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Implementation strategies for earlier ICU discharge
130 Our waste fluid collection and disposal system designed and developed is effective, safe and with no touch. This method is considered to be original in the world wide CRRT context. doi:10.1016/j.aucc.2011.12.024 A feasibility study of the national observations chart across a metropolitan health service D. Charlesworth, S. Brean ∗ Eastern Health, Australia Patients are at risk of deterioration and the mechanism of detection is crucial to early activation of rapid response systems, clinical review and escalation of care. The national observation chart, including risk stratification based upon key physiological variables, was trialled across six wards in three acute hospitals within a Melbourne metropolitan health service. The use of this observation chart is seen as a risk stratification tool by the intensive care service in defence against clinical deterioration. We assessed the usability of the national observation chart with a two tier response by nursing staff in comparison to the usual observation chart in a 24 h period. The comparison data show that the national observation chart provides useful information as to the stability of patients. It identified a current gap in the activation of rapid response systems to physiological deterioration. The key finding was of a chart of high usability, with a clearly defined escalation algorithm in response to clinical deterioration. Due to comparison between sites with different rapid response systems, differences in escalation of care were noted. The gaps identified are now being used as the drivers for a Clinical Deterioration Framework (CDF) across the health service. The observation chart is now being modified to ensure consistency with feedback from nursing staff to maximize usability. doi:10.1016/j.aucc.2011.12.025 Incidence of MET criteria in ward patients at a non-MET hospital A. Doric ∗ , R. Mistarz, K. Gellie, D. Charlesworth Box Hill Hospital, Australia All patients are at risk of deterioration. General ward patient needs have changed as a result of increased patient acuity. Suboptimal care of more acutely ill patients on the ward may be related to a lack of skills and knowledge among nursing and
Papers and Poster Abstracts medical staff regarding the management of deteriorating patients and this may be associated with higher rates of mortality and morbidity. Intensive Care Unit Liaison Nurse (ICU LN) and Medical Emergency Team (MET) are services which assist ward staff in responding to the deteriorating patient. At a Melbourne metropolitan hospital, the ICU LN’s audited general ward observation charts in a specified 24 h period with a view to providing information for the organisation prior to a planned implementation of a MET response. The point prevalence study aimed to identify the number of patients in medical and surgical wards with MET criteria in a designated 24 h period. This was an observational study, without intervention, and involved collecting data regarding the recording of observations and the presence of markers of clinical deterioration. The study was undertaken on a weekday in December 2010. The charts of 227 patients were examined and revealed 14 patients with MET criteria in the preceding 24 h period. The total number of MET breaches was 38 in these 14 patients. The results showed there is a place for a MET response at this hospital but also a need to address the early signs of deterioration and an appropriate escalation of care. doi:10.1016/j.aucc.2011.12.026 Implementation strategies for earlier ICU discharge A. Doric ∗ , D. Jones, D. Gibney, D. Charlesworth Eastern Health, Australia It is well documented that after hours discharge of patients from the intensive care unit (ICU) is associated with increased mortality and morbidity. In 2010, the median discharge time from ICU in a Melbourne metropolitan hospital was 3 pm however the mode was 5 pm and also 22% of all ICU discharges occurred after hours. In order to facilitate earlier discharge from ICU, it was decided to introduce a number of strategies to address these issues. One of the strategies implemented was the ‘‘four by four’’ which was an earlier discussion between key stakeholders to plan discharge for ICU patients. Each afternoon at 4pm this meeting occurred, in ICU with the bed manager, the ICU consultant, the Nurse Unit Manager and the Associate Nurse Unit Manager, to discuss possible discharges for the following day and elective admissions.
