Stefano Elli

Nursing Activities Score (NAS): 5 Years of experience in the intensive care units of an Italian University hospital

OBJECTIVE To retrospectively analyse the application of the Nursing Activities Score (NAS) in an intensive care department from January 2006 to December 2011. METHOD The sample consists of 5856 patients in three intensive care units (GICU: General Intensive Care Unit, NeuroICU: Neurosurgical Intensive Care Unit, CICU: Cardiothoracic Intensive Care Unit) of an Italian University hospital. The NAS was calculated for each patient every 24 hours. In patients admitted to general ICU, the following scores: SAPS 2 and SAPS 3 (Simplified Acute Physiology Score), RASS (Richmond Agitation Sedation Scale) and Braden were also recorded along with the NAS. RESULTS The mean NAS for all patients was 65.97% (Standard Deviation ± 2.53), GICU 72.55% (± 16.28), NeuroICU 59.33% (± 16.54), CICU 63.51% (SD ± 14.69). The average length of hospital stay (LOS) was 4.82 (SD ± 8.68). The NAS was high in patients with increasing LOS (p<0.003) whilst there were no significant differences for age groups except for children 0-10 years (p<0.002). The correlation of NAS and SAPS 2 was r=0.24 (p=0.001), NAS and SAPS 3 r=-0.26 (p=0.77), NAS and RASS r=-0.23 (p=0.001), NAS and Braden r=0.22 (p=0.001). CONCLUSIONS This study described the daily use of the NAS for the determination of nursing workload and defines the staff required.

[Invasive and non-invasive ventilation: impact on nursing workload].

INTRODUCTION Non invasive ventilation (NIV) is increasingly used in intensive and non intensive wards. OBJECTIVE To detect the impact of ventilation modes on nursing workload. METHODS Retrospective observational study of 200 patients admitted to a general Intensive Care Unit (ICU). Nursing Activities Score (NAS) was used to measure the nursing workload. Patients enrolled were treated with the following ventilation modes: oxygen therapy without positive end-expiratory pressure (PEEP), helmet Continuous Positive Airway Pressure (CPAP), controlled mechanical ventilation, Invasive pressure support ventilation (I-PSV). RESULTS The overall mean NAS score of patients was 74.3% (SD ±8.88 - range 39/143) corresponding to an ideal nurse/patient ratio of 0.7 and varied with the different ventilation modes. In the days in oxygen therapy, the average NAS was 64.5% (±11.9), with helmet CPAP 69.7% (±12.7), with controlled mechanical ventilation 86.1% (SD ±15.1) and with invasive assisted ventilation 76.4% (±11.4) [p=0.0001]. In patients with helmet CPAP the NAS increased of 14% when FiO2 >0.6 and PEEP >10 compared to oxygen therapy. The average NAS score of the 15 patients (7.5%) with mask-PSV was 80.2% (±12:5). CONCLUSIONS Overall, the nursing workload of patient with helmet CPAP was lower than with invasive ventilation. In Helmet CPAP, with FiO2 >0.6 and PEEP level >10 cmH2O and mask-PSV, the nursing workload is similar to that of patients with invasive ventilation. NAS scores in patients with Invasive ventilation in the controlled mode is higher than with assisted mode.

“Extended subcutaneous route” technique: a quick subcutaneous tunnelling technique for PICC insertion

Purpose To describe a quick tunnelling technique for peripherally inserted central catheter (PICC) insertion called the “extended subcutaneous route” technique. Methods The “extended subcutaneous route” technique is described step by step. Results In 18 consecutive PICCs, inserted with extended route technique in ASST Monza, no complications during insertion were registered. In 969 catheter days observed, we identified only one accidental dislodgement. No other mid-term complications were observed. Conclusions Extended subcutaneous route technique allows the creation of a subcutaneous tunnel <5 cm, without skin incision and additional manipulation. Extended subcutaneous route technique may be feasible and useful, particularly for patients with high risk of bleeding or infection.

In vitro evaluation of fluid reflux after flushing different types of needleless connectors

Purpose To evaluate fluid reflux, when disconnecting syringe, for different needleless connectors. Materials Nine connectors were tested; 540 measurements were carried out. Results The connectors tested showed very different performances, about reflux, on disconnection of the syringe used for flushing. The calculated reflux volumes are: Max Zero® - BD: 6.90 (±2.47) mm3; MicroClave Clear® - ICU Medical: 6.14 (±1.46) mm3; Bionecteur® - Vygon: 1.24(±0.73) mm3; Neutron® - ICU Medical: 0.12 (±0.15) mm3; SmartSite® Carefusion: 33.51 (±11.50) mm3; Safe Plus® - Cremascoli: 23.54 (±3.56) mm3; NeutraClear® - Cair: 9.36 (±1.87) mm3; NeutroX® - Cair: 0.33 (±0.31) mm3; Dasa® BTC: 2.38 (±1.67) mm3. Differences between investigated devices were statistically significant (p<0.001). Discussion It is difficult to establish the best quality-price ratio for needleless connectors. It is important to consider several variable factors: continuous or discontinuous infusion, catheter type, usage environment and caliber of catheter used. It would therefore be useful to have an indication of the intraluminal space potentially affected by blood reflux in relation to a specific device. Conclusions Needleless connector is one of the main factors involved in keeping catheter patency. It is important to perform the best choice among the connectors available. An empirical reflux measurement, relative to the needleless connector and the catheter in use, can be obtained using an 18G cannula.

[The impact of closed system and 7 days intravascular administration set replacement on catheter related infections in a general intensive care unit: a before-after study].

