31st Australia & New Zealand Annual Scientific Meeting 2006 Hobart, Tasmania — 12–15 October 2006

A,\

Australian Critical Care

Abstracts 31st Australia & New Zealand Annual Scientific Meeting 2006 H o b a r t , T a s m a n i a - 12-15 October 2006

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Do clinicians know how to use pulse oximetry?

Increasingly, Acinetobacter is a significant ICU nosocomial pathogen that frequently develops antimicrobial resistance and increases patient morbidity. In 2004 increasing nun, bers of positive Acinetobacter isolates were identified in patients admitted to a 24 bed, combined medical-surgical and trauma adult ICU in an Australian university associated teaching hospital. A retrospective audit of all admissions from March to October was performed to identify factors associated with the Acinetobacter outbreak.

This article is reproduced in full in this issue of Australian Critical Care.

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A randomised comparative crossover study to assess the affect

A total of 1259 patients were admitted, of which 110 (9%) had a positive Acinetobacter isolate identified in sputum (95%), blood (2%) or wound site (3%). Acinetobacter colonisation occurred in 20% of trauma patients, 10-13% of patients with respiratory, cardiac or miscellaneous diagnoses, and 4% of postoperative patients. Positive isolates were mostly obtained in patients admitted to bedspaces in close proximity to colonised patients (73% located within two bed spaces). Acinetobacter colonisation was identified following prolonged ICU stay (median Day 5) and occurred in patients with higher APACHE II scores (mean score 20.4 vs 13.6, p < 0.001). Colonised patients had a longer duration of ICU stay (median 10 vs 2 days, p <0.001) and were more likely to require ICU readmission (20% vs 8%, p <0.001).

on circuit life of varying pre-dilution volumes associated with continuous veno-venous haemofiltration (CVVH) and continuous veno-venous haemodiafiltration (CVVHDF) H u g h Davies i & Dr Gavin Leslie 1'2

1. Royal Perth Hospital, Perth, W A 2. Edith Cowan University, Perth, WA Circuit time for continuous renal replacement therapy is an important factor in determining the effectiveness of treatment. This study sought to determine whether circuit lif0 is imquenced by the higher pro-dilution volume technique C V V H w h e n con, pared with the lower pro-dilution volume approach CVVHDF.

Acinetobacter colonisation was associated with increased severity of illness, duration of ICU stay, trauma diagnosis and proximity to another colonised patient. Increased incidence of Acinetobacter colonisation indicates the potential for increased patient morbidity and the need for improved infection control processes. Therefore these data serve as a baseline o n which to quantify future infection control strategies.

A comparison of circuit life was undertaken at a single-site using a randomised crossover study design. A crossover was deemed to have occurred w h e n both circuits had adequate blood flow and was terminated due to clotting. Standardisation of variables included blood flow rate, vascular access site, haemofilter, anticoagulation and trtacl'dne hardware. A n ulwafiltrate dose of 35mL/kg/hr delivered pro-filter was used for CVVH. A fixed pro-dilution volume of 600mLs/hr with a dialysate dose of between 500mLs to 2L was used for CVVHDE

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Forty five patients received either CVVHDF or C V V H followed by the alternative treatment. A total of 50 C V V H circuits and 43 CVVHDF circuits survived to clotting. I n 31 patients, clotting of the circuit occurred sequentially. Based o n an intention-to-treat analysis an 'In' (logarithm base e) dataset transformation was followed by a paired-samples t-test to evaluate circuit lif0. There was a statistically significant increase in circuit lif0 in favour of CVVHDF [mean 18hr 6rain (1n6.78), SD l l h r 55rain (1n0.67)] compared with C V V H [mean 9hr 8trtin (1n6.16), SD 5hr 43rain (In0.51), t(42) 5.18, p<0.001. The eta squared statistic (0.39) indicated a large effect size.

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Dr Beverley Copnell 1~, A/Prof Peter A Dargaville 2,3, Dr Ethel M Ryan 1, Michael J Gordon 1,4, Lisa Chin 1, Dr John F Mills 1,2, Prof Colin J Morley 1,2,4& Dr David G Tingay 1,2

1. Deparmu,nt of NeonatoIogy, Royal ChiIdr,m 's Hospital, Melbourne, VIC 2. Murdech Children's Research Institute, MeIbounw, VIC 3. Deparmwnt of Paediatrics, Royal Hobart Hospital, TAS 4. Deparmwnt of NeonatoIogy, The Royal Wom~'n 's Hospital, Melbourne, VIC Closed endotracheal suction is believed to cause less lung volume loss than open suction, but little is known of the effbct of other factors. The aim was to identify the eftbct of suction pressure, catheter size and suction method o n change in lung volume (AV) during endotracheal suctiot~ Anaesthetised piglets (n 6) were intubated with a 4.0 cuftbd endotracheal tube and ventilated conventionally (CMV). Lung injury was induced with repeated saline lavage. Open and closed (in-line and side-port adaptor) suction were performed in random order using 6, 7 and 8 Fr catheters, at pressures of 80, 140 and 200mnfftg. The protocol was repeated o n high frequency oscillatow ventilation (HFOV). AM relative to pr0-suction baseline was measured with respiratory inductive plethysmography.

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The effect of suction method, catheter size and suction pressure on lung volume changes during endotracheal suction

This tightly controlled study found pro-diluted CVVHDF to have an extended circuit lif0 when compared to CVVH.

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Kelly Goom 1, Louise Rose 1,2, Leanne Redl i & Prof Jack Cade 1. Ttu, Royal Melboume Hospital ICU, VIC 2. RMIT University, VIC

1. Doctoral Ca~vAidate & Lecturer, Sct~oI of Nursing, Deakin University, VIC 2. Research Administrator, ANZICS Clinical Trials Group 3, Research Fellow, SctmoI of Nursing, Deakin University, VIC

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Clinical impact and factors associated with an Acinetobacter outbreak

Malcolm Elfiott 1, Rhiannon Tate 2 & Karen Page 3

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Critical care nurses caring for patients and their family Janet Berry, Professor Marl Botte & Professor Ruth Endacott

Greater Souttu,rn Area Health Service Deakin University, VIC, Australia La Trobe University, VIC Abstract not submitted for pubficatiot~

145

Volulnp 19

Number4 November2006

AK Overoll, open suction resulted m greater maxim~* loss of l~*g vol~*e (AW "~) and m ore per,i~tent vol~*e io,,at 60 ,coon& po~t-~uction (AV~°), than either closed method (p
Paediatric

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N e w t eclmology: multiphase p ~ e n t ~ a l nutrition in paediatrics J ~ Mater B m e h

Recent technological alia scientific advances m parenteral n u m t i o n worldwide have to lead to sighiricant changes in tile type, composition and adndnistrotion of pamnterol nutrition across all age groups From the 1990s parenteral numtion for adults has been available m muluphase adnlmistrotion fomla, with the majonW of parenteral nut ntion for adults adnlmistered m this malmen Multlphase pamnteral nutntion is superior to single component solutions with its e=ended sheir life, phamlacological solution stability, reduction of adn:mistration mistakes, cost, m edico-legal aspects and use in home based nutritionalcare and safety in non-teaiary health care s e : i c e s In 20)5 redevelopmentof parent erol nutritionfor babies and children aged 0-17 years commenced a the Maer Ohildren s Hospital, South Bnsbane, Queensland, Australia Multiphase (dual phase) parenterol nutritionwas fommlaed for introduction a the hospital with the solutions amino acid base PnmeneTM and S?llthammTM and fatty acid OlmoleicTM In early 20)6 the multlphase solutions were introduced to the m p a i e n t and home parenterol nutritionpaediaric paients ages bi~h (tern*) to age 17 years In the hospital, 65-70% of parenteral nutritionis commenced in the I OU The muluphase solutions have been widely accepted The overoll cost of parenterol nutrition has been reduced by approximaely 40% when compared to single phase solutions Ability to mdivldualise parenterol nutritionprescriptions throughmodification is still available Ir required by tile tre a m g physician Tile Mater CLildren's Hospital is tile first paedianc hospital to move across to multlphase parenterol nutntion solutions V/e have demonstroted that multlbbase parenterol nutntion is a safe, suitable, cost effective and t eclalologicallysu~nor way to adadnister mtrovenousn ~ n t i o n Acknowledgement to Ba=er Phamlaceuticals Australia with the development, stability mfomlation and technological assistance with development of this parenterol nut nt ion dellve ry system

Faldotr aebeal suetiot~ing praetiees o f neonatal a l d paediatrie mtm~ve c~e n~ses

