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Analgesia and sedation audits—Facilitating change to optimise patient comfort
The 36th Australian and New Zealand Scientific Meeting on Intensive Care around central line insertion, management and elimination of guidewire retention. Tools to support safe practice (including consensus guidelines) were developed and a 2009 safety alert on guidewire retention was issued. Objectives: To quantify improvements and ongoing improvement areas. Methods: NSW incident data (April 08—March 11) on central venous access devices, related to insertion and management was reviewed to identify themes. Search terms included: central line, central venous catheter, central venous line, CVC, peripherally inserted central catheter, PICC. The narratives of 572 incidents where ICU was an involved service were reviewed. Results: Unplanned removal represented 23% of incidents (n = 131). Inadequate fixation by suture or fixation device was identified as the contributing factor in 41 reports. Where fixation was not identified, issues included patient movement, confusion, aggression and limited supervision. There were 71 insertion complications. Notably there were 15 retained guidewires and 25 incidents of arterial puncture, of which 13 went unrecognised and fluid and medication was infused. 84 incidents made specific reference to various policy breaches. Post insertion care incidents (n = 72) indicated inadequate staff knowledge particularly in relation to lumen choice, drug compatibility, dilution of drugs and fluid therapies. Conclusions: Central line insertion and management remains variable despite guidelines and supportive tools in NSW. The guidewire safety alert did not reduce the number of retained guidewires. Mechanisms to further support and embed guidelines needs to be explored to sustain practice change. doi:10.1016/j.aucc.2011.12.041 A positive fluid balance post cardiac surgery results in prolonged ventilation, intensive care unit and hospital length of stay B. Pearse 1,2,∗ , C. Cole 1 , A. Barnett 3 , P. Pohlner 1 , J. Fraser 1,2 1 Cardiac
Surgery Program, The Prince Charles Hospital, Australia 2 Aneasthetic Program, The Prince Charles Hospital, Australia 3 Critical Care Research Group, Australia Cardiac surgical patients routinely receive many litres of fluid in the pre, peri and post-operative period.
137
Liberal fluid administration has been shown to be associated with poor outcomes in respiratory and non-cardiac surgery admissions to the Intensive Care Unit (ICU). We hypothesised that the volume of fluid gain post cardiac surgery, would negatively affect morbidity and ICU length of stay. We weighed 300 consecutive on-pump, cardiac surgical patients pre and post-operatively and each morning, excluding patients with prolonged ventilation or those too large to fit in the weigh chair. An increase in weight from baseline of 1% resulted in significantly prolonged hospital length of stay (LOS) (Hazard ratio (HR) of discharge 0.95, p < 0.001). The prolonged LOS due to a 1% increase in weight, was equivalent to a 5 year increase in age (HR 0.95, p = 0.007). For all patients, there was an increase in length of ventilation hours associated with a 1000 ml increase in day one 24 h fluid balance (HR 0.78, p < 0.001) and day one crystalloid total (HR 0.61, p < 0.001). Length of ICU stay and total length of hospital stay were also prolonged (p < 0.05), associated with a 1000 ml increase in postoperative totals for fluid balance and colloid administration in the first 24 h. Ventilation and length of ICU stay increased for every 1000 ml of crystalloid (HR 0.58, p < 0.001: HR 0.41, p < 0.001) or colloid (HR 0.53, p < 0.001: HR 0.08, p < 0.001), given on day one. These parameters were statistically significant when corrected for ejection fraction and pre-existing renal impairment. Patients post cardiac surgery should be kept dry to minimise ventilation time, ICU stay and hospital stay. doi:10.1016/j.aucc.2011.12.042 Analgesia and sedation audits—–Facilitating change to optimise patient comfort D. Rajbhandari 1,2,∗ , H. Koelzow 1 , A. Stirling 1 1 Royal 2 The
Prince Alfred Hospital, Australia George Institute for Global Health, Australia
Analgesia and sedation are important components of intensive care treatment. Pain in ICU patients is caused by surgery, therapeutic devices and nursing interventions. Unrelieved pain contributes to inadequate sleep, agitation, delirium and the physiological stress response and possibly to post-traumatic stress disorder. Sedation relieves anxiety and agitation and facilitates ventilation and other interventions. Oversedation is associated with prolonged ventilation and ICU stay. Thus patient comfort without coma is an important ICU patient outcome.
