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Longitudinal changes in body composition and impact on self-reported physical function following traumatic brain injury
112
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
airways causing turbulence and shear forces to move mucus. At Univ. Hospital, Hannover, Germany, ACT is provided using positive expiratory pressure therapy (PEP) and oscillating PEP to vibrate airways during expiration. In Paris (La Pitie Salpetriere and Hôpital Foch) physiotherapists (PT) treat patients awake with physical exercise and walking on ECMO and use French Assisted Autogenic Drainage manually applying thoracic pressure to exhale towards residual volume to mobilize secretions; and PEP using a bottle, tubing and a column of water. In two centres in the USA (Duke and New York Presbyterian) and Toronto General Hospital in Canada exercise as ACT is emphasized and forms part of daily ACT. Exercise to preserve muscle mass consists of bed exercises for weaker patients progressing to sitting over the side of the bed, standing, walking on a portable treadmill beside the bed or walking outside the room. Patients can walk for up to 20 minutes at a time and aim to walk daily. These activities require a dedicated trained team with safety the primary priority. There are no RCTs relating to ACT or exercise while on ECMO. Multi-centre research is needed to determine safe and effective forms of ACT and physical exercise and the optimal dosage to afford patients the best possible outcomes after LTx. Supported by a Winston Churchill Fellowship.
was descriptively identified. Consequently, we performed an interclass correlation to measure CVC tip agreement amongst a vascular access expert, ICU consultant and interventional radiologist with moderate agreement at 0.57. Conclusion(s) As a result of our QI a re-evaluation of CVC insertion care and maintenance occurred. New securement strategies have been implemented and reevaluated. Additionally, the ECG method may be a better empiric method for confirming CVC tip termination. http://dx.doi.org/10.1016/j.aucc.2017.02.010 Longitudinal changes in body composition and impact on self-reported physical function following traumatic brain injury Lee-Anne Chapple a,b,∗ , Adam Deane a,b,c , Lauren Williams d , Richard Strickland c , Chris Schultz e , Kylie Lange f , Daren Heyland g , Marianne Chapman a,b,c a
http://dx.doi.org/10.1016/j.aucc.2017.02.009
The state of the art of central venous catheter care in the intensive care unit of a tertiary hospital; A quality initiative and call to action Peter J. Carr a,∗ , Grainne Ni She b , Haley Pickersgill b , Tracey Bessley b , Kevin Murray c , Gavin Jackson a , Kevin Ho d , Ed Litton b a
PICC Service ICU, Fiona Stanley Hospital c Statistics, The University of Western Australia d Radiology, Fiona Stanley Hospital, Perth, Australia b
Introduction The acute central venous catheter (CVC) is the most common vascular access device found in the intensive care unit (ICU). Appropriate CVC tip termination, device patency along with minimizing the number of CVC dressing changes are evidence-based interventions proven to reduce central line-associated blood-stream infections. Study Objectives The objectives of our quality initiative (QI) were to assess: 1. The quality of the securement device. 2. Documentation of insertion and management of the CVC. 3. CVC tip termination from an x-ray. Methods Using a convenient sample we performed a clinical audit using a statewide electronic quality system; Governance, Evidence, Knowledge and Outcome (GEKO). A case report form was devised and underpinned with face validity and relevant current literature. We selected a pragmatic sample of 50 patients. Results The mean age was 60 +/- 14.7 years and the male gender accounted for 60% of our study population. Five-lumen CVCs were inserted in 80% of patients with 84% of CVCs located on the patient’s right side. Over 50% were inserted high up in the internal jugular (IJ) vein. 100% of CVCs were sutured in place. The edges of the dressings were loose in 40% with an additional border fixation found in 68%. Our specific CVC clinical information system portal was completed in 86% of patients. However, all required fields were not completed in 86%. Over 50% of the CVC tip termination
Discipline of Acute Care Medicine, University of Adelaide b National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes c Intensive Care Unit, Royal Adelaide Hospital, Adelaide d Menzies Health Institute of Queensland, Gold Coast e Nuclear Medicine and Bone Densitometry, Royal Adelaide Hospital f Discipline of Medicine, University of Adelaide, Adelaide, Australia g Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Canada Winner: Best Allied Health Paper sponsored by