The response rate was 64% 231 respondents (57 PIOU and 174 NIOU nur,es) from 34 ~*ltS Closed suction was used exclusively by 64% of MICU nur,es and 4% of PIOU nurses, and for selected paients by 24% and 75% respectively ( p < 0 ~ 5 , chi-squar@ Suction caheters t h a occlu&d >50% of the ETT cross-sectional area were used 28% of the t i m e Suction pressure tonged from 38-263mmHg (5-35kPa) PIOU nur,es used h g h e r pressures than NIOU nur,es ( p < 0 ~ 5 ) Adndnistrotion of supplemental oxTgenwas the most common means of ovenommgprocedurol side-effects Increase of ventilaorseaings was used by 76% of NIOU nur,es and 5~% of PIOU nurses (p=0 016) Saline instillationwas proctised always by 32% of NIOU nur,es, and sometimes by 60% of NIOU and all PIOU nur,es ETT suctioningproctices varied widely between and within 4 i l t s Some knowledge deficits were evident

Slid ona fil prevents rebomld p ~ nlOtl ~ y h y p ~ t ension a f f ~ discontinuation o f inhaled nitric oxide: a r a n d o m i s e d , double, b l i n d placebo.cont*olled s t u d y i n cbildr en D r P ~ n g ~ & ~ N ~ e Nvay~/1, U Theflen1, CF S t o k e r 1,~, W Bu~ l, DJ P ~ y "~ & LS S h & e r & n f i ~to i D,portment c~ Inens~e Co~, T}~ P,-yal C}g~r~n; H~pital, VIC 2 D.p~rtment c¢ Card.bogy,T}~ Ruya)C},ibJ~r,~ H~pi~), VIO

hff:aled n l t n c oxide (NO) reduces puln:onary vascular resistance and improve s oxygenaionwithoutalteringsystemic haemodynamics in children with acute pulmonary hgpe ~ension (PHT) Rebo~ld PHT is charect ensed by all acute increase m pukn:onary a~ery (PA) pressure, cardiopukn:onary instabilityand, in some cases, the need to continue NO therepy beyond the intended period of use Sildenafil, a puknlonary vasodilaor increases inmnsiccOMP levels by prevent mg its breakdown The aim of this study was to establBh whethersildenafilhad a role m prevention of rebo~ld PHT after withdrawal of inhaled NO Thi~y ventilaed children, medial: weight 42kg, receiving 10 pans per million (ppm) or more of NO were rendomised to either 04mg&g of sildenafil or placebo; 29 completed the stud,~ NO was weaned by lppm every hair hour and study drag was given when NO was a 2ppm PA pressures and blood gaseswere m easured before givingthe study drag, and at 1 and 4 hours after stoppmg N O Dad were e :pressed as medial:(IQR) Rebo~ld PHT occu~ed in 10114 placebo paients and 0115 sildenafil paients ( p < 0 0 ) l ) PA pressure increased by 25% (14, 67) m placebo paients, and by 1% (-9, 5) in sildenafll paients ( p < 0 0 ) l ) NO was resta~ed m 4114 placebo and 0115 sildenafil paients (p 0042) Oxygenaion was ~:changed for both groups after stopping NO therepy Duret ion of ventilaionafter study was 980 ( 470, 2235) hours for placebo and 282 (157, 546) hrs for sildenafll group (p 0024) A single dose of sildenafll prevented rebo~ld PHT after withdrewal of NO, and reduced the durotion of mechanical ventilation Prophylaxis with slidenafil should be considered when weaningpaients from inhaledNO

Effect of breathing elf euit size on paedlauie ventilat ~ y p~amet~s Alison P~lor & A s s ~ . Pmf An&ms Sehiblor

Mawr C},il,~rL's H~pi~l, Br~bone, QLD Pmf til~ Johr~ton"2a i D~pt crfN~onat,obogy,Tt~ Rvyal Wumen~ H~pital, VIC 2 D~pt of N~onat,obgy, T}~ Rvyal C}~b~n ~ Huspi~l, VIC 3 M,rd~hC}~r~n% R~,~r~hfnstit~e, VIC

4 Sc}~ol#N.rsing, T}~ Uni~rsi0 #Me~.rne, ~qC Endotracheal tube (ETT) suction is a complex proctice that, m newborns and children, is largely ~:suppo~ed by a strong evidence base Identifying nur,es' actual proctices call provide a basis for fu~her studies The am* of the study was to descnbe the endotracheal suctioning proctices of nur,es in Austrolian and New Zealand neonaal (NIOUs) and paediamc intensivecare ~*ltS (PIOUs) A 27 item questionnaire covering all aspects of suctionmg was developed by the reseanher, and piloted for content and fete validity Ten copies of the su~ey were mailedto the nurse milt m anager~ of all 28 NIOUs and eight PIOUs, and subsequently dist nbuted an:ongnur,es with a ronge of erpenence in the speciality

In most paediatric intensive care rants (PIOU) three s~es of cinUltS are used Ou~ent practice is to use a neonatal circuit up to 8kg, a paediatnc c i n u i t from 8-35kg and an adult circuit above 35kg This study aimed to detem:me whether cu~ent practice can be replaced usingnew two circuits (neonatal<15kg and adult >15kg) In a 24 hour cross-over study deslgh we compared our paediat nc c i n u i twith the se two circuit s m the weightrange 845kg Delivered tidal v o l ~ : e (VT), compliance ahd resistallCe were hi ~asur~dwith t}l~ ~lMiltflow sensor of all EVlta-4 ventilaorand compared to parometers measured with a Flonan flow sensor situated at tile ETI~ In 16 ventilatedchildren the measured Vt usingthe study c i n u i twas 63+ 2 4 (m L&g, SD) and in tile control cinult 71+18 (m Ukg, SD) Oompliance was 11+16 (mL]cmH20&g) and 13+09 respectively Resistance was 5 0 + 4 0 (L]cmH2OMkg) and 4 7 + 3 0 respectively (all p n s ) The overall difference of VTFlonan and Vq-EVITA was 11+15 (mL]kg), with all obse~ed m a x m l ~ l difference of 48%

AN There is no significallt difference m dehvered tidal v 0 1 : l e s using either civuit,hence the results suggestt h a cument proct ice maybe replaced using two circuits only There may be sighificallt mlderestmlation of measured delivered V T using all inbuiltflow senson

Sev~e sepsis in intensive care patients is not identified by i n t onsive c ~ e ditlieians w i t h i n 24 h o ~ s o f a d m i s s i o n D N e C~ / } r l N 1, T ~ N H ~ t i Flin&rs Uni~sity, SA 2 Flin&rs MdscalCentf~, SA

& A l f r i ~ Hany *

Nursin 9 free papers N u r s i n g activitiesm I c u : a t i m e and motion study Michael Abbey i P~fessor WeI~y Chaboyer i Pnnc.ss Ale~n&o H~pit~l IC U, fPLD

& D r Marion Mitchell3

2 Grrffit}, Uni~rsity Gold C~,t Co,r@~s, OLD, 3 Grrffit}, Uni~rsity Logo,, Camp~s OLD, qhe use of enrolled nur,es m the ICU, coupled with global sho~ages of specialist nurses, makes it imperative that the utilisation of troined critical care nurses is appropnae Additionally, it requires all accurote mlderstailding of tile activities currently mldeaaken by tile ICU nursing workfove This tmle alld motion audy u~ed amctured obse~aion to capture the daily activities ~:deaaken by 10 ICU regiaered nur,es (RNs) dumlg the early shift, resulting in 765 hour, of d a d Activities were classified as direct p a i e n t cam, redirect p a i e n t care, ~ : i t relaed or personal (see table) The applicaion of a (knowledge m action' theory m suited m act lvlties being allalysed in relation to the degree of rout meness, discretion, intensitymuluplicit y comple mty alld accessibihty Nur,es peffom:ed on average 308 activities (ral:ge 193-500) in a shift Of all 3081 acuvities obse~ed dunng dad collection, them were 354 (39%) installces where two activities or morn occurred m the same timefrome Combiningtmle alld motion with the concepts of routineness, discretion, intensity multiplicitycomplexity al*d accessibility provided insight into factors t h a mlpact on RNs' decision makingprocesses Impoaalltly60% of Pdqs' time was spent on direct patient care Understanding w h a the liltensive care nurse does as they care for acut ely illpaients provides usefal n£omlaiont h a ca1*i n b m : de cisions involvingm sour(e allocaion

