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Emergency responses for clinical deterioration within and beyond 24 hours of emergency admission: Patient outcomes and ICU implications
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Papers and Poster Abstracts / Australian Critical Care 28 (2015) 37–53
are not met. An Australian developed MET/RRT nurse satisfaction instrument offered an opportunity to quantify nurse satisfaction following implementation of an RRT. However, its psychometric properties had not been determined; nor had the RRT instrument been used in the US. Objectives: The objectives of the study were to measure US nurse satisfaction of RRT implementation and determine the psychometric properties of the instrument. Methods: Nurses (N = 313) gave verbal consent and completed the 20-item instrument. Items were modified to reflect US terminology and expressions, and then face validity was confirmed by the Australian collaborator, with no loss of intent. Factor analysis and one-way ANOVA were conducted to establish psychometrics and nurse satisfaction respectively. Results: The 20-item instrument demonstrated overall reliability (Cronbach’s Alpha = 0.76). Four factor subscales were identified: Critical thinking, 5-items (Alpha = 0.74), Patient Management, 5items (Alpha = 0.71), Perceived value of RRT, 7-items (Alpha = 0.74), Ethics, 3-items (Alpha = 0.67). Experienced nurses were significantly more satisfied with RRT implementation than inexperienced nurses (p < 0.0001). Nurses’ satisfaction with RRT was significantly higher when calls were made based on parameters rather than nurse concern criteria (p = 0.02). Conclusions: This study established reliability and validity of the RRT nurse satisfaction instrument in a US context post implementation of a RRT program. These finding support the opportunities for this valid instrument’s use in further study to link nurse satisfaction with RRT patient outcomes. http://dx.doi.org/10.1016/j.aucc.2014.10.008 Emergency responses for clinical deterioration within and beyond 24 hours of emergency admission: Patient outcomes and ICU implications J. Currey 1,∗ , D. Charlesworth 2 , J. Considine 1,2 1 2
Deakin University, Australia Eastern Health, Australia
Introduction: The National Emergency Access Target was implemented to ensure 90% of patients leave emergency departments (EDs) within 4 h. The impact of time driven performance on the number of physiologically unstable ward-based patients is unknown. An increase in clinical deterioration episodes potentially leading to adverse events will have resource implications for intensive care units (ICUs). Objectives: To compare the characteristics and outcomes of patients who required an emergency response for clinical deterioration (cardiac arrest team or rapid response system activation) within and beyond 24 h of emergency admission to general medical and surgical units. Methods: A retrospective exploratory design was used. The study site was a 365 bed urban hospital in Melbourne. Emergency responses for clinical deterioration during 2012 were examined. Results: Of 819 emergency responses for clinical deterioration, 587 patients were admitted via ED. The median time to first response was 59 h, 28.4% of patients required this <24 h after admission. One in eight patients required ICU admission. Comparison of patients requiring a response within and beyond 24 h of admission showed no significant differences in age, gender, waiting times, ED length of stay or in-hospital mortality rates. Patients in whom first emergency response occurred <24 h after admission were less likely to be admitted to ICU immediately following the emergency response (7.6% vs 13.9%, p = 0.039), less likely to have recurrent
emergency responses during their hospitalisation (9.7% vs 34.0%, p < 0.001), and had shorter median hospital length of stay (7 vs 11 days, p < 0.001). Conclusions: Considerable ICU resources were utilised given one in eight patients required ICU admission following emergency response, and patients admitted via the ED constituted 55% of all rapid response system activations. Exploring potential antecedents to clinical deterioration in this cohort may assist in establishing risk management strategies to reduce utilisation of ICU resources. http://dx.doi.org/10.1016/j.aucc.2014.10.009 Forecasting Level of Ultraflitration and Intensity of Dialysis (F.L.U.I.D.): Phase 1. A retrospective review of fluid balance control in CRRT H. Davies 1,2,∗ , G. Leslie 1,2 , D. Morgan 1,2 1
