treatment in progress. During treatment, nurses prepare fluids, adjust fluid settings to provide fluid balance, prepare electrolyte additives, monitor acid base and electrolyte levels, monitor patient and machine “vital signs,” and, when necessary, diagnose circuit clotting and perform a disconnection of the EC from the patient. All of these aspects of CRRT nursing are essential for a successful CRRT nursing policy or protocol. This chapter provides a clinical review for this every day sequence when using CRRT in the ICU setting.

Amino Acid Balance with Extended Daily Diafiltration in Acute Kidney Injury

Background: The impact of hybrid dialysis therapies on amino acid (AA) balance in critically ill patients with acute kidney injury is unknown. Methods: We examined prospectively the AA balance with extended daily diafiltration (EDDF). Results: We studied 7 patients. AA clearances with EDDF ranged from 21.6 ml/min (tryptophan) to 66.9 ml/min (taurine). AA loss was 4.2 (IQR 1.4–12.3) g/day and 4.5% of daily protein intake for patients on enteral nutrition (EN). Percentage AA loss per hour on EDDF was highest for glutamine (32.1%) and lowest for glutamic acid (0.8%). Blood AA levels correlated with corresponding EDDF losses. Median total nitrogen appearance was 25.0 (IQR 20.6–29.3) g/day for patients on EN. This resulted in a negative nitrogen balance of –10.7 (IQR –16.6 to –1.4) g/day, of which 6.5% was attributable to AA loss. Conclusions: AA loss with EDDF was limited, but with much individual variability, and contributed to a strongly negative daily nitrogen balance.