~ t ~ t c~e I n ~ m t c~e U~t tdat~ petmnd T~td

M,jo~ ~ou~

1% of,o,i~i,y

1,~5? 986 98 140 3,0@1

(603%) (320%) (32%) (45%)

Severe sepsis is a common disease process in the critically ill alld is associated with substantial morbidity alia m o~alit'~ The impo~allce of the early identificaionof sepsis has been highlightedby the %u~lvmg sepsis guidelines' m order to provide early alld aggressivem allagement m order to improve outcome qhe study oblectives were to detemlineif intensive care clmiciallscall identifysepsis m those paients m their care within the fi=t 24 hou= of adnlission The p a i e n t coho~ were prospect lvelyscreened alld enrolled on admission to intensive care within the fi=t 24 hours Clinical data were collected prospectively Diaghosis was based on microbiologically confimled clinical findings Clmicialls canng for each p a i e n t were prospectively su~eyed regarding the p a i e n t m their cam All 47 sublects had refection Severn sepsis was defined as new-onset acute orgal*dy{ul*ction, using consensus criteria Infection sites included 52% pne:*onia, 17% urinary 15% ablommal, 6% wo~*d al*d skin al*d 10% isolaed orgal*s al*dbone Single orgal*failure was evident in 21%, 42% two orgal: foilure, 29% three organ failure and 8% four orgal: foilure Nur,es identified sepsis m 16 of the 47 patients (p
nurse or physiciallwas sig~lificallt iy associatedwith pile:ionia (p
Nurse.d~ived c~diac output n l e a s ~ e n l o n t u ~ n g a non invasive cardiac output n l o l ~ t o r A n ~ d a Corloy l, Dr John F~sor i & D r Dan Mullany"

i Critical Con P,~s~rehOm~p, T}~ Prince C}~b, g~pital, OLD 2 D~re-torcCAdult I n e n s ~ Con Semic,s, Prince C}~b, H~pital, nED The US C'OM ( Ultrosonic cardiac output monitor) device is a non-mvasive m orator whichutilises continuous wave doppler to detemlme cardiac output (CO) The aims of our study were to compare CO usingUSCOM with CO

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Australian Critical Care

using puhnonary artery catheter (PAC) and assess the learning curve when performed by a non-echocardiograhically trained ICU nurse. Ton patients, aged 24-65 years, who were spontaneously breathing add required PAC as part of evaluation for heart failure were studied. Demographic add clinical data were recorded. In a bfinded fashion, we simultaneously compared CO obtained by U S C O M with themxodifurion measurements obtained by PAC add estimated from a modified Fick equation. A generafised estimating equation was used to assess correlation between methods due to muhiple recordings per patient. BlaDd add A h m a n method was used to assess agreement.

A n audit was conducted from February to May and compfiance rates are illustrated in the table. The application of the M-FAST H U G 2 S mne lnonic with checklist add resources encouraged a team approach to recognising and preventing VAP add improving care for ICU patients. February/2006 Mouth-care Feeding established Analgesia: Pain-score

The CO measured by PAC ranged from 2.6-7.11hnto for themlodifurion add from 3. L&71hnto by Fick. U S C O M derived CO was highly correlated with both themxodilurion add Fick methods. The mean difference was 0.35hnin (CI 0.74-0.04) with limits of agreement from 1.9-1.2. From cotnnlencement of the study to conclusion, rime to optimal image acquisition reduced from 25 minutes to 5 minutes despite the technically difficult study populatiotz

Prescription Sedation: Score Prescription Thromboprophylaxis: Prescribed

U S C O M has been found to be reliable and accurate in measuring CO. The learning curve for successful usage of U S C O M by an ICU nurse is satisfactorily short, which suggests U S C O M could be used by appropriately trained nursing staff" to non-tovasively determine CO. Further work is required in ventilated patients.

TEDs/@ompressors Head-up Ulcer-prophgiaxis Glucose-control GU~ Assessment

Pulmonary thromboendarterectomy: 2 years of outcome data

Bowel activity

Amanda Corley 1, Cherie Franks 2, Dr Fiona Kermeen 2, Dr Keith McNeiD, Dr John D u n n i n g 4, Dr John Fraser 1 & Dr Dan Mullany s

Aperients Skin: Pressure-risk

1. Critical Care Research Group, The Prince Char/es Hospital, QLD 2. Puhno~lary V~scuIar Diseases Unit, The Pri~ce Charles Hospital, QLD 3. Director of Transplant Medicine, The Prime Char/es Hospital, QLD 4. Director of Cardiothoracic Surgery, The Pri~KeCharles Hospital, QLD 5. Director of Intensive Care Services, The Prince Char/es Hospital, QLD

Positioning Devices VAP

May 2006

78% 65%

90% 96%

4% 57%

14% 78%

43% 51%

98% 100%

76% 74% 53% 78% NICE

82% 96% 98% 84%

73% 25% 76%

90% 50% 58%

4% 57% 49% 6%

46% 92% 94% 16%

Quality of care provided to donor families in intensive care before and during organ donation: ATCA 4th National Donor F a m i l y Study

Chronic thronxboenxbolic pulmonary hypertension (CTEPH) is emerging as a leading cause of severe pulmonary hypertensiotz Without surgical intervention, the coDdirion has a poor prognosis, with a survival of oaly 20% at 2 years for those with mean pulmonary artery pressure >50mnMg. Definitive therapy, pulmonary thronlboendarterectomy (PTE), has been performed at our ilastitution sider 2004. A detailed pro add postoperative data collection o n demographic, clinical and investigative factors was performed. Data pro and post surgery were compared using a paired t-test for continuous variables add Chi squared for categorical variables.

Jennifer Gillott I & Dr Geoff White 2 1. A D A P T Australasian Do,mr Aware~wss Program~ 2. Centre for Medical, Nursing & Health Sciences Education, Movlash Univerrity, VIC Australian donor familieg experiences add perceptions of the service provided by critical care health professionals before add during the organ donation process were investigated. A descriptive study with closed and open-ended questions, self-administered and anonymous, was distributed by post. A total of 193 families of organ donors from 2002 were asked to recall events and experiences from between 16-28 months prior to the study; 131 families rerponded, represenring a 68% response rate.

SiDer 2004, 20 patients have undergone PTE from 32 referrals. Two of these 20 patients were found to have pulmonary sarcoma. The group included 13 females add seven males, aged 16 77. The average ventilation time add ICU length of stay was 168 and 222 hours respectively. The mortality rate was 5%. 6-12 months following PTE, median New ~)rk Heart Association Class improved from Class III to Class I; there was a mean decrease in right ventricular systolic pressure of 31.5mmHg; and an improvenxent in mean right ventricular fuDcrion from moderate dysfuDction to normal fuDcriolz

Over 90 % of the respondents were at the horpital from before death of their relative, through confimxarion of death and the explanation of the organ donation process. 97% of ramifies regarded their treatment by hospital staff" as considerate add sensitive. More than 90% uDderstood the explanation of brain death, and had enough opportunities to ask quesriotas about brain d e a t h 90% of families felt they were approached about organ donation in a selasirive lnalaner, had enough tilne to ask questions and to make a decisiot~ 78% were offbred to-hospital support from a social worker or bereavement counsellor, and 88% met the organ donor coordtoator. More than 90% of families involved in the organ donation process recalled that they were treated with care and consideration in intensive care.

PTE has been performed successfully at our institution for 2 years, with marked haemodynanxic and funcrional improvenxent achieved for these patients. PTE is a viable ahemarive to heart lung transplantation for patients with CTEPH.

Hijacking the hugs: using the 'fast hugs' mnemonic to improve team work, quality of care and reduce the incidence of ventilator acquired pneumonia (VAP) in ICU

Qualitative data highhghted the importance of sensitive add consistent communication from intensive care staff', respectful of both family and donor, and the critical importance of providing multiple opportunities for families to develop add check their understanding of the death of their relative and the oprions available to then]~

Maureen Edgtton.Winn, Sharon-Ann Shunker, Dr Gilfian Bishop & Colleen Suter L~verpooI Hospital, Liverpool, N S W A total of 13 - 18% of all nosocomial infections relate to VAP, with a 20-50% mortality rate. Liverpool Hospital ICU is participating in the Safer Systems Saving Lives (SSSL) project to reduce the iDcidence of VAE We identified activities from SSSL and the literature that would improve care add reduce the iDcidence of VAE We altered the FAST H U G mnetnonic to iDcfude skin integrity, mouth and bowel-care to remiDd staff" of key actions to reduce VAE A daily checklist with resources was placed at the bedside add newsletters, notice board, bedside education and practice reviews improved care add compliance.