138 A survey was used to assess patients pain status and standard practice prior to implementing analgesic (numeric rating scale and behavioural pain scales), and sedation (Richmond Agitation and Sedation Scale) scoring systems. The survey included patient assessments, questions for staff and patient files review. The first audit, 180 surveys, found: 1/3 of extubated patients reported moderate to severe pain and ¼ of intubated patients were comatosed when the order was for endotracheal tube tolerance, bolus doses of sedatives and analgesics were not being documented and sedation was given before adequate pain relief. Twelve months after the implementation of new protocols to assess and treat, pain and agitation, the second audit, 202 surveys, were conducted. It found: the only patients in pain had not been assessed in the previous 6 h, bolus doses of analgesia and sedation was being well documented and pain was more often treated first. The focus of the education program was changed to target assessment compliance. This audit cycle is a useful tool, monitoring practice change and enabling focused education, to optimise patient comfort without coma. doi:10.1016/j.aucc.2011.12.043 Preliminary data suggests ICU visitors will use a computer kiosk to access information in the waiting room K. Rolls 1,∗ , M. Smith 2 , A. Zhang 1 , C. Wise 3 , E. McGloin 3 1 Intensive
Care Coordination and Monitoring Unit, Australia 2 Macquarie University Hospital, Australia 3 Royal Prince Alfred Hospital, Australia Appropriate and timely information is essential if families of critically ill patients are to function effectively as surrogate decision makers. A recent systematic review found that a structured communication program that includes written information improved family emotional outcomes and reduced ICU length of stay and treatment intensity. However there are no Australian specific data regarding the information needs of ICU visitors. As part of a quality improvement program a computer kiosk, containing the community section of an Australian website, was placed in the waiting room of a tertiary referral ICU. The aims of this pilot study were to evaluate kiosk usage using access logs and visitor satisfaction with content using a 3-question pop-up survey.
Papers and Poster Abstracts Over three months daily page views averaged 9.2 with 86 pages viewed 816 times. Sections accessed were: (1) equipment-19%; (2) conditions-17%; (3) visiting-17%; (4) treatment-16%; (5) general-10%; (6) definitions-9%; (7) ICU team-1%. This access data was different when matched against Internet data (p = .000). Thirty-three useable surveys were completed (18 women; 18 aged >40). Participants were satisfied with content indicating that the information was useful (22/33) and right (20/33). This pilot study indicates that ICU visitors will use a computer kiosk in a waiting room. ICU clinicians can use these results to ensure they communicate effectively with visitors by providing targeted information specific to individual patient and visitor needs. Further research is required in alternate settings and to evaluate the effects of providing this intervention for visitors including emotional outcomes, satisfaction, understanding and knowledge acquisition. doi:10.1016/j.aucc.2011.12.044 ‘Superglue’—–Super effective securement technique for intravascular catheters G. Simonova 1,∗ , K. Dunster 1 , C. McMillan 2 , J. Fraser 1
Rickard 2 , D.
1 The
Critical Care Research Group, TPCH, Brisbane, Australia 2 NHMRC Centre of Research Excellence in Nursing Interventions, Griffith University, Australia Intravascular catheter (IVC) partial or complete dislodgement remains a significant problem in hospitals despite current securement methods. Cyanoacrylate tissue adhesives are currently used to close skin wounds as an alternative to sutures, have high mechanical strength and can remain in place for several days. This study investigated the use of tissue adhesives (TA) for securing IVCs in vitro for safety and feasibility. We compared TA with current fixation methods for compatibility with IVC material, and ability to prevent both pull out and microbial growth. Two TAs (Dermabond and Histoacryl), one standard dressing (Tegaderm) and an external stabilization device (Statlock) were tested to secure 16G peripheral IVCs in newborn porcine skin. Control IVCs with no securement were also studied. Tensile testing was performed with an Instron 5567 (Instron Co) and tensile strength [N] measured at a crosshead speed of 250 mm/min. Agar media containing pH sensitive dye was used for assessment of antimicrobial properties. Testing was carried out using Staphylococcus aureus.
Surgery Program, The Prince Charles Hospital, Australia 2 Aneasthetic Program, The Prince Charles Hospital, Australia 3 Critical Care Research Group, Australia Cardiac surgical patients routinely receive many litres of fluid in the pre, peri and post-operative period.
137
Liberal fluid administration has been shown to be associated with poor outcomes in respiratory and non-cardiac surgery admissions to the Intensive Care Unit (ICU). We hypothesised that the volume of fluid gain post cardiac surgery, would negatively affect morbidity and ICU length of stay. We weighed 300 consecutive on-pump, cardiac surgical patients pre and post-operatively and each morning, excluding patients with prolonged ventilation or those too large to fit in the weigh chair. An increase in weight from baseline of 1% resulted in significantly prolonged hospital length of stay (LOS) (Hazard ratio (HR) of discharge 0.95, p < 0.001). The prolonged LOS due to a 1% increase in weight, was equivalent to a 5 year increase in age (HR 0.95, p = 0.007). For all patients, there was an increase in length of ventilation hours associated with a 1000 ml increase in day one 24 h fluid balance (HR 0.78, p < 0.001) and day one crystalloid total (HR 0.61, p < 0.001). Length of ICU stay and total length of hospital stay were also prolonged (p < 0.05), associated with a 1000 ml increase in postoperative totals for fluid balance and colloid administration in the first 24 h. Ventilation and length of ICU stay increased for every 1000 ml of crystalloid (HR 0.58, p < 0.001: HR 0.41, p < 0.001) or colloid (HR 0.53, p < 0.001: HR 0.08, p < 0.001), given on day one. These parameters were statistically significant when corrected for ejection fraction and pre-existing renal impairment. Patients post cardiac surgery should be kept dry to minimise ventilation time, ICU stay and hospital stay. doi:10.1016/j.aucc.2011.12.042 Analgesia and sedation audits—–Facilitating change to optimise patient comfort D. Rajbhandari 1,2,∗ , H. Koelzow 1 , A. Stirling 1 1 Royal 2 The
Prince Alfred Hospital, Australia George Institute for Global Health, Australia
Analgesia and sedation are important components of intensive care treatment. Pain in ICU patients is caused by surgery, therapeutic devices and nursing interventions. Unrelieved pain contributes to inadequate sleep, agitation, delirium and the physiological stress response and possibly to post-traumatic stress disorder. Sedation relieves anxiety and agitation and facilitates ventilation and other interventions. Oversedation is associated with prolonged ventilation and ICU stay. Thus patient comfort without coma is an important ICU patient outcome.
