Panagiotis Kiekkas

Association Between Nursing Workload and Mortality of Intensive Care Unit Patients

PURPOSE To investigate differences in mortality of intensive care unit (ICU) patients according to the ratio between total patient care demands and nurse staffing. DESIGN Observational, prospective study. Patients consecutively admitted in the medical-surgical ICU of a Greek hospital over a 1-year period were enrolled. METHODS The Therapeutic Intervention Scoring System (TISS)-28 was used for measuring patient care demands. Daily sum of TISS-28 of patients and daily number of nurses were considered for estimating median and peak patient exposure to nursing workload. According to the values of median and peak patient exposure to nursing workload, patients were divided into three groups (low, medium, and high). Logistic regression was used for evaluating the associations between mortality during ICU length of stay and median or peak patient exposure to nursing workload, after adjusting for patient clinical severity. FINDINGS 396 patients were included and 102 died. Differences in ICU mortality between high and low groups of median and peak patient exposure to nursing workload, although not statistically significant, were clinically remarkable, both when all patients were studied and when medical and surgical patients were separately studied. CONCLUSIONS Consideration of individual differences in patient acuity might add sensitivity to the detection of associations between nurse understaffing and ICU mortality. CLINICAL RELEVANCE The findings indicate that not only differences among nurse characteristics, but also differences in patient care demands, are important when investigating the effect of nurse understaffing on mortality of ICU patients. Proper nurse staffing levels should be based on the estimation of total patient acuity, rather than on the absolute number of patients.

Medication Errors in Critically Ill Adults: A Review of Direct Observation Evidence

OBJECTIVE To systematically review clinical evidence gathered by direct observation of medication errors in adult patients in intensive care units. METHODS Articles published between 1985 and 2008 in English-language journals indexed by the Cumulative Index for Nursing and Allied Health Literature and PUBMED were searched for studies on medication errors made by intensive care unit nurses. Studies in which errors were detected via direct observation were included. RESULTS Six studies met the inclusion criteria, and error incidence varied considerably among them. Wrong dose, wrong administration time and rate, and dose omission were the most common errors. Antibiotics, electrolytes, and cardiovascular drugs were commonly associated with errors, but the evidence about factors contributing to errors was inconclusive. Increased monitoring was the most common consequence of medication errors, whereas life-threatening and fatal adverse events were rare. CONCLUSIONS Identification of patterns and characteristics of medication errors can guide preventive interventions. Factors contributing to errors, as well as drugs and error types associated with severe adverse events, deserve further investigation.

Unplanned extubation in critically ill adults: clinical review

AIMS AND OBJECTIVES To investigate and synthesize the evidence on the incidence and consequences of unplanned extubation (UE) in intensive care unit (ICU) patients, and on risk factors for UE. BACKGROUND ICU patients generally spend considerable time being intubated via the endotracheal route. Non-planned endotracheal tube removal, either deliberate or accidental, may pose significant safety risks for them. As UE is among the most studied critical incidents in the ICU, evaluation and summary of existing findings could provide important implications for clinical practice. SEARCH STRATEGIES, INCLUSION AND EXCLUSION CRITERIA: Observational studies published between 1990 and 2012 in English-language journals indexed by Cumulative Index for Nursing and Allied Health Literature (CINAHL), PubMed, Web of Science and the Cochrane Library were searched for studies on UE of critically ill adults. Thirty-three articles were considered eligible for inclusion. CONCLUSIONS UE incidence varies considerably among reports, with self-extubation representing the majority of cases. Agitation, especially when combined with inadequate sedation, and decreased patient surveillance are the major risk factors for UE. Inexperienced personnel and improper tube fixation may also be important, while physical restraint use remains controversial. UE can be followed by serious complications, mainly aspiration, laryngeal oedema and increased risk for pneumonia. Need for re-intubation is a major determinant of patient outcomes. Implementation of educational or quality improvement programs is expected to advance personnels knowledge about risk factors for UE, promote skills on safe, standardized procedures for patient care and increase compliance with them. RELEVANCE TO CLINICAL PRACTICE Identifying risk factors for UE and minimizing UE incidence through appropriate preventive strategies are prerequisites for improving nursing care quality and patient safety in the ICU.

Changes in nursing practice: associations with responses to and coping with errors

AIMS AND OBJECTIVE To investigate emotional responses of nurses and perceived senior staff responses to errors, error-coping strategies used by nurses and how these are associated with constructive or defensive changes in nursing practice. BACKGROUND Healthcare professionals have generally reported distressing emotional responses to errors and fear concerns about their consequences. However, errors can also be part of a developmental process, by offering opportunities for learning and leading to constructive changes in clinical practice. DESIGN Prospective, correlational, multicentre study. METHODS Five hundred and thirty-six structured questionnaires completed from nurses employed in various hospital departments were considered eligible for data extraction. The revised questionnaire used was evaluated for content validity. RESULTS Data analysis indicated that positive perceived senior staff responses (p = 0·030), accepting error responsibility (p = 0·031) and seeking social support (p = 0·019) predicted constructive changes in nursing practice, while negative perceived senior staff responses (p = 0·040) and error escape-avoidance (p = 0·041) predicted defensive changes. CONCLUSIONS Errors promote constructive changes in clinical practice when nurses are encouraged to use adaptive error-coping strategies within a supportive, non-blaming culture. RELEVANCE TO CLINICAL PRACTICE These findings highlight the role of senior staff in the establishment of a supportive, trustful ward climate, so that nurses can learn from errors, prevent their recurrence and improve patient safety.