INTRODUCTION The incidence of catheter related Bloodstream infections (BSI) is high in intensive care units (ICU). AIM To evaluate the BSI rate in a population of patients admitted to a General ICU before and after the implementation of the 2011 CDC guidelines. METHODS Retrospective observational study on patients admitted from January 2009 to December 2013. The infusion and monitoring lines were changed every 96 hours for the first 30 months, and every 7 days for the next 30. In all patients a closed infusion line with needle-free connectors pressure was used (Microclave). The following catheters were considered in the study: central venous catheter (CVC), arterial cannula (ART) and Swan Ganz catheter (SG). RESULTS During the period with change every 96 hours 15 BSI were observed over 13395 catheters/days (C/D), 1.12 per 1000 C/D, while when lines where changed every 7 days 11 BSI were observed over 13120 C/D, 0.83 per 1000 C/D. A statistically significant reduction of BSI was observed in SG catheters (4.17 vs. no BSI p = 0.02), while the CVCS (1.12 vs 1.45 - p = 0.37) and ART (0.35 vs 0.36 - p = 0.61) infection rates remained unchanged. CONCLUSIONS The replacement of infusion lines every 7 days in our sample did not increase the BSI, helping to reduce the costs.

Alterazioni dei parametri vitali indotte dalle cure igieniche nel paziente critico: uno studio esplorativo

Le cure igieniche effettuate nel paziente critico possono indurre modificazioni dei parametri vitali. Obiettivo. Rilevare le variazioni dei parametri vitali nel paziente critico durante le cure igieniche e le variazioni a manovre concluse, rispetto al valore basale. Metodo. Sono stati osservati i parametri vitali di 6 pazienti in 10 giorni di degenza pre-cure igieniche (ore 06.00), durante le cure igieniche (ore 08.00) e a 90 minuti dal termine (ore 10.00). Risultati. Sia durante le cure igieniche, sia a due ore dalla fine vi e una modificazione dei parametri del paziente: Frequenza cardiaca +11.20%/+1.48 (aumento medio/differenza media a 2 ore rispetto ai valori basali), Pressione arteriosa sistolica +22.68/+1.56, Saturimetria capillare arteriosa -4.31/+0,27, Frequenza respiratoria +8.10/+2.66, Volume corrente +4.04/-7.51, Volume di CO2 prodotta al minuto +5,34/-22.33, Temperatura Vescicale -0,85/-0,60. Conclusioni. Le cure igieniche nel paziente critico inducono modificazioni rilevanti dei parametri vitali. In questa fase e fondamentale mantenere il monitoraggio emodinamico e respiratorio e applicare protocolli per la gestione della sedazione e del supporto farmacologico vasoattivo.

Positioning the Critically Ill Patient: Evidence and Impact on Nursing Clinical Practice

Critically ill patients lay in bed since the beginning of the acute clinical condition. Often they are forced to rest in bed for long periods, due to lifesaving treatments and technologies supporting organ/system failures. Patient repositioning in critical care is strongly linked to the interventional patient hygiene model concerning pressure ulcers, ventilator-associated pneumonia, and immobilization syndrome prevention. At the same time, patient positioning is the antecedent of his/her mobilization and early physiotherapy, which are part of the ABCDE bundle. This chapter discusses the rationales, the evidences, and the contradictions present in medical and nursing scientific literature about patient positioning in critical care units. Moreover, therapeutic advantages and limits for every position are showed. Some technologic support in patient repositioning are described. Lastly, this chapter will provide some suggestions for the repositioning of hemodynamically unstable patients. The main message of this chapter is that all kinds of patients deserve to be early repositioned, if there are not severe contraindications. However, a reassessment of patients aiming to begin a trial of positioning should be conducted at least every 8 h.

Posizionamento della punta del catetere durante l’impianto di PICC: Analisi retrospettiva dell’affidabilità del metodo ECG vs. controllo radiologico

. Evaluation of tip location reliability of intraprocedural ECG vs. chest Xrays in PICC placement. INTRODUCTION Among the methods to assess the correct positioning of the tip of central venous catheters, the ECG method is safe and reliable. AIM To compare the reliability of tip location by intraprocedural ECG and post-procedural radiological examination as implemented in routine care in a tertiary hospital PICC Team. METHODS 119 PICCs positioned by the Monza hospital PICC Team were examined positioned by either ECG technique or post procedural x-rays technique. The tip location was assessed in retrospect, through occasional chest ray reports. We assessed the reliability of the ECG and X rays techniques. RESULTS In the ECG group (75 catheters), 71 (95.7%) were correctly located vs 33/44 (75%) in the x-rays group. CONCLUSIONS Tip location by ECG technique implemented by the PICC team is feasible and safe. The cost/benefit ratio suggests its adoption as main tip location technique.

Utilization of Behavioral Pain Scale and Critical Care Pain Observation Tool for pain evaluation in Intensive Care Unit

AIM To compare two evaluation pain scale the Behavioral Pain Scale (BPS) e Critical Care Pain Observation Tool (CPOT) in Intensive Care Unit in the Azienda Ospedaliera di Monza, and their correlation. To evaluate if consciousness level (evaluate through a third scale the Ritchmond Agitation Sedation Scale - RASS) influence the use of the pain scales. METHODS 1083 data were collected from May 2012 and November 2012. The sample was made up by 36 patients, of these 20 men and 16 women, average age of 62,94±13,21 and hospital stay on average of 17±12 days. RESULTS BPS median is 3 (Q1: 3 - Q3:3 - range 3-12), CPOT median is (Q1-Quartile 25%: 0 - Q3- Quartile 75% : 1, range 0-8), RASS median is-1 (Q1: -4, Q3: 0 - range 0/- 5). Corellational coefficient is 0.784. There is a overall difficulty on use BPS and CPOT expecially with individuals with RASS -1. CONCLUSIONS Results of this study suggest the need to carry out further research, expanding the validation of the pain scales for patients not able to speach to unexplored patients.