Intensive Care Unit, Royal Perth Hospital, Australia School of Nursing & Midwifery, Curtin University, Australia 2
Introduction: One effect of severe AKI is the loss of fluid balance control. Recent literature has reported an association between fluid accumulation and increased mortality. Achieving the required loss of fluid is an important part of dose delivery in CRRT. Objective: To compare the prescribed dose with the delivered dose in terms of fluid balance control for CRRT. Methods: A retrospective review was undertaken of daily fluid balances and fluid removal for patients who required CRRT. Each ICU flow chart and prescription order for every treatment day was reviewed. Each patient was exposed to the same treatment mode (predilutional CVVHDf). A comparison was made of fluid balance control delivered to the patient over 24 h against the dose of fluid removal prescribed. Results: The charts of 20 patients were reviewed for total of 91 treatment days. Mean effluent volume of 29.17 mL/kg per hour was prescribed. Mean number of days patients received CRRT was 5.52. Median circuit life was 23.75 h. Ability to achieve even balance control or attain predicted versus actual fluid removal did not occur in 28 treatment days (31%). Mean fluid removal shortfall was 487 mL (range 12–2108 mL). Mean number of treatment interruptions was 0.82 per day (excluding interruptions for assessment of renal function). The most frequent cause of treatment downtime was circuit clotting (44%), procedures outside ICU (18%), machine malfunction (13%) and access problems (10%). Mean length of treatment down time was 6.2 h with longest delays attributed to patient mobilisation. Conclusion: In almost a third of treatment days prescribed fluid removal was not achieved. Frequency of interruptions and delays in resumption of treatment compromised fluid balance control. Daily targets for fluid removal which are not achieved contribute to fluid accumulation and may worsen the outcome of patients who require CRRT. Acknowledgements: Financial support for this study was provided by: Foundation for Nursing Research, Royal Perth Hospital. 2013 Clinician Research Fellowship sponsored by Raine Medical Research Foundation and Western Australia Department of Health. http://dx.doi.org/10.1016/j.aucc.2014.10.010
Papers and Poster Abstracts / Australian Critical Care 28 (2015) 37–53
are not met. An Australian developed MET/RRT nurse satisfaction instrument offered an opportunity to quantify nurse satisfaction following implementation of an RRT. However, its psychometric properties had not been determined; nor had the RRT instrument been used in the US. Objectives: The objectives of the study were to measure US nurse satisfaction of RRT implementation and determine the psychometric properties of the instrument. Methods: Nurses (N = 313) gave verbal consent and completed the 20-item instrument. Items were modified to reflect US terminology and expressions, and then face validity was confirmed by the Australian collaborator, with no loss of intent. Factor analysis and one-way ANOVA were conducted to establish psychometrics and nurse satisfaction respectively. Results: The 20-item instrument demonstrated overall reliability (Cronbach’s Alpha = 0.76). Four factor subscales were identified: Critical thinking, 5-items (Alpha = 0.74), Patient Management, 5items (Alpha = 0.71), Perceived value of RRT, 7-items (Alpha = 0.74), Ethics, 3-items (Alpha = 0.67). Experienced nurses were significantly more satisfied with RRT implementation than inexperienced nurses (p < 0.0001). Nurses’ satisfaction with RRT was significantly higher when calls were made based on parameters rather than nurse concern criteria (p = 0.02). Conclusions: This study established reliability and validity of the RRT nurse satisfaction instrument in a US context post implementation of a RRT program. These finding support the opportunities for this valid instrument’s use in further study to link nurse satisfaction with RRT patient outcomes. http://dx.doi.org/10.1016/j.aucc.2014.10.008 Emergency responses for clinical deterioration within and beyond 24 hours of emergency admission: Patient outcomes and ICU implications J. Currey 1,∗ , D. Charlesworth 2 , J. Considine 1,2 1 2
Deakin University, Australia Eastern Health, Australia