A praxis exploration of the transformational process from a specialist to an expert critical care nurse Dr Karen Page 1.21Prof Annette Street 3 & A/Prof Linda Worrall-Carter 1

1. Deakin/Eastern Health Parr*wrship, VIC 2. The Northern Hospital, Eloping, VIC 3. La grebe Unioersity, VIC

151

Volume 19

Number4 November2006

AN Australian Critical Care

A highly conservative approach to phlebotomy may maintain haemoglobin concentrations in critically ill patients

It is well recognised that expert critical care nurses make a significant difference to patient outcomes; however, understandings of the transformational process from a specialist to an expert critical care nurse are fimited. Hence, the purpose of this project was to examine expert practice and explore this process. Praxis methodology was selected, as nursil]g knowledge is embedded in practice. A request for volunteers, who met the C A C C N criteria of either a specialist or an expert critical care nurse, was made. All six participants were female, had a post registration qualification in critical care, at least 5 years as a practising critical care nurse and worked at least 3 days per week. The participants kept written records of significant incidents related to expert practice. These incidents guided the examination of expert practice at three focus group interviews. The interviews lasted 1.5 hours and were transcribed verbatim to enable further exploration of expert practice.

Kelfie Sosnowski

Logan Hospital, QLD Anaemia is conxmon to critic ally ill patients. Although pathological processes are a likely cause, phlebotomy associated blood loss may also be implicated. The purpose of this study was to explore current phlebotomy practices within Australian ICUs and to determine the impact of highly conservative phlebotomy procedures o n haemoglobin concentrations. A telephone survey to all ICUs registered with ANZICS determined phlebotomy practice in Australia. Using a prospective randomised controlled trial, 49 consecutively admitted patients were studied over a 4 m o n t h period. Patients were randomised to either a conservative phlebotomy group or a standard practice control group, hlformarion regarding APACHE II score, pre and post-admission haemoglobin, phlebotomy associated blood loss volun, e, and transfusion requirements was recorded. Regional ethical approval for the study was obtained.

Extensive knowledge and experience with the ability to critically reflect were identified as prerequisites of expert nurses. Experts acted without cotlscious thought (intuition) and used humour. The motivating forces behind experts were caring 'as we would like to be cared for' and a need to be valued. Expert practice was enhanced by role models, junior staff" and a need to survive difficult situations. It was limited when nurses felt intimidated by peers and medical colleagues. In summary, if specialist nurses are to become experts, the acquisition of the ability to critically reflect is as important as knowledge and skills.

The telephone survey showed that conservative phlebotomy practices are not routinely performed by any ICUs in Australia. The randomised controlled trial resulted in the reduction of phlebotomy associated blood loss by over 80% in the conservative group (p <0.0001). A difference in mean haemoglobin reduction occurred with 2.0g/dl (p 0.002) in the control group and 1.3g/dl (p 0.0735 ) in the conservative group (p 0.0735). Average length of stay was 3 days in both groups.

Neonatal outcome related to maternal critical illness

Highly conservative phlebotomy may maintain haemoglobinconcentrations in the ICU. The volume of blood reaching laboratories from ICUs are hugely in excess of actual amounts required to perform tests. Phlebotomy associated blood loss can be significantly reduced using conservative phlebotomy protocols. Future research utifising a larger sample of patients with longer length of stay is required to determine clinical significance.

Wondy Pollock

The University of Melbourne, VIC Little is known about critical illness during pregnancy and the impact it has o n the mother and baby. A prospective multi-centre observational study was conducted during 2002-2004 to examine critically ill pregnant and postnatal womet~ A n aim of this study was to atlalyse the impact of maternal critical illness on neonatal outcome. Pregnant and postnatal women were recruited into the study from ICUs, high dependency units and delivery suites (DS) in seven tertiary hospitals in Melbourne. Clinical staff"formed core research teams, assisting with recruitment and time-crirical data collecriotx Data were extracted from the medical record and the Victorian Perinatal Data Collection Unit to complete the data set. Data were entered into SPSS (v12) and analysed.

APA@HE-II scores median (range) Phlebotom-f associated blood loss per da'f in mls: median (range) Phlebotom'~ associated blood loss per admission in mls: median (range) Haemoglobin concentration in g/dl at admission: mean Haemoglobin concentration in g/dl at discharge: mean

A total of 137 women consented to participate; ICU (n 33 ), H D U (n 46) and DS (n 58). Neonates born during the episode of critical illness were born earlier, were more likely to have low Apgar scores and were more likely to have died than those neonates born either before the onset of critical illness or following maternal recovery from critical illness (see tables). Aside from neonatal mortafity, maternal cfinical area was not significant. Seven of the eight pregnant women admitted to ICU recovered from critical illness prior to delivery. The perinatal mortality rate for the study was 54/1000 births.

ICU

Birth gestation (wks) 352+54 Birth weight (grams) 2416+1025 1 rain Apgar 54+30 Intubation within 1st 24 hours 10132 Stillborn 2 28 da-~mortaht7 5 ~ming of dehver-f in rdation to maternalcriticalillness: Birth gestation (wks) Birthweight(grams) 1 rain Apgar Intubation within 1st 24 hours Stillborn 28 da-~mortahty

Volume 19 Number 4

HDU

Before 385+24 3135+633 74+21 3135 0 0

DS

352+49 353+45 2523+1100 2526+1016 66+22 65+28 10146 14157 1 0 0 0

During

After

18 (12-24)

8 (%10)

40 (28-43)

25 (14-33)

141 (80-202)

128

137

117

115

Teresa Williams 1,2, Suzanne Martin 2, Dr Gavin Leslie 2,3, Timothy Leen 2, Linda Thomas 2, Sherabe Tamafiunas 2, Dr KY Lee 2 & Dr Geoff Dobb 1,2 1. Un~verrity of Western Austmlia, W A 2. Royal Perth HvspitaI, W A 3. Edith Cowan University, WA Adequate sedation and analgesia minimises anxiety, discomfort and complications from mechaixical ventilation (MV). Sedation scales have improved management of patientg sedation and analgesia. This study aimed to evaluate the eff}'ct o n duration of MV before and after implementation of the Richmond Agitation Sedation Scale and Behaviour Pain Scale in patients receiving MV in a 22 bed general ICY. Baseline data were collected for 6 months followed by a period of staff educatioi~ Data were then collected for 6 months after introduction of the scales.

Significance NS NS NS NS

There were 1344 patient admissions to ICY. Excluding patients who died (n 121, 9%), 764 (57%) patients receiving MV for at least 6 hours (48% before and 52% after the intervention) were evaluated. Age and APACHE II scores were similar between groups but there were more males in the post-intervention group and there were sigtxificant differences in diagnosis between groups. MV duration increased after scales were introduced; difference non-sigtxificant (median 24 hours versus 28 hours; z 1.6, p 0.11). ICY length of stay was similar (z 1.4, p 0.16). Adjusting for age, gender, worst in first 24 hours APACHE II score, ICY admission diagnosis, comorbidity (chrotxic health evaluation) and pro- or postintervention group using logistic regression analysis, APACHE II score (p<0.001) and diagnosis (p<0.001) were independent predictors for MV

Significance

336+50 383+22 p<005 2185+1072 3047+624 p<005 57+28 77+17 p<005 31188 0112 p<005 3 0 5 0

November 2006

Control group

17 (13-22)

Use of a sedation scoring tool and a pain scale did not shorten duration of mechanical ventilation in a general ICU

Maternal critical illness impacted negatively o n neonates born during the episode of illness, with little apparent impact o n neonates born following maternal recovery from critical illness. Vdriabie

Conseivative group

152

A;". Australian Critical Care

96 hours or lotger. In conclusion, sedation scales can help matxagement of sedation but did not change patient outcome in an Australian ICU.

