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ICU volume–outcome relationship: Is bigger better?
Australian Critical Care (2012) 25, 119—142
PAPERS AND POSTER ABSTRACTS
The 36th Australian and New Zealand Scientific Meeting on Intensive Care and the 17th Annual Paediatric and Neonatal Intensive Care Conference
Nursing Scholarship Papers A study to improve sleep for patients in an Australia ICU is inconclusive R. Elliott 1,2,∗ , S. McKinley 1,2 , P. Cistuli 2,3 1 University
of Technology Sydney, Australia Sydney Local Health District, Australia 3 University of Sydney, Australia 2 Northern
Winner: Best Nursing Scholarship Prize sponsored by Covidien. Research indicates that ICU patients frequently experience sleep disruption. Few studies have attempted to improve sleep for ICU patients. The aim of this study was to improve the amount and quality of patients’ sleep while treated in an Australian ICU. Secondary aims evaluated sound and light levels and the patients’ perception of the quality of their sleep while in ICU. In a before (n = 30) and after (n = 27) design study the effect of a rest and sleep guideline on patient sleep was evaluated. Patients’ sleep was recorded for 24 h using polysomnography, with quantification of sound and light levels. Patients rated their sleep using the Richards Campbell Sleep Questionnaire. Mean patient age was 58 ± 20 years. There were 17 women. The median total sleep time in hours before the intervention was 05:12 h versus 04:03 h after (p = 0.164). Nighttime sleep increased from 51 to 68% (p = 0.012). The majority of sleep was 1036-7314/ $ — see front matter
doi:10.1016/j.aucc.2011.12.001
stages 1 and 2 in both phases with an average of <5% stage 3 and 4 (slow wave) sleep. The median sleep period without waking was 4.7 min versus 6.4 min (p = 0.013). Sound levels were high throughout and light levels at night were ≤1 Lux; neither varied between phases. Patients rated their sleep as poor (49/100 versus 54/100). Patients’ sleep was similar to baseline after the introduction of the rest and sleep guideline. There was a lack of slow wave and REM sleep and substantial sleep fragmentation. Despite inconclusive results, the study contributes to our knowledge of sleep in the ICU patient. Acknowledgements: This study was supported by research grants provided by the Intensive Care Foundation, Australian College of Critical Care Nurses, the RNSH Nursing Scholarship, Northcare and the RNSH Pink Ladies Committee. doi:10.1016/j.aucc.2011.12.002 ICU volume—outcome relationship: Is bigger better? B. Abbenbroek 1,∗ , C. Duffield 2 , D. Elliott 2 1 NSW
Health, Australia of Technology, Sydney, Australia
2 University
Introduction: Increasing demand for intensive care and rising costs require organisational change to improve efficiency. Increasing bed capacity in isolation is not sustainable in terms of economic and
120 workforce factors. The Australasian Health Facility Guidelines have adopted the Intensive Care Unit (ICU) ‘hot-floor’ model for new and redeveloped ICUs. This strategy aims to optimise efficiencies and better manage demand through co-location of multiple critical care specialties within a single organisational structure, resulting in large capacity ICUs with high volumes of activity. The literature indicates hospitals performing high volumes of procedures are associated with better patient outcomes. There is however only limited evidence of the ICU volume—outcome relationship, and no evaluation of the hot floor model. Objectives: To identify any association between high-volume ICUs and risk-adjusted mortality in the available literature. Methods: A systematic review identified 13 ICU specific volume—outcome studies conducted from 1995 to 2010. Results: Sample sizes ranged from 450 to 196,000 ICU patients. Ten studies identified a significant inverse volume—outcome relationship (OR 0.77—0.98; p < 0.05). All 95%CIs were narrow and below 1.0 indicating lower mortality in high-volume units. High-risk and ventilated ICU patients benefited most with lower risk-adjusted mortality rates. A non-linear ‘U’ relationship between volume and outcome was observed in 2 studies indicating increased mortality below and above certain volume thresholds. Conclusion: Patient mortality is improved in large ICUs but this relationship may not be linear suggesting there is a threshold at which a bigger ICU is not necessarily better. Further research is recommended to explore patient outcomes and staff factors in the hot floor model. doi:10.1016/j.aucc.2011.12.003 Procedural characteristics and outcomes of three intensive care based, nurse-led catheter placement services E. Alexandrou 1,∗ , M. Murgo 2 , E. Calabria 2 , T. Spencer 3 , H. Carpen 4 , K. Brennan 5 , S. Frost 1 1 University