The 36th Australian and New Zealand Scientific Meeting on Intensive Care Another strategy implemented was the ‘‘two before ten’’. This was a hospital wide implementation encouraging each ward to discharge at least two patients before 10 am daily, thus facilitating bed availability for all patients including ICU patients. After five months, our hospital has seen significantly earlier discharge from the intensive care unit. The median and mode discharge time is now 2 pm and after hours discharges have reduced to 19% of all ICU discharges. doi:10.1016/j.aucc.2011.12.027 Centrally administered parenteral paracetamol: A potentially under-reported cause of haemodynamic instability within the adult intensive care unit C.N. Duncan 1,2,∗ , Jason Seet 1 , Stuart Baker 1 1 Intensive
Care Unit, Sir Charles Gairdner Hospital Nedlands, Western Australia, Australia 2 School of Pharmacy, Murdoch University, Murdoch, Western Australia, Australia Intravenous (IV) paracetamol administration is considered safe and effective. ICU patients receiving enteral or IV paracetamol were assessed for non-therapeutic (side) effects potentially related to administration. Additionally, nursing compliance with administration guidelines and rationales for route of administration were surveyed. Objectives were to describe: ◦ Non-therapeutic (side) effects potentially attributable to paracetamol administration. ◦ Incidence of inappropriate parenteral administration. ◦ Rationales for routes of administration. Blood pressure, heart rate and urine output were recorded at baseline and after 122 doses of paracetamol (enteral or IV), along with any observed nontherapeutic (side) effects. Doses were excluded where other factors could explain observed changes (e.g. fever, haemodynamic instability, procedures or drug administration). Questionnaires were distributed to all clinical nursing staff (response rate 75%). Intravenous administration was associated with reduced systolic (−13 mmHg, p < 0.0001) and mean (−8 mmHg, p < 0.0001) arterial blood pressures, with no significant effect on urine output or heart rate. Diaphoresis occurred after 4% of doses via either route. 88% of nurses reported intravenous paracetamol administration should only occur where enteral
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administration is not possible, while only 17% of intravenous doses fulfilled these guidelines. Senior nurses cited haemodynamic instability following intravenous administration as reasoning for enteral administration, while junior staff preferred enteral administration—citing patient comfort and rectal access. Cost was a consideration in choice of route for 70% of nurses. Conclusion: Intravenous administration of paracetamol was associated with reduced arterial blood pressure, while heart rate and urine output remained unchanged. Adverse effects from intravenous paracetamol administration may be underreported. doi:10.1016/j.aucc.2011.12.028 Haemodynamic impact of a slower pump speed at start of CRRT G. Eastwood 1,∗ , L. Peck 1 , H. Young 1 , M. Bailey 2 , M. Reade 1 , I. Baldwin 1 1 Department
of Intensive Care, Austin Hospital, Victoria, Australia 2 Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia Critically ill adult patients with acute kidney injury (AKI) are at risk of haemodynamic instability when starting continuous renal replacement therapy (CRRT). We describe the haemodynamic impact of our ‘‘routine protocol’’ versus ‘‘slower’’ CRRT pump speed starts in such patients. Using a prospective before and after design we compared data for ‘‘routine protocol’’ pump speed increases of 50 ml/min over 1—4 min with ‘‘slower’’ increases of 20—50 ml/min over 3—10 min to achieve an operating blood flow of 200 ml/min. We obtained patient demographic, haemodynamic, and vasopressor requirement data during the first 30 min of CRRT. We studied 21 routine and 20 slower CRRT starts. ‘Routine protocol’ starts reached the target pump speed quicker than slower CRRT start (p < 0.05). Heart rate was higher in the routine group compared to the slower group at baseline (p < 0.01) and remained so throughout. There were no significant changes in CVP or MAP, and no episodes of hypotension or hypertension, in either group. In the subset of 17 (41%) CRRT starts in vasopressor dependent patients, no episodes of hypotension or hypertension were observed and heart rates remained within ±5% of the rate at the time of CRRT commencement.
Papers and Poster Abstracts medical staff regarding the management of deteriorating patients and this may be associated with higher rates of mortality and morbidity. Intensive Care Unit Liaison Nurse (ICU LN) and Medical Emergency Team (MET) are services which assist ward staff in responding to the deteriorating patient. At a Melbourne metropolitan hospital, the ICU LN’s audited general ward observation charts in a specified 24 h period with a view to providing information for the organisation prior to a planned implementation of a MET response. The point prevalence study aimed to identify the number of patients in medical and surgical wards with MET criteria in a designated 24 h period. This was an observational study, without intervention, and involved collecting data regarding the recording of observations and the presence of markers of clinical deterioration. The study was undertaken on a weekday in December 2010. The charts of 227 patients were examined and revealed 14 patients with MET criteria in the preceding 24 h period. The total number of MET breaches was 38 in these 14 patients. The results showed there is a place for a MET response at this hospital but also a need to address the early signs of deterioration and an appropriate escalation of care. doi:10.1016/j.aucc.2011.12.026 Implementation strategies for earlier ICU discharge A. Doric ∗ , D. Jones, D. Gibney, D. Charlesworth Eastern Health, Australia It is well documented that after hours discharge of patients from the intensive care unit (ICU) is associated with increased mortality and morbidity. In 2010, the median discharge time from ICU in a Melbourne metropolitan hospital was 3 pm however the mode was 5 pm and also 22% of all ICU discharges occurred after hours. In order to facilitate earlier discharge from ICU, it was decided to introduce a number of strategies to address these issues. One of the strategies implemented was the ‘‘four by four’’ which was an earlier discussion between key stakeholders to plan discharge for ICU patients. Each afternoon at 4pm this meeting occurred, in ICU with the bed manager, the ICU consultant, the Nurse Unit Manager and the Associate Nurse Unit Manager, to discuss possible discharges for the following day and elective admissions.