Peak body temperature predicts mortality in critically ill patients without cerebral damage

OBJECTIVES We investigated whether mortality in intensive care unit (ICU) patients without cerebral damage is associated with fever manifestation and characteristics. METHODS Patients admitted to a medical-surgical ICU between October 2005 and July 2006 were prospectively studied. Exclusion criteria were acute brain injury, intracerebral/subarachnoid hemorrhage, ischemic stroke, and brain surgery. An ear-based or axillary thermometer was used to measure body temperature. The association between fever (ear-based temperature, >38.3 degrees C), fever characteristics, and ICU mortality was evaluated using univariate and multivariate analysis. RESULTS Two hundred and thirty-nine patients were enrolled. Fever was not associated with ICU mortality after adjustment for confounding patient factors. A significant dose-response increase of ICU mortality according to 1 degree C increments of peak body temperature was demonstrated, whereas peak body temperature was an independent predictor of ICU mortality. CONCLUSION These findings imply that, although fever is not generally associated with mortality in patients without cerebral damage, it can be harmful and should be suppressed when it becomes very high. Rigorous clinical trials are needed to help establish antipyretic therapy guidelines.

Fever effects and treatment in critical care: Literature review

Considering that the incidence of fever may reach up to 75% among critically ill adults, healthcare professionals employed in the Intensive Care Unit (ICU) are called to evaluate and manage patient temperature elevation on a daily basis. This literature review synthesizes the evidence about the effects of fever and antipyretic treatment in ICU patients. Although the febrile response acts protectively against infections, noxious effects are possible for patients with cerebral damage, neuropsychiatric disorders or limited cardiorespiratory reserve. Observational studies on ICU populations have reported associations between fever magnitude and patient mortality. Especially recent findings indicated that infected patients may significantly benefit from temperature elevation, while high fever may be maladaptive for non-infected ones. Aggressive antipyretic treatment of ICU patients has not been followed by decreased mortality in randomized trials. However, fever suppression and return to normothermia improved outcomes of septic shock patients. Antipyretic treatment should begin with drug administration and proceed with external cooling in case of refractory fever, but adverse effects of both antipyretic methods should always be considered. This article concludes by providing implications for antipyretic treatment of critically ill adults and suggesting areas for future research.

Greece reports prototype intervention with first peripherally inserted central catheter: case report and literature review

Placement of peripherally inserted central catheters (PICCs), definitely offers a clear advantage over any other method regarding central venous catheterization. Its ultrasonographic orientation enhances significantly its accuracy, safety and efficacy, making this method extremely comfortable for the patient who can continue his or her therapy even in an outpatient basis. We present the first reported case of a PICCS insertion in Greece, which has been performed by a university-degree nurse. The aim of this review of literature was to present the evolution in nursing practice in Greece. A PICC was inserted in a 77-year-old male patient suffering from a recent chemical pneumonia with a history of Alzheimers disease. A description of all the technical details of this insertion is reported, focusing on the pros and cons of the method and a thorough review of the history and advances in central venous catheterization throughout the years is also presented. PICCs provide long-term intravenous access and facilitate the delivery of extended antibiotic therapy, chemotherapy and total parenteral nutrition. We strongly believe that PICCs are the safest and most effective method of peripherally inserted central venous catheterization. Larger series are necessary to prove the above hypothesis, and they are under construction by our team.

Knowledge of pulse oximetry: comparison among intensive care, anesthesiology and emergency nurses.

AIMS AND OBJECTIVES To evaluate pulse oximetry knowledge of nurses employed in the Intensive Care Unit (ICU), Anesthesiology Department (AD) and Emergency Department (ED) and to compare knowledge among these departments/units. BACKGROUND Although pulse oximetry has been widely used in clinical practice, previous studies have reported knowledge deficits among nurses, which may adversely affect patient outcomes. DESIGN   Prospective, cross-sectional, multicentre study. METHODS All nurses employed in the ICU, AD and ED of six hospitals were asked to complete in private a 21-item, knowledge-evaluating questionnaire, which was evaluated for content-related validity and reliability. RESULTS Two hundred and seven questionnaires were completed (a response rate of 74·5%). Mean pulse oximetry knowledge score was 12·8 ± 3·2, with ICU nurses having significantly higher scores than ED nurses (p = 0·001) and those with more than 10 years of experience having significantly higher scores than less experienced ones (p = 0·015). Correct responses did not exceed 50% for six questionnaire items, five of which covered principles of pulse oximetry function. ICU nurses had significantly more correct responses in five items compared to ED nurses, and in two of them compared to AD nurses. CONCLUSIONS Longer professional experience and being employed in the ICU were associated with higher pulse oximetry knowledge of Greek nurses. Considering knowledge deficits and differences among nurses, pulse oximetry knowledge seems to mainly develop through clinical experience. RELEVANCE TO CLINICAL PRACTICE These findings highlight the need for pregraduate education to follow clinical advances, and especially for the implementation of high-quality, continuing education programmes to provide systematic learning and support professional development of nurses.