Free papers

-

multidisciplinary

Interhospital patient transfers admitted to a n ICU: regional variation and trends over time

After-hours discharge from intensive care increases the risk of readmission and d e a t h

Dr Arthas Flabouris & Dr Graeme Hart Royal Adelaide Hospital, SA ANZICS Pati~it Database

Dr David Pilcher 1.3, Dr Graeme Duke, Carol George 3, Dr Michael Bailey 4 & Dr Graeme Hart 3.5

It is expected that regional geographical difl)'rences are likely to it~queDce the frequeDcy and type of patients undergoitN interhospital tramfer (IHT). The objective of this study was to characterise IHT patients and identify dift)'rences in patterns amotNst the Australian States, Territories and New Zealand. Admission records of patients undergoing IHT were identified from the ANZICS Patient Database. Records of patients admitted to ICU between 1994-2003, aged 16 years and older with a known hospital and/or ICU source of were iDcluded (n 355648).

i. T/u, AIJYed Hospital, VIC 2. Ttw Northern Hospital, EtYping, VIC 3. Australia a~v2New Zeala~v2 Intensive Care Society ( ANZICS) Adult Patient Database ( APD ) 4. Deparm~lt of Epid~niobgy g Preventive Medicine, Munash University, VIC 5. Ttw Austin Hospital, Melbourne, VIC

SiDce 1994, there has been a 25% iDcrease in the proportion of patients admitted to an ICU following an IHT. The majority of such IHT occur during the June-October and December-Januarf periods, on a Thursday, Friday or Saturday. The frequeDcies of the more common diagnostic categories (sepsis, drug overdose and trauma) showed regional and monthly variariot~ IHT patients with trauma made up the greatest proportion of IHT during March, drug overdose during September-April and sepsis during July-September. Amongst tertiary hospitals, the proportion of IHT patients was highest for South Australia (15.3%) followed by New South Wales (12%), Queemland (11.2%) and Tasmania (10.9%). Amongst rural/ regiotxal hospitals, the proportion of IHT patients was highest for TasmaNa (9.6%) followed by New South Wales (8%) and Queensland (6.6%). The appropriateness of such tramfers was not addressed in this study. This study identified regiotxal add temporal variations in IHT patients. Such information can be useful for future planNng and preparation for such patients.

Our aim was to detemxine the prevaleDce, trends and effect on patient outcome of discharge timitN from ICUs in Australia and New Zealand. Data were examined from the Australian and New Zealand Intemive Care Society Adult Patient Database (ANZICS APD). Primary outcome measures were hospital mortality add ICU readmission rate. Between 1 January 2003 and 31 December 2004, the ANZICS APD reported 76,690 patients discharged alive from ICU. Of these, 13968 (18.2%) were discharged after-hours (between 18:00 and 05:59 hours). Patients discharged after-hours had a higher readmission rate (6.3% v 5.1%; p <0.0001) and a higher mortality (8.0% v 5.3%; p <0.0001). Peak readmission (8.6%) and mortality rates (9.7%) were seen in ICU patients discharged between 03:00 and 0:400 hours. After-hours discharge was a significant predictor of mortality (odds ratio 1.42, 95% cotxfidence interval 1.32-1.52; p <0.0001) in a multivariate analysis. Similar outcomes were

Interhospital patient transfers admitted to a n ICU: demographics and outcomes

identified in all (medical/surgical, elective/emergency) subgroups.

Dr Arthas Flabouris & Dr Graeme Hart Royal Adelaide Hospital, SA ANZICS Pati~lt Database

A n analysis of data trends across 40 hospitals from 2000-2004 showed that the proportion of ICU patients discharged after-hours is increasing (p 0.0015), with seasonal peaks duritxg winter. The risk of death increases as the proportion of patients discharged after-hours rises. After-hours discharge from ICU is becoming more frequent and is associated with iDcreased risk of death and readmission to ICU in all subgroups of patients. No fitxancial support received.

Outcomes post lutN tramplantarion continues to improve. Isclxaemiareperfusion injury (IRI) remains a major contributoF factor to postoperative compficatiom that may result in primary graft dysfunction (POD). A nunxber of inflammatory processes are thought to contribute to POD. We wished to detenmne the eft~'ct of brain stem death on endothdinl expression, and ET-A and ET-B receptors.

• E x c e l l e n c e in p a t i e n t c a r e • Investing in t h e f u t u r e • Professional d e v e l o p m e n t • C o m m i t m e n t to staff development: • Two full time ICU Educators and a full time Equipment Nurse • Learning Packages and Senior Staff Seminar Days • Opportunity to rotate to CCU/A&E if desired • Recognition and appreciation of contribution

restern Hospit& Registered Nurses Intensive Care Unit Full l i m e / P a r t T i m e

Tired of beina a little fish in a bia POnd? The 9 10 bed Adult Intensive Care Unit at Western Health is looking for motivated, experienced and qualified Critical Care Nurses to join our team Western Hospital is a Level II tertiary referral teaching hospital with a very busy Emergency Department, Cardiac Catheterisation facilities, extensive Radiological facilities, on site Pathology and links to Melbourne University The hospital is a short drive from the city, and is well serviced by public transport

Why Western? • • • • •

Small friendly unit offering 8 and 12 hour shifts, part time and full time hours Cheap on site parking Salary Packaging for permanent staff Challenging variety of patients State of the art equipment and spacious bed areas

We are looking for enthusiasfic critical care nurses who want to share their knowledge, experience and who are looking for a supportive environment in which to further develop their skills

Enquiries and Tours: Ros MacLeod, Nurse Unit Manager, Intensive Care Unit, Ph: 83&5 6069 or Email: Ros MacLeod@wh org au Applications (including Western Health Application Form) to Human Resources, Western Hospital, Private Bag, Footscray Vic 3011 or Emaib [email protected] by 20/10/2006 A l l applications must include a completed application form and a resume.

Applicants may be required to undergo a police records check and will be requested to provide copies of qualifications and registration where al~l~roDriate.

153

Volume 19

Number 4 November 2006

AK Australian Critical Care

Following ethics approval, 14 Wistar-Kyoto rats were anaesthetised, had a tracheostomy created, and carotid and venous cannulatiot~ A catheter was placed in the sub-dural space and the balloon inflated inducing brainstem deatl~ The control group had a sham operation where the catheter was not inflated. After 4 hours of ventilation, atximals were euthanased and specimens fixed for histological analysis. H & E stains were used for morphological review and CD68 specifically to detect alveolar macrophages. Monoclonal anti-ET- 1 and polyclonal anti-ETA and ETB Abs were applied using a standard. Alveolar staining was determined as mild+, moderate + + or strong +++. All animals survived the experiment.

U p o n completion of the 3 months, a survey was conducted. 97% of those surveyed, including staff that had not used the service, supported its continuation. O f those massaged, 89% claimed to have reduced emotional stress, with 100% experiencing various physical benefits. 100% claimed there were no physical disadvantages; however, 15% stated it was difficult to go back to work. The conclusioi18 drawn from this study demonstrated massage to be beneficial in relieving physical and emotional stress in a busy hospital environment. The progratrmle has been approved to continue indefinitely o n a fortnightly basis.

There was a significant increase in the ratio of alveolar macrophages to neutrophils in experimental vs control groups (p 0.002). Alveolar macrophage endothefin localisarion was dramatically increased post brain stem death 27.57+5.26 vs 7.01+1.75 (p<0.0001). I n this model, BSD is associated with up-regulation of the pulmonary endothefin axis. The ratio of alveolar macrophage to infiltrating neutrophils is significantly increased after 4 hours of BSD compared to the shamcontrol. Alveolar macrophages express significantly higher levels of ETI in BSD compared to control. Endothelin blockade in BSD donors may reduce the risk of IRI.

Towards a model for best practice for oral hygiene in ICU: a systematic review of the literature Angela Berry 1, Prof Patricia Davidson 2, Janet Masters & Kaye Rolls 1 1. Wesmwad Hospital, N S W 2. Nursing Research Unit WSAHS & Sctu,oI of Nursing UWS, N S W ICCMU, Nepea, N S W T h e role of oral hygiene in maintaining the h e a h h and well-being of patients in the I C U is indisputable. I n fact, oropharyngeal colonisation w i t h pathogenic organisms is noted to be a cause of ventilator associated p n e u m o n i a in the ICU. However, in spite of this, the importance of evidence based oral hygiene is n o t reflected in the body of research related to I C U practice. T h e aim of the study was to appraise the peer reviewed literature to determine the best available evidence to infomx nursing intervention in the provision of oral care in ventilated I C U patients. Articles published from 1985 to 2005 in English and indexed in the most commonly used databases were searched.

Trauma verification: a qualitative assessment of the Australian experience Dr Arthas Plabouris Royal Adelaide Hospital, SA Royal Australian College of Surgeons Trauma Verification Subcommittee The 1993 report of the Working Party o n Trauma Systems by the National Road Trauma Advisory Committee recommended trauma verification as part of the wider development of trauma systems. In 2000 the Royal Australasian College of Surgeons sponsored a multi-collegiate process from which the trauma verification progratrmle arose. Trauma verification is an obj ective and structured review of a hospital's trauma care deliver¢.