The 36th Australian and New Zealand Scientific Meeting on Intensive Care Another strategy implemented was the ‘‘two before ten’’. This was a hospital wide implementation encouraging each ward to discharge at least two patients before 10 am daily, thus facilitating bed availability for all patients including ICU patients. After five months, our hospital has seen significantly earlier discharge from the intensive care unit. The median and mode discharge time is now 2 pm and after hours discharges have reduced to 19% of all ICU discharges. doi:10.1016/j.aucc.2011.12.027 Centrally administered parenteral paracetamol: A potentially under-reported cause of haemodynamic instability within the adult intensive care unit C.N. Duncan 1,2,∗ , Jason Seet 1 , Stuart Baker 1 1 Intensive
Care Unit, Sir Charles Gairdner Hospital Nedlands, Western Australia, Australia 2 School of Pharmacy, Murdoch University, Murdoch, Western Australia, Australia Intravenous (IV) paracetamol administration is considered safe and effective. ICU patients receiving enteral or IV paracetamol were assessed for non-therapeutic (side) effects potentially related to administration. Additionally, nursing compliance with administration guidelines and rationales for route of administration were surveyed. Objectives were to describe: ◦ Non-therapeutic (side) effects potentially attributable to paracetamol administration. ◦ Incidence of inappropriate parenteral administration. ◦ Rationales for routes of administration. Blood pressure, heart rate and urine output were recorded at baseline and after 122 doses of paracetamol (enteral or IV), along with any observed nontherapeutic (side) effects. Doses were excluded where other factors could explain observed changes (e.g. fever, haemodynamic instability, procedures or drug administration). Questionnaires were distributed to all clinical nursing staff (response rate 75%). Intravenous administration was associated with reduced systolic (−13 mmHg, p < 0.0001) and mean (−8 mmHg, p < 0.0001) arterial blood pressures, with no significant effect on urine output or heart rate. Diaphoresis occurred after 4% of doses via either route. 88% of nurses reported intravenous paracetamol administration should only occur where enteral
131
administration is not possible, while only 17% of intravenous doses fulfilled these guidelines. Senior nurses cited haemodynamic instability following intravenous administration as reasoning for enteral administration, while junior staff preferred enteral administration—citing patient comfort and rectal access. Cost was a consideration in choice of route for 70% of nurses. Conclusion: Intravenous administration of paracetamol was associated with reduced arterial blood pressure, while heart rate and urine output remained unchanged. Adverse effects from intravenous paracetamol administration may be underreported. doi:10.1016/j.aucc.2011.12.028 Haemodynamic impact of a slower pump speed at start of CRRT G. Eastwood 1,∗ , L. Peck 1 , H. Young 1 , M. Bailey 2 , M. Reade 1 , I. Baldwin 1 1 Department
of Intensive Care, Austin Hospital, Victoria, Australia 2 Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia Critically ill adult patients with acute kidney injury (AKI) are at risk of haemodynamic instability when starting continuous renal replacement therapy (CRRT). We describe the haemodynamic impact of our ‘‘routine protocol’’ versus ‘‘slower’’ CRRT pump speed starts in such patients. Using a prospective before and after design we compared data for ‘‘routine protocol’’ pump speed increases of 50 ml/min over 1—4 min with ‘‘slower’’ increases of 20—50 ml/min over 3—10 min to achieve an operating blood flow of 200 ml/min. We obtained patient demographic, haemodynamic, and vasopressor requirement data during the first 30 min of CRRT. We studied 21 routine and 20 slower CRRT starts. ‘Routine protocol’ starts reached the target pump speed quicker than slower CRRT start (p < 0.05). Heart rate was higher in the routine group compared to the slower group at baseline (p < 0.01) and remained so throughout. There were no significant changes in CVP or MAP, and no episodes of hypotension or hypertension, in either group. In the subset of 17 (41%) CRRT starts in vasopressor dependent patients, no episodes of hypotension or hypertension were observed and heart rates remained within ±5% of the rate at the time of CRRT commencement.