Patients with a traumatic brain injury (TBI) admitted to intensive care are at risk of muscle wasting but this has not previously been quantified. The aims were (1) to describe changes in body composition over the entire hospitalisation and at 3-months from admission and (2) to assess the relationship between body composition and self-reported quality of life (QoL) measurements. Body composition measurements were performed weekly throughout hospitalisation and at 3-months: subjective global assessment (SGA), bodyweight and ultrasound-derived quadriceps muscle layer thickness (QMLT). Health-related QoL and functional outcome was assessed 3-months post-ICU admission using the Short-Form-36 Version 2 (SF-36v2) and dichotomised Glasgow Outcome Scale-Extended (GOS-E). Thirty-seven patients (45.3 (15.8) years, 87% male) were studied. Median ICU and hospital length of stays were 13.4 [IQR: 6.4-17.9] and 37.8 [19.4-52.4] days, respectively. Patients had significant weight loss in hospital (4.9 (7.7) %; p=0.001) and more patients were classified as malnourished via the SGA at hospital discharge than admission (12 vs 5 patients; p=0.005). For patients that had QMLT measured more than once (n=28) the mean baseline measurement
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
was 1.78 (0.72) cm and proximate measurement was 1.59 (0.57) cm, with a decrease of 3.91 (33.06) % between these time-points. The mean within-patient standard deviation was 0.14 (0.12) cm. SF36v2 Physical Component Score at 3-months was correlated with QMLT and BMI at hospital discharge (r=0.536, n=22; r=-0.440, n=22) and QMLT at 3-months (r=0.658, n=11). There were strong correlations between GOS and QMLT at hospital discharge (r=0.595, n=23) and 3-months (r=0.642, n=12). In general, head-injured patients admitted to ICU lose muscle mass in hospital and quadriceps muscle thickness at hospital discharge is associated with a reduction in functional status at 3 months. http://dx.doi.org/10.1016/j.aucc.2017.02.011 Lost in translation? Interpreting universal pressure injury prevention guidelines into a practical reference for intensive care Jane-Louise Cook a,∗ , Fiona Coyer a,b , Amanda Vann b , Jill Campbell a,c , Greg McNamara b a
Queensland University of Technology Intensive Care Services c Skin Integrity Services, Royal Brisbane and Women’s Hospital, Brisbane, Australia b
International guidelines for pressure injury prevention (PIP) apply equally to all general and specialty nursing areas. However, intensive care unit (ICU) patients are a unique population due to their severity of illness. Not only are these patients susceptible to pressure injuries (PIs) over bony prominences, they are at increased risk for medical device-related pressure injuries from chemical restraint, physical restrictions, and the many invasive procedures they undergo. The juxtaposition of urgent life-saving interventions with the adherence to best practice PIP guidelines poses problems for nursing staff who constantly juggle these priorities. In our ICU these challenges were highlighted during the weekly skin integrity nursing rounds and from analysis of the integument-related patient incident reports. To develop an evidence-based, clinical guideline that integrates PIP strategies into a tertiary intensive care context as a strategy to reduce PI prevalence. A survey of nurses’ perceptions of barriers, enablers and attitudes towards pressure injury prevention and skin integrity care was conducted in combination with focus groups. The need for an ICU-specific guideline was identified. Collaboration with the ICU nursing leadership and medical team, hospital skin integrity service and quality and safety unit, resulted in the development of a clinical guideline with simplification of the PI risk assessment categories, clarification of PIP strategies in ICU and documentation recommendations to improve consistency and minimise skin disruptions. An ongoing reduction in the prevalence and incidence of PIs in the ICU occurred that was evidenced by weekly PIP prevalence audits from 16% to 9% over 6 months and other reporting measures. Implementation of a standardised, evidence-based approach to PIP and skin integrity optimisation with expert collaboration and explicit interpretation in an intensive care context should be considered in order to achieve sustained PI reduction.