T h e search strategy retrieved 53 articles; 12 PRCTs, 16 observational studies and 26 descriptive papers. O n the basis of the review, the following conclusions can be made: a paucity of h i g h level evidence exists to infomx clinical practice; the low n u m b e r of studies relative to the importance and frequency of this important nursing activity is noteworthy and may reflect nurses' perception of the importance of this activity; there is an absence of standardised process and outcome measures to facilitate meta-analysis; methodological challenges exist in standardising the research process given the frequency of this nursing activity and n u m b e r of personnel involved in patient care; and, given the association of this important nursing care activity to patient outcomes, additional attention and research is warranted.

Following a pilot phase, 11 hospitals have undergone consultative (n 9) and/or formal verification (n 3). A n n u a h n e d i a n n u m b e r o f t r a u m a p a t i e n t presentations were: 7437 emergency departments presentation; 283 with an ISS> 15; 92 with a head injury requiring ICU admission; 120 admitted to an ICU; 82 admitted to hospital following a retrieval. EMST trained hospital staff was variable with the greatest proportion being within emergency (75% consultants, 25% registrars) followed by surgery (50% consultants, 42% registrars), intensive care (38% consultants 30% registrars) and anaesthesia (20% consultants, 20% registrars). Using predetermined model resource criteria, against which trauma resources were evaluated, the commonly identifiable strengths were expertise and enthusiasm of trauma service start; local and outreach trauma education; rehabilitation and retrieval services and application of locally developed better practice guidelines. Identifiable weaknesses were absence of any consultant inhouse 24 hours; a trauma bed card; trauma service designation; quality loop closure and documentation and infrastructure deficiencies.

Patients reporting of PTSD symptoms 1 month after ICU discharge Prof Wondy Chaboyer, Karen Wallen & Prof Debra Creedy Griffith University, VIC Admission to the ICU is often sudden and unexpected, two factors thought to influence the developnxent of YFSD. The aim of this study was to identify the frequency of YFSD, and factors associated with PTSD, in patients 1 m o n t h after ICU discharge. Over a 9 m o n t h rimeffame, 137 patients in one ICU met the inclusion criteria and, after itxformed COllsent, 100 (73%) completed a mailed survey that included the Impact of Event Scale Revised (IES-R). The IES-R has three subscales, avoidance (8 items), hyperarousal (7 items) and intrusion (7 items), with possible response optiotls from 0 (not at all) to 4 (extremely). The IES-R was reasonably reliable (see table).

Trauma verification, as a peer review process, helps identify local and global system trauma resource strengths and weakness and through follow up visits aims to document improvements in trauma care deliver/.

Nursing

posters

N poster

orals

Massage: is there a place for it in ICU?

The median total IES-R score was 0.7 (IQR 0.8) where the possible range was 0-4. Ten participants (10%) scored above the cut-off for YFSD. There was no relationship between gender or ICU length of stay and the development of PTSD symptom% there was a small but significant inverse relationship between APACHE II scores and PTSD symptoms (see table). Recruitment was less than expected and, because of that, the small sample size prevented multivariate analysis to be undertaken. It is possible that factors other than severity of illness may influence the development of PTSD after ICU, thus larger, multi-site studies are indicated.

Mefinda Beezley, Candy Reid & Vic Hamilton Souttu, m Health, VIC Working in a busy ICU places many physical and emotional demands o n healthcare workers. Caring for sick patients and their relatives places undue stress o n ICU staff. Previous research has proven massage is beneficial in improving well-being and reducing stress levels. A study was undertaken by two critical care nurses to ascertain whether there would be a requirement for staff massages; 46 people were surveyed, with 86% of recipients stating they would use a massage service if provided. A 3 m o n t h trial was approved o n a formightly basis by the nurse ullit manager. Massages were given by two critical care nurses qualified in massage therapy. Sessions lasted for 30 minutes and were conducted o n a massage table. The massage service was made available to all staff within ICU. A total of 38 people received massages, with 45% utifising the service more than once. Staff giving the massages were allocated a management day of 8 hours.

Volume 19 Number 4

November 2006

Subscale Avoidance Hyperarousal Intrusion Total NS Not significant

154

@ronbach's APACHE II alpha 080 O66 079 095

.024 .029 .027 .029

pvalue 002 OO3 NS <0001

ICUlength of stay

pvahe

001 010 001 041

NS NS NS NS

A,'--.

Australian Critical Care

More than 90% agreed that the majority of their patients had complex medical problem and that the MET service helped prevent the development of major problems. However, the results also indicated that over 60% of nurses would not illitiate a MET call if the patient did not look unwell, but fulfilled MET criteria. Importantly, almost one in six (17%) nurses were reluctant to call the MET for fear of criricisn~

Pre-oxygenation for tracheal and endotracheal suction aspiration with in line closed suction apparatus Daniel Dobbyn, Michelle Wight & Lynette Morrison Logan Hospi~aI, QLD Evidence supporting pre-oxygenation prior to suc r i o a h g is irrefutable when open sucrioahg techaiques are employed. Recent research has indicated that pre-oxygenarion may not be necessary. The study objectives were, primarily, to show that endotracheal suction aspiration, using in line suction apparatus, does not require pre-oxygenarion and that there is no statistical difference between the pre-oxygenation group and the no preoxygenation group; and also to prove that n o n pre-oxygenation when suctiotxing with in line apparatus is not harmful to the patient with moderate oxygen and ventilation requirements.

Following completion of the survey, there was an increased number of MET calls for ward patients. Overall, the nurses surveyed reported positive attitudes towards the MET service. Increasing awareness of the role of the MET and the cliatcal sigtxificance of MET call criteria proved valuable in assessing barriers to nurseg utilisarion of the service.

The organ donation decision: families elaborate on factors surrounding their decision to donate - 4th A T C A National Donor Family Study

I n a 6 bed general ICU, 15 intubated, ventilated patients were tested. Suction aspiration, using in line suction apparatus, with FiOj of 0.5 or less and PEEP <10.1cmHj0. Without pre-oxygenation and with prooxygenation at a later rime. Haemodynamic parameters and ABGs were recorded at 1 rain intervals for 5 minutes. Pre-oxygenation resulted in a sigatficant increase in (p<0.001) in Pa02 (mmHg), Sa02 (%) and Sp02 (%). Responses to pre-oxygenarion averaged 133.14 + 99.52, 2.22 + 2.36 and 3.12 + 2.5 for Pa02 (mnlHg), Sa02 (%) and Sp02 (%) respectively. Despite Pa02, SpOj & SaOj being significantly diftbrent (p<0.001), (p<0.005), (p<0.005) in the pro-sucrion period, this difference was not sustained. Results from the pre-oxygenarion and n o n pro-oxygenarion groups were found not to be sigatficantly diftbrent at + 1, 2, 3, 4 and 5 minutes post-suction.

Jennifer Gillott I & Dr Geoff White 2 1. A D A P T Australasian Donor Awareness Pmgram~w 2. Centre for Medical, Nursing & Health Scievlces Education, Movlash University, VIC As part of a study exploring all aspects of the organ donation experience, 193 families of organ donors from 2002 were asked to recall events and experiences surrounding their decision to agree to organ donation for their deceased relative. A descriptive study with closed and open-ended quesrions, self-admitxistered and anonymous, was distributed by post. A total of 131 families responded, represenritg a 68% respotlse rate.

There was no statistical difference between the pro-oxygenation group and the no pro-oxygenarion group. N o n pro-oxygenarion of patients with modest oxygen requirements using in line suction is not harmful

97% of respondents believed that their decision to consent to organ donation was the right choice and was congruent with the values of the donor. Consistent with this response, the importance of not overriding a previous decision of the deceased was also highlighted. In response to the question "why did you decide to donateF', 40% of families had discussed organ donation before the death of their relative, and were aware of their wishes. 60% indicated that having this knowledge assisted then, in making their decision to donate. Addirional factors influencing the decision to donate included altruistic motives (60%) and an opportunity for something positive to come out of a tragedy (70%). 67% of respondents indicated that being approached about organ donation did not add to their distress; however, 18% recalled feelitg rushed or pressured.

ICU liaison nurse: role with a twist! Andrea Doric, Cathryn Street, Dr Graeme Duke, Dr Karen Page & Geoffrey Gleeson North Shore Hospital, Auckla~d, New Zeala~d The ICU liaison nurse (LN) service is a now iattiarive designed to facilitate ICU discharges, assist in the lnallagelllent of complex, ward patients and provide a cliaical resource forward staff. I n January 2006, an outer Melbourne t e a c h h g hospital introduced an ICU LN service 7 days per week. In order to address specific local issues, the ICU LN role was expanded to include acute pain management and attendance at Medical Emergency Team (MET) calls and Code Blues.