Introduction: The National Emergency Access Target was implemented to ensure 90% of patients leave emergency departments (EDs) within 4 h. The impact of time driven performance on the number of physiologically unstable ward-based patients is unknown. An increase in clinical deterioration episodes potentially leading to adverse events will have resource implications for intensive care units (ICUs). Objectives: To compare the characteristics and outcomes of patients who required an emergency response for clinical deterioration (cardiac arrest team or rapid response system activation) within and beyond 24 h of emergency admission to general medical and surgical units. Methods: A retrospective exploratory design was used. The study site was a 365 bed urban hospital in Melbourne. Emergency responses for clinical deterioration during 2012 were examined. Results: Of 819 emergency responses for clinical deterioration, 587 patients were admitted via ED. The median time to first response was 59 h, 28.4% of patients required this <24 h after admission. One in eight patients required ICU admission. Comparison of patients requiring a response within and beyond 24 h of admission showed no significant differences in age, gender, waiting times, ED length of stay or in-hospital mortality rates. Patients in whom first emergency response occurred <24 h after admission were less likely to be admitted to ICU immediately following the emergency response (7.6% vs 13.9%, p = 0.039), less likely to have recurrent
emergency responses during their hospitalisation (9.7% vs 34.0%, p < 0.001), and had shorter median hospital length of stay (7 vs 11 days, p < 0.001). Conclusions: Considerable ICU resources were utilised given one in eight patients required ICU admission following emergency response, and patients admitted via the ED constituted 55% of all rapid response system activations. Exploring potential antecedents to clinical deterioration in this cohort may assist in establishing risk management strategies to reduce utilisation of ICU resources. http://dx.doi.org/10.1016/j.aucc.2014.10.009 Forecasting Level of Ultraflitration and Intensity of Dialysis (F.L.U.I.D.): Phase 1. A retrospective review of fluid balance control in CRRT H. Davies 1,2,∗ , G. Leslie 1,2 , D. Morgan 1,2 1
Intensive Care Unit, Royal Perth Hospital, Australia School of Nursing & Midwifery, Curtin University, Australia 2
Introduction: One effect of severe AKI is the loss of fluid balance control. Recent literature has reported an association between fluid accumulation and increased mortality. Achieving the required loss of fluid is an important part of dose delivery in CRRT. Objective: To compare the prescribed dose with the delivered dose in terms of fluid balance control for CRRT. Methods: A retrospective review was undertaken of daily fluid balances and fluid removal for patients who required CRRT. Each ICU flow chart and prescription order for every treatment day was reviewed. Each patient was exposed to the same treatment mode (predilutional CVVHDf). A comparison was made of fluid balance control delivered to the patient over 24 h against the dose of fluid removal prescribed. Results: The charts of 20 patients were reviewed for total of 91 treatment days. Mean effluent volume of 29.17 mL/kg per hour was prescribed. Mean number of days patients received CRRT was 5.52. Median circuit life was 23.75 h. Ability to achieve even balance control or attain predicted versus actual fluid removal did not occur in 28 treatment days (31%). Mean fluid removal shortfall was 487 mL (range 12–2108 mL). Mean number of treatment interruptions was 0.82 per day (excluding interruptions for assessment of renal function). The most frequent cause of treatment downtime was circuit clotting (44%), procedures outside ICU (18%), machine malfunction (13%) and access problems (10%). Mean length of treatment down time was 6.2 h with longest delays attributed to patient mobilisation. Conclusion: In almost a third of treatment days prescribed fluid removal was not achieved. Frequency of interruptions and delays in resumption of treatment compromised fluid balance control. Daily targets for fluid removal which are not achieved contribute to fluid accumulation and may worsen the outcome of patients who require CRRT. Acknowledgements: Financial support for this study was provided by: Foundation for Nursing Research, Royal Perth Hospital. 2013 Clinician Research Fellowship sponsored by Raine Medical Research Foundation and Western Australia Department of Health. http://dx.doi.org/10.1016/j.aucc.2014.10.010