of Western Sydney and Liverpool Hospital, New South Wales, Australia 2 New South Wales Clinical Excellence Commission, Australia 3 Liverpool Hospital, New South Wales, Australia 4 Nepean Hospital, New South Wales, Australia 5 Bankstown Health Service, New South Wales, Australia Introduction: Central line associated bacteraemia (CLAB) have been implicated in contributing
Papers and Poster Abstracts up to 60% of nosocomial acquired infections in intensive care patients. The Central Line Associated Bacteraemia-Intensive Care Units (CLAB-ICU) project was an initiative aimed at reducing CLAB in New South Wales (Australia). All adult and paediatric ICUs participated in the project. Objectives: The purpose of this study was to undertake a post hoc review of three ICU nurse-led catheter insertion services that contributed to the project. Methods: The project promoted a clinical practice bundle to reduce infections using a collaborative methodology. A post hoc analysis using data from the CLAB project was undertaken. Results: Between March 2007 and June 2009, 760 central venous catheters were placed by three nurse-led services (5% of total catheters inserted, N = 15,757). Over the study period, insertion outcomes for the nurses were favourable with 1 pneumothorax (1%), 1 arterial puncture (1%) and 1 CLAB (1%) being recorded. The CLAB rate was lower in comparison to the aggregated CLAB data set [1.3 per 1000 catheters (95% CI = 0.03—7.3) vs. 7.2 per 1000 catheters (95% CI = 5.9—8.7)]. Conclusion: This study has demonstrated safe patient outcomes with nurse led CVC insertion. Nurses who are formally trained and credentialed to insert CVCs can improve organisational efficiencies. This study adds to emerging data that developing clinical roles that focus on skills, procedural volume and competency can be a viable option in critical care areas. doi:10.1016/j.aucc.2011.12.004 Central line associated bloodstream infection (CLABSI) at gold coast hospital (GCH) intensive care unit L. Foster ∗ , T. Clark, T. Patrick, M. Foster, G. Comadira Gold Coast Hospital, Australia Patient’s in ICU are at particular risk of developing central line associated bloodstream infection (CLABSI) due to their multiple comorbidities, need for surgical procedures and use of broad spectrum antibiotics and steroids. The incidence of CLABSI in ICUs has been used as a measure of safe clinical practice. At Gold Coast Hospital, Infusion Therapy nurses have been collecting and reporting ICU CLABSI clinical indicator data for the last 5 years. A customised database is used at the point of care to collect patient demographic and other specific central venous catheter (CVC) information. Data is collected for each CVC
PAPERS AND POSTER ABSTRACTS
The 36th Australian and New Zealand Scientific Meeting on Intensive Care and the 17th Annual Paediatric and Neonatal Intensive Care Conference
Nursing Scholarship Papers A study to improve sleep for patients in an Australia ICU is inconclusive R. Elliott 1,2,∗ , S. McKinley 1,2 , P. Cistuli 2,3 1 University
of Technology Sydney, Australia Sydney Local Health District, Australia 3 University of Sydney, Australia 2 Northern
Winner: Best Nursing Scholarship Prize sponsored by Covidien. Research indicates that ICU patients frequently experience sleep disruption. Few studies have attempted to improve sleep for ICU patients. The aim of this study was to improve the amount and quality of patients’ sleep while treated in an Australian ICU. Secondary aims evaluated sound and light levels and the patients’ perception of the quality of their sleep while in ICU. In a before (n = 30) and after (n = 27) design study the effect of a rest and sleep guideline on patient sleep was evaluated. Patients’ sleep was recorded for 24 h using polysomnography, with quantification of sound and light levels. Patients rated their sleep using the Richards Campbell Sleep Questionnaire. Mean patient age was 58 ± 20 years. There were 17 women. The median total sleep time in hours before the intervention was 05:12 h versus 04:03 h after (p = 0.164). Nighttime sleep increased from 51 to 68% (p = 0.012). The majority of sleep was 1036-7314/ $ — see front matter
doi:10.1016/j.aucc.2011.12.001
stages 1 and 2 in both phases with an average of <5% stage 3 and 4 (slow wave) sleep. The median sleep period without waking was 4.7 min versus 6.4 min (p = 0.013). Sound levels were high throughout and light levels at night were ≤1 Lux; neither varied between phases. Patients rated their sleep as poor (49/100 versus 54/100). Patients’ sleep was similar to baseline after the introduction of the rest and sleep guideline. There was a lack of slow wave and REM sleep and substantial sleep fragmentation. Despite inconclusive results, the study contributes to our knowledge of sleep in the ICU patient. Acknowledgements: This study was supported by research grants provided by the Intensive Care Foundation, Australian College of Critical Care Nurses, the RNSH Nursing Scholarship, Northcare and the RNSH Pink Ladies Committee. doi:10.1016/j.aucc.2011.12.002 ICU volume—outcome relationship: Is bigger better? B. Abbenbroek 1,∗ , C. Duffield 2 , D. Elliott 2 1 NSW