138 A survey was used to assess patients pain status and standard practice prior to implementing analgesic (numeric rating scale and behavioural pain scales), and sedation (Richmond Agitation and Sedation Scale) scoring systems. The survey included patient assessments, questions for staff and patient files review. The first audit, 180 surveys, found: 1/3 of extubated patients reported moderate to severe pain and ¼ of intubated patients were comatosed when the order was for endotracheal tube tolerance, bolus doses of sedatives and analgesics were not being documented and sedation was given before adequate pain relief. Twelve months after the implementation of new protocols to assess and treat, pain and agitation, the second audit, 202 surveys, were conducted. It found: the only patients in pain had not been assessed in the previous 6 h, bolus doses of analgesia and sedation was being well documented and pain was more often treated first. The focus of the education program was changed to target assessment compliance. This audit cycle is a useful tool, monitoring practice change and enabling focused education, to optimise patient comfort without coma. doi:10.1016/j.aucc.2011.12.043 Preliminary data suggests ICU visitors will use a computer kiosk to access information in the waiting room K. Rolls 1,∗ , M. Smith 2 , A. Zhang 1 , C. Wise 3 , E. McGloin 3 1 Intensive
Care Coordination and Monitoring Unit, Australia 2 Macquarie University Hospital, Australia 3 Royal Prince Alfred Hospital, Australia Appropriate and timely information is essential if families of critically ill patients are to function effectively as surrogate decision makers. A recent systematic review found that a structured communication program that includes written information improved family emotional outcomes and reduced ICU length of stay and treatment intensity. However there are no Australian specific data regarding the information needs of ICU visitors. As part of a quality improvement program a computer kiosk, containing the community section of an Australian website, was placed in the waiting room of a tertiary referral ICU. The aims of this pilot study were to evaluate kiosk usage using access logs and visitor satisfaction with content using a 3-question pop-up survey.
Papers and Poster Abstracts Over three months daily page views averaged 9.2 with 86 pages viewed 816 times. Sections accessed were: (1) equipment-19%; (2) conditions-17%; (3) visiting-17%; (4) treatment-16%; (5) general-10%; (6) definitions-9%; (7) ICU team-1%. This access data was different when matched against Internet data (p = .000). Thirty-three useable surveys were completed (18 women; 18 aged >40). Participants were satisfied with content indicating that the information was useful (22/33) and right (20/33). This pilot study indicates that ICU visitors will use a computer kiosk in a waiting room. ICU clinicians can use these results to ensure they communicate effectively with visitors by providing targeted information specific to individual patient and visitor needs. Further research is required in alternate settings and to evaluate the effects of providing this intervention for visitors including emotional outcomes, satisfaction, understanding and knowledge acquisition. doi:10.1016/j.aucc.2011.12.044 ‘Superglue’—–Super effective securement technique for intravascular catheters G. Simonova 1,∗ , K. Dunster 1 , C. McMillan 2 , J. Fraser 1
Rickard 2 , D.
1 The
Critical Care Research Group, TPCH, Brisbane, Australia 2 NHMRC Centre of Research Excellence in Nursing Interventions, Griffith University, Australia Intravascular catheter (IVC) partial or complete dislodgement remains a significant problem in hospitals despite current securement methods. Cyanoacrylate tissue adhesives are currently used to close skin wounds as an alternative to sutures, have high mechanical strength and can remain in place for several days. This study investigated the use of tissue adhesives (TA) for securing IVCs in vitro for safety and feasibility. We compared TA with current fixation methods for compatibility with IVC material, and ability to prevent both pull out and microbial growth. Two TAs (Dermabond and Histoacryl), one standard dressing (Tegaderm) and an external stabilization device (Statlock) were tested to secure 16G peripheral IVCs in newborn porcine skin. Control IVCs with no securement were also studied. Tensile testing was performed with an Instron 5567 (Instron Co) and tensile strength [N] measured at a crosshead speed of 250 mm/min. Agar media containing pH sensitive dye was used for assessment of antimicrobial properties. Testing was carried out using Staphylococcus aureus.