Families' decision making processes about organ donation are multi-factorial and complex. Public awareness campaigns and professional education programmes about organ donation are itxformed by the factors identified.

During the first 5 months (30 January 06 30 June 06) this service has seen 498 patients. Most patients required more than one visit; the total nun, ber was 1866 with an average visit lasting 30 minutes. The role also included research activities and home discharge planatng for complex patients. Nationally, the ICU LN role continues to evolve. In this hospital, the role has been successfully tailored to meet organisational needs in order to achieve optimal outcomes for our patients. Reason for visit

Wide variations in Olanzapine use for ICU delirium/agitation Lisa He & Dr Stephen Warrillow Austin Health, VIC Deliriunx affbcts up to 80% of ICU patients. Haloperidol is traditionally the first-line therapeutic agent, however, olanzapine use has increased substantially. The objective was m examine olanzapine use in ICU to guide development of a guideline m optimise delirium management. All ICU patients prescribed olanzapine between January 2005 and April 2006 were identified fronx pharmacy dispensing records. A retrospective medical record review was undertaken for 30 available his mries of the 44 patients identified.

No patients

ICU discharge MET call Follow-up of an out of hours MET call Code Blue Acute pain service referral Ward referral

273 70 25

Median patient age was 69 years (interquartile range 53-79). Median time to deliriunx onset was 3 days. Olanzapine 5rag daily (26.7%) was the most commonly proscribed starting dose, followed by 5rag bd (23.3%) and 10rag daily (20%). A median daily dose of 10rag was admiatstered for a median of 7.5 days (range 1-79 days). 24 patients (80%) were given wafers, five patients (16.7%) received tablets, and one patient (3.3%) received olanzapine intramuscularly. Of the 25 patients who received haloperidol prior to commencenxent of olanzapine, 19 (76%) received a mean total daily dose of < 12.5rag haloperidol. Total haloperidol dose administered per day prior to starting olanzapine ranged from 0.5-35ng for 1 to 4 days. No side effbcts of haloperidol or olanzapine were identified.

18

61 51

Nurses' attitudes to the medical emergency team in a metropolitan public hospital Catherine Dunlop, Dr Daryl Jones & Dr Karen Page The Nortt~m Hospital, N SW The Medical Emergency Team (MET) was introduced into our hospital 8.5 years ago to provide rapid medical assessment and intervention for ward patients who have clinically deteriorated. Although nurses iattiate the majority of MET calls, their attitudes to the MET service remain largely unknowt~ The study objective was to determine nurses' attitudes towards the MET in our hospital A survey using a 17 item Likert agreement scale quesrionnaire was distributed to 188 nurses to assess the attitudes to the MET in our hospital The response rate was 73%.

Olanzapine was largely used as a second-line agent for treatment of ICU associated deliriunl/agitariot~ The starting dose was variable and most patients did not receive a reasonable trial of haloperidol before olanzapine was commenced. A guideline has been developed to optimise the lnallagelllent of deliriun,/agitation in ICU. This p re-intervention data will be used to guide evaluation of the guideline.

155

Voluln~ 19

Number4 November2006

AN Australian Critical Care

Withdrawal of care at home: transfer from the ICU to provide end of life care at home Elizabeth Jackson

A prospective observational study examining the occurrence of adverse events in patients within 72 hours of discharge from the ICU

Counties Manukau District Health Board, South Auckla~d, New Zeala~d

Noreen McLaughlin i & Assoc Prof Gavin Leslie ~

Trans ferrltg a patient home for end of lif0 care from the ICU is a formidable

1. Royal Perth Hospital, Perth, WA 2. Edith Cowan University, Perth, WA

task. The role of the ICU nurse moves from that of primary caregiver of lif0 supporting therapy, to that of a supportive coordinator in a situation far

Numerous reports have identified sub-optimal patient care o n hospital

removed from the familiar envirotxment of ICU. Using case study analysis,

wards but limited data exists o n the characteristics and outcomes of adverse

this presentation discusses the positive and negative nursing experiences of

events in patients recently discharged from ICU. A n adverse event has been defined as an utxintentional event that caused harm or injury as a

taking patients home for end of lif0 care.

result of health care managenxent. The aim of this project was to detem, ine

SiDce 1999, 15 patients from our ICU have been taken home to die, the last being earlier this year.

the incideDce of adverse events within 72 hours of ICU discharge and

66% of the patients have been Maori, 20%

report associated clinical outcomes. A prospective, observational study was

Pakeha, 7% Samoan and 7% Pacific Island. Positive experiences included

undertaken over 12 weeks. Patients were reviewed every 24 hours. Adverse

being able to meet the fanxfly's wishes and meeting the cultural needs of

events were categorised according to clitxical antecedent.

the patient. Negative experiences included concerns surrounding nursing

Preventability

was rated using a pre-defined scale. The project was approved by utxiversity

safety, inadequate nursing knowledge and experience of the procedure,

ethics committee and classified as a hospital quality audit.

unfamiliarity in providing care in the home environment, lack of primary family support systems after hours, and out of date policies and procedures.

A total of 167 discharges met iDclusion criteria; 10% were classified with

A successful transfer of a patient home for end of lif0 care is dependant upon

an adverse event; 52% were judged probably preventable. Serious clinical interventions included three ICU re-admissions, two H D U admissions and

adheritg to an up to date nursing policy and check list procedure and liaison

two required one-to-one ward nursing. 41% resulted in prolonged hospital

with primary health care teams.

stay and 12% died. 47% of adverse events were fluid matiagement issues. Delay in detecting abnormal vital signs, itxfrequent charting and subsequent

Use of guidelines: a survey of N S W ICU practices demonstrated varied existence and implementation

delay to appropriate treatment was evident. 41% of adverse events occurred

Serena Knowles 1,3, Kaye Rolls 2, Dr A n t h o n y Burrefl 2, Di Kowal 2,

found to be udder utflised. A review of ICU discharge practices, current ward support systems and processes is recommended, along with staff roles

over weekend periods, and 41% of afterhours discharges resulted in an adverse event. MET and after-hours clitxical nurse specialist services were

Karena Hewson 2, Prof Doug Elliott 2'4, Jenni Hardy 3 & Prof Sandy Middleton 3

in targeting ICU discharges, fluid managenxent and monitoring. Increased use of MET services is warranted.

1. St. Vi~lcent's Public Hospital, Syd~ley, N S W 2. N S W Intensive Care Coordivlation & Monitoring Unit ( ICCMU) 3. A C U Nat~laI 4. University of Tectmology, Sydvley, N SW

IOU and ward nurses attitudes towards the IOU discharge process Kelli Mitchener, Tammie Mclntyre, Paula Carry, Melodic Heland &

Clitxical practices, such as those prompted by the FASTHUG mnemotxic, are being promoted in ICU to improve outcomes, despite varied evidence of effectiveness.

Prof Rinaldo Bellomo

Prince of Wales HospitaI, N S W

We undertook a telephone survey of setxior nurses

from N S W ICUs, and HDUs ofl'eritg short-ternx ventilation to identify written formal guidelines for the following 11 practices: enteral nutrition,

Patients admitted to the ICU have multiple medical and nursing care needs. The aim of ICU discharge planning is to ensure a safe and eflicient

parenteral nutrition, analgesia, sedation, thtomboembolic prevention, head We

transition to the ward. Inadequate planning may result in poor continuity of care, delayed recover~, increased risk of ICU re-admission and increased hospital length of stay. Study objectives were to identify ICU and ward

also asked about the likelihood of these guidelines being implemented for

nurses' experieDces with the ICU discharge process, and their ability to

all patients.

provide ongoing care for their patients. This study was conducted at the Austin Hospital, Melbourne, VIC. Data collection was achieved by an

of bed elevation, ulcer prophylaxis, glucose control, bowel matiagement, endotracheal tube stabflisation, and tracheostomy tube stabflisatiot~