Health, Australia of Technology, Sydney, Australia
2 University
Introduction: Increasing demand for intensive care and rising costs require organisational change to improve efficiency. Increasing bed capacity in isolation is not sustainable in terms of economic and
120 workforce factors. The Australasian Health Facility Guidelines have adopted the Intensive Care Unit (ICU) ‘hot-floor’ model for new and redeveloped ICUs. This strategy aims to optimise efficiencies and better manage demand through co-location of multiple critical care specialties within a single organisational structure, resulting in large capacity ICUs with high volumes of activity. The literature indicates hospitals performing high volumes of procedures are associated with better patient outcomes. There is however only limited evidence of the ICU volume—outcome relationship, and no evaluation of the hot floor model. Objectives: To identify any association between high-volume ICUs and risk-adjusted mortality in the available literature. Methods: A systematic review identified 13 ICU specific volume—outcome studies conducted from 1995 to 2010. Results: Sample sizes ranged from 450 to 196,000 ICU patients. Ten studies identified a significant inverse volume—outcome relationship (OR 0.77—0.98; p < 0.05). All 95%CIs were narrow and below 1.0 indicating lower mortality in high-volume units. High-risk and ventilated ICU patients benefited most with lower risk-adjusted mortality rates. A non-linear ‘U’ relationship between volume and outcome was observed in 2 studies indicating increased mortality below and above certain volume thresholds. Conclusion: Patient mortality is improved in large ICUs but this relationship may not be linear suggesting there is a threshold at which a bigger ICU is not necessarily better. Further research is recommended to explore patient outcomes and staff factors in the hot floor model. doi:10.1016/j.aucc.2011.12.003 Procedural characteristics and outcomes of three intensive care based, nurse-led catheter placement services E. Alexandrou 1,∗ , M. Murgo 2 , E. Calabria 2 , T. Spencer 3 , H. Carpen 4 , K. Brennan 5 , S. Frost 1 1 University
of Western Sydney and Liverpool Hospital, New South Wales, Australia 2 New South Wales Clinical Excellence Commission, Australia 3 Liverpool Hospital, New South Wales, Australia 4 Nepean Hospital, New South Wales, Australia 5 Bankstown Health Service, New South Wales, Australia Introduction: Central line associated bacteraemia (CLAB) have been implicated in contributing
Papers and Poster Abstracts up to 60% of nosocomial acquired infections in intensive care patients. The Central Line Associated Bacteraemia-Intensive Care Units (CLAB-ICU) project was an initiative aimed at reducing CLAB in New South Wales (Australia). All adult and paediatric ICUs participated in the project. Objectives: The purpose of this study was to undertake a post hoc review of three ICU nurse-led catheter insertion services that contributed to the project. Methods: The project promoted a clinical practice bundle to reduce infections using a collaborative methodology. A post hoc analysis using data from the CLAB project was undertaken. Results: Between March 2007 and June 2009, 760 central venous catheters were placed by three nurse-led services (5% of total catheters inserted, N = 15,757). Over the study period, insertion outcomes for the nurses were favourable with 1 pneumothorax (1%), 1 arterial puncture (1%) and 1 CLAB (1%) being recorded. The CLAB rate was lower in comparison to the aggregated CLAB data set [1.3 per 1000 catheters (95% CI = 0.03—7.3) vs. 7.2 per 1000 catheters (95% CI = 5.9—8.7)]. Conclusion: This study has demonstrated safe patient outcomes with nurse led CVC insertion. Nurses who are formally trained and credentialed to insert CVCs can improve organisational efficiencies. This study adds to emerging data that developing clinical roles that focus on skills, procedural volume and competency can be a viable option in critical care areas. doi:10.1016/j.aucc.2011.12.004 Central line associated bloodstream infection (CLABSI) at gold coast hospital (GCH) intensive care unit L. Foster ∗ , T. Clark, T. Patrick, M. Foster, G. Comadira Gold Coast Hospital, Australia Patient’s in ICU are at particular risk of developing central line associated bloodstream infection (CLABSI) due to their multiple comorbidities, need for surgical procedures and use of broad spectrum antibiotics and steroids. The incidence of CLABSI in ICUs has been used as a measure of safe clinical practice. At Gold Coast Hospital, Infusion Therapy nurses have been collecting and reporting ICU CLABSI clinical indicator data for the last 5 years. A customised database is used at the point of care to collect patient demographic and other specific central venous catheter (CVC) information. Data is collected for each CVC