Knowledge is power: studying critical incidents in intensive care

Despite their difficult definition and taxonomy, it is imperative to study critical incidents in intensive care, since they may be followed by adverse events and compromised patient safety. Identifying recurring patterns and factors contributing to critical incidents constitutes a prerequisite for developing effective preventive strategies. Self-reporting methodology, although widely used for studying critical incidents, has been criticized in terms of reliability and may considerably underestimate both overall frequency and specific types of them. Promotion of non-blaming culture, analysis of critical incident reports and development of clinical recommendations are expected to minimize critical incidents in the future.

Nurse understaffing and infection risk: current evidence, future research and health policy.

In recent years, the association between nurse staffing and infection rates has attracted considerable interest. Especially in Intensive Care Unit (ICU) settings, there has been a progressively worsened imbalance between patient care demands and the amount of care that nurses are capable to provide (Ewart et al., 2004). Increasing number and acuity of critically ill patients account for increased demand, while staff shortage has mainly been attributed to cost-containment efforts. Understaffing can negatively affect nursing care quality by impeding provision of planned care. Among patient outcomes potentially affected by nursing resources, mortality has traditionally been the most studied; however, the importance of investigating intermediate outcomes has been highlighted. ICU patients generally sustain many invasive procedures, being thus at higher risk for health careassociated infections than those treated in non-critical care areas (Suljagić et al., 2005). In this context, infection rates are expected to be particularly sensitive in capturing the impact of nurse staffing, while their study will enlighten the processes by which patients deteriorate towards death (Numata et al., 2006; West et al., 2009). There is growing evidence that ICU understaffing contributes to infection risk increase. Fridkin et al. (1996) were the first to identify low nurse : patient ratio as an independent risk factor for developing central venous catheter-associated bloodstream infections in surgical ICU patients. In a following study, the incidence of infection with methicillin-resistant Staphylococcus aureus in the general ICU was significantly correlated with peaks of nursing staff workload and times of decreased nurse : patient ratio (Vicca, 1999). Similarly, increased risk for pneumonia and septicaemia in patients admitted to the ICU after esophagectomy was significantly associated with low night-time nurse : patient ratio (<1:2) (Amaravadi et al., 2000). In a more recent study that enrolled 51 ICUs, registered nurse staffing per patient independently predicted the incidence of central line-associated bloodstream infections and ventilatorassociated pneumonia, with higher staffing being associated with progressively decreased infection rates (Stone et al., 2007). In addition, in the single-centre study of Hugonnet et al. (2007a), an increase of nurse : patient ratio by one unit was associated with a >30% decreased risk for any infection, while 26·7% of all infections could have been prevented if nurse : patient ratio was maintained >2·2. Especially the risk for late-onset ventilator-associated pneumonia was independently and inversely associated with nurse : patient ratio (Hugonnet et al., 2007b). The association between understaffing and infection risk needs to be further investigated. Nurse : patient ratio is a crude staffing measure; the use of more sensitive measures has therefore been suggested, such as night-time and registered nurse : patient ratio, along with standardization for ICU clinical experience of nurses (Tourangeau et al., 2002). Furthermore, considering that ICU patients differ in terms of care intensity they need, the use of total patient acuity should be preferred instead of absolute patient number. Peak nursing workload in which a patient was exposed during ICU stay, defined as the sum of patient care demands divided by the number of available nurses for a given day, was identified as more sensitive measure for detecting mortality differences than nurse : patient ratio (Kiekkas et al., 2008). Similarly, in contrast to nurse : patient ratio, a higher nurse : ventilated patient ratio was associated with a significantly decreased incidence of nosocomial bloodstream infections and pneumonia (Schwab et al., 2012). More recommendations for future research include the identification and adjustment for confounding factors associated with individual infection risk and the use of more sophisticated study designs (e.g. case-crossover) for incorporating temporal information about nursing workload variations (Hugonnet et al., 2007c; West et al., 2009). Assumed causality and underlying mechanisms linking understaffing and increased infection risk have to be corroborated. Existing evidence has advocated for nursing personnel’s contribution in minimizing central venous catheter-related bloodstream infection rates through the implementation of simple preventive measures, such as hand washing and using full-barrier precautions during catheter placement (Richardson, 2009; Goeschel, 2011). However, limited compliance with infection control recommendations and suboptimal care of indwelling devices (endotracheal tubes, urinary or endovascular catheters etc.) are