Data were provided from 41 utxits (reFpollse rate 93%). No utxits reported

ICU and ward nurse agreement scale questionnaire investigating their experiences. The 10 item questionnaire was developed and pr0-tested in

having written formal guidelines for all 11 practices but all had at least one guideline (median 5). The highest number of existing guidelines was txine,

focused group meetitgs prion

reported from one unit. Guidelines with flxe highest reported frequency were A total of 220 nurses completed the surveys; 130 ward nurses from five wards, and 90 ICU nurses. There was agreement that patients discharged from ICU have complex nursing issues (ICU 62%, Ward 56%). Satisfaction with the handover between the ICU and ward nurses was also in

enteral nutrition (n 33, 81%) andparenteral nutrition (n 31, 76%). Level 2 and 3 ICUs were significantly more likely to report having >5 guidelines (76%) flian flie smafler ICUs/HDUs (45%) (p 0.04 ); however, employment of a C N C and a CNE were not predictors for the number of guidelines

agreement (ICU 67%, Ward 60%). There was also agreement regarditg

reported. Thromboembolic prevention was the guideline most frequently

the information exchanged at discharge handover (ICU 71%, Ward 67%). However, there was a mixed attitudinal response regarditg the ward's preparedness to receive an ICU patient (ICU 31%, Ward 63%), and in

reported as "highly likely" or "likely" to be implemented for all patients. All 10 utxits (100%) wiflx this guideline reported flfis to be flxe case. Findings suggest that implementation of guidelines for these everyday developing and implementing such guidelines including identification of

addition the ability to identify an ongoing plan of care (ICU 62%, Ward 23%). This study suggests that both nursing groups involved in the ICU discharge process are satisfied with the handover and itxformation exchange

local barriers is warranted.

for ongoing care. However, ward preparedness could be improved.

clitxical practices is less than optimab

Volume 19 Number 4

November 2006

A coordinated approach to

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Australian Critical Care

prophylaxis was associated with a reduced incidence of urinary futgal itifecriotls and a trend toward a reduced incidence of fungetrtia and respiratory fungal ilifecriolls. The objective of this audit was to determine the incidence of uritiary fungal itifecriotls in R D H ICU patients before and after the cessation of routine Nystarin antifungal agent in critically ill, ventilated patients. The result was used to determine if a more rigorous study or a change in current practice was warranted.

Comparison of bolus and pulsed heat thermodilution with arterial pressure cardiac output measurement in cardiac surgery patients Martin Boyle, Dr John Lawrence, Dr Andrew Belessis, Margherita Murgo & Dr Yahya Shehabi

Prince of Wales Hospital, N S W Cardiac output (CO) can be measured using cold bolus pulmonary artery thermodilution (COTD) and continuous cardiac output (CCO), using pulsed heat thermodilurios¢ Recently a continuous arterial pressure waveform CO device (APCO) [FloTrac/Vigileo, Edwards Lifesciences] has become available that can use a radial artery line. We studied the bias (mean difference) and limits of agreement (LOA) (+2SD of difference), and mean percent error (LOA/Mean X 100) of A P C O and C C O against COTD. After ethics approval, COTD measurements were obtained at 30 minute intervals for the first 2 hours in seven patients with a radial arterial line. Recordings were made of C C O and APCO. Comparisons (25 COTD v C C O and 28 COTD v APCO) frost, six patients were analysed.

The incidence of fungal urinary tract infections in two groups of critically ill, ventilated adult ICU patients was compared. Group 1 includes all ventilated adult patients administered Nystarin routinely in the RDH ICU between 1 January 2002 to 31 December 2003. Group 2 includes all such patients seen in the RDH ICU between 1 January 2004 to 31 December 2005. This latter group were administered the new oral care protocol. I n Group 1 (617 patients) there were 17 cases (2.8%) and in Group 2 (621 patients) there were 14 cases (2.3%). There is no significant diffbrence, with odds ratio 1.22 (0.56-2.70) giving p 0.59. This local audit shows no benefit in routine topical antifungal prophylaxis. Despite the retrospective nature of the audit, the findings do not support a change in our current oral care protocol.

Median age was 70 years (range 36-84) and all were male. Heart rhythmwas regular (sinus rhythm, sinus tachycardia or paced). The mean (SD) COTD and cardiac index (CITD) were 5.6 ( 1.1 ) L/rain and 2.7 (0.5) L/min/ng with mean (SD) coefficient of variation for triplicate CITD measurements of 5.02 (2.9)%. The bias, L O A and mean % error are presented in the table. I n this limited study A P C O (and CCO) demonstrated negligible bias; however, the L O A were unacceptable compared to COTD. O0mparls0n OOTD and COO OlTD and OOI COTD and APCO CITD and APCI

Bias -02 -01 003 -001

SD 09 044 108 048

LOA

Mean

Mean % error

500-160 098-078 513-219 097.095

552 272 554 274

326 324 389 350

Evaluation of an oral care protocol 2 years after implementation Jane Thomas Royal Danwin Hospital, N T The ICU at Royal Darwin Hospital (RDH) implemented a new oral care protocol in January 2004. W h e n the oral care protocol was implemented in our ICU, we decided to regularly audit the incident e of ventilator associated pneumonia (VAP) and adherence to protocol to motxitor the eff~tiveness of our new progratrm,e. The objective of this audit was to determine the incidence of VAP in ICU patients before and after the implementation of the oral care protocol and to determine the adherence to protocol. The incidence of VAP in two groups of critically ill, ventilated ICU patients was compared. Group 1 included patients exposed to non-standardised oral care. Group 2 included the new oral care protocol. To determine the adherence to the protocol, patient charts were audited to determine oral care practice. There was a reduction in the amount of VAP seen in the R D H ICU in the 2 year period post implementation of the oral care protocol. There was an overall 64% adherence to three key facets of the protocol (range 43-86%).

Perceptions of stress and its impact in intensive care nurses Joseph Perry Australian Catholic University, VIC W h e n examining reasons for attrition in nursing numbers, the topic of burnout comes to the fore very quickly. Closely associated with burnout is stress. There are many pub fished studies into what nurses find stressful; however, there is a scarcity of research into the everyday experience of stress and the in, pact of this stress o n performance. This presentation presents the findings from focus groups held to explore how nurses recognise that they are stressed and what impact they believe that stress has o n their performance. This is one aspect of a broader study undertaken in a Doctor of Nursing candidature. Common themes evident in the focus groups include the loss of compassion, an inabifity to prioririse, attention to the 'basics' and therefore not attending to broader issues. Participants described dreaming about work, wanting to flee the bedside, becoming sensitive to the noise of the unit with particular sensitivity to alarms, and wanting to withdraw into their own space as signs that they are stressed. One nurse reported, "You become aware of your heart racing. It feels like it's going to jump out of your chest. I can hear it booming in my ears".

There has been a sustained reduction in the amount of VAP seen in the ICU at R D H since the itxlplementarion of the oral care protocol. A direct causal relationship is impossible to determine, but these results are encouraging. This audit highlights the difficulties and limitations of auditing ICU flow charts for evidence of care, thus demonstrating a requirement to encourage thorough documentatiot~ C a r i n g for one of our own: a study into the experiences of nurses caring for a critically ill colleague Michelle Wight & Kelfie Sosnowski Queensla~d Health Logan HospitaI, QLD Counties Manukau District Health Board, South Aucklav~d, New Zealand The purpose of this study was to generate knowledge. The discipline of nursing as caring represents an essential h u m a n need and, despite the wealth of information discussing the enormous in, pact that a critical illness has o n the patient and their family, there is very little related to the in, pact upon nurses when a colleague is admitted for a critical illness. The aim of this study was to explore the impact of having to care for a critically ill colleague and to gain illsight into how these experiences compare to that of a family using Hoff"s crisis paradign~ The study was descriptive and qualitative. Sen, i-structured interviews were conducted to gather data o n the experiences of eight nurses.

This presentation gives voice to the experiences of intensive care nurses when they find themselves stressed. There is a very real impact of stress o n performance and also the likelihood of nurses remaisxisg in ICU. The experience of stress and its potential impact o n retention, coupled with its in, pact o n performance, requires that it be addressed.

The use of Nystsatin antifungal agent in the Royal Darwin Hospital ICU Jane Thomas Royal Darwin Hospital, N T

Findings suggest that the nurses in the study who participated in the care of their colleague found that privacy was a constant issue and challenge, and that the incident brought about concerns for their own mortality. I n conclusion, this study revealed that, in caring for a critically ill colleague, nurses follow the same crisis paradigm as that of a family, thereby illustratitg the need for coping mechatxisms to be put in place in order to manage this internal crisis.

For many years, Nystarin was routinely used as fusgal prophylaxis therapy in critically ill ventilated patients in the ICU at Royal Darwin Hospital (RDH). The routine use of Nystatinwas stopped in January 2004. Recent literature found that topical nonabsorbable gastrointestinal antifungal

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Number4 November2006