113
End-of-life-care in the ICU: a qualitative meta-synthesis investigating the experiences and perceptions of the patients family Alysia Coventry a,∗ , Elizabeth McInnes b , John Resenberg c , Rosemary Ford d a
School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne b School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney c School of Nursing, Queensland University of Technology, Brisbane d School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Ballarat, Australia End-of-life-care (EOLC) practices in the ICU, vary considerably in the absence of evidence-based clinical guidelines. Families are optimally positioned to identify important domains of EOLC, but their views are often overlooked. A systematic review and meta-synthesis was conducted to identify the experiences and perceptions of families of adult intensive care patients on the adequacy of EOLC, following withdrawal of life-support. Qualitative studies published between January 2005 and May 2016 that addressed this phenomenon were eligible for inclusion. A comprehensive search was used in 28 databases. Critical appraisal, data extraction, data synthesis and ConQual were conducted using the guidelines of the Joanna Briggs Institute with the addition of a thematic analysis. Critical appraisal and ConQual were used to rate the confidence of the synthesised findings. Twelve studies met the inclusion criteria; none were excluded after critical appraisal. Data analysis and meta-synthesis resulted in 23 categories and five synthesised findings: (1) communication; (2) care of the patient; (3) promoting a peaceful death and dying environment; (4) caring behaviours and support of the family; and (5) bereavement care. The synthesised findings have demonstrated families have unmet needs for support, communication and care after the withdrawal of life-support and death of a patient in the ICU. Also, despite the psychological reactions associated with grief and loss, death in the ICU can be a positive experience for families. There is an opportunity for healthcare teams to align care and support with the values, needs and wishes of families during EOLC. The delivery of timely EOLC that is compassionate, individualised and involves effective communication may also promote a more patient and family-centred death and dying environment. As no studies were eligible for inclusion from Australasia, a study from this region could further inform policy and guideline development in this area. http://dx.doi.org/10.1016/j.aucc.2017.02.013 Are Australian ICU patients more overweight than the general population, and is it important: a single site observational study? Diane Dennis a,∗ , Chrianna Bharat b , Timothy Paterson c , Adele Clair a , Tracy Hebden-Todd a , Emily Brough c , Wendy Jacob a a
Sir Charles Gairdner Hospital, Nedlands, WA University of Western Australia c Western Australian Neuroscience Research Institute (WANRI) b
http://dx.doi.org/10.1016/j.aucc.2017.02.012
Obesity is a world-wide health issue in developed nations and although national population data are available for many countries, little pertains to hospitalised populations, particularly those who are critically ill requiring expensive care. The objective of this study
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
airways causing turbulence and shear forces to move mucus. At Univ. Hospital, Hannover, Germany, ACT is provided using positive expiratory pressure therapy (PEP) and oscillating PEP to vibrate airways during expiration. In Paris (La Pitie Salpetriere and Hôpital Foch) physiotherapists (PT) treat patients awake with physical exercise and walking on ECMO and use French Assisted Autogenic Drainage manually applying thoracic pressure to exhale towards residual volume to mobilize secretions; and PEP using a bottle, tubing and a column of water. In two centres in the USA (Duke and New York Presbyterian) and Toronto General Hospital in Canada exercise as ACT is emphasized and forms part of daily ACT. Exercise to preserve muscle mass consists of bed exercises for weaker patients progressing to sitting over the side of the bed, standing, walking on a portable treadmill beside the bed or walking outside the room. Patients can walk for up to 20 minutes at a time and aim to walk daily. These activities require a dedicated trained team with safety the primary priority. There are no RCTs relating to ACT or exercise while on ECMO. Multi-centre research is needed to determine safe and effective forms of ACT and physical exercise and the optimal dosage to afford patients the best possible outcomes after LTx. Supported by a Winston Churchill Fellowship.
was descriptively identified. Consequently, we performed an interclass correlation to measure CVC tip agreement amongst a vascular access expert, ICU consultant and interventional radiologist with moderate agreement at 0.57. Conclusion(s) As a result of our QI a re-evaluation of CVC insertion care and maintenance occurred. New securement strategies have been implemented and reevaluated. Additionally, the ECG method may be a better empiric method for confirming CVC tip termination. http://dx.doi.org/10.1016/j.aucc.2017.02.010 Longitudinal changes in body composition and impact on self-reported physical function following traumatic brain injury Lee-Anne Chapple a,b,∗ , Adam Deane a,b,c , Lauren Williams d , Richard Strickland c , Chris Schultz e , Kylie Lange f , Daren Heyland g , Marianne Chapman a,b,c a
http://dx.doi.org/10.1016/j.aucc.2017.02.009
The state of the art of central venous catheter care in the intensive care unit of a tertiary hospital; A quality initiative and call to action Peter J. Carr a,∗ , Grainne Ni She b , Haley Pickersgill b , Tracey Bessley b , Kevin Murray c , Gavin Jackson a , Kevin Ho d , Ed Litton b a
PICC Service ICU, Fiona Stanley Hospital c Statistics, The University of Western Australia d Radiology, Fiona Stanley Hospital, Perth, Australia b
Introduction The acute central venous catheter (CVC) is the most common vascular access device found in the intensive care unit (ICU). Appropriate CVC tip termination, device patency along with minimizing the number of CVC dressing changes are evidence-based interventions proven to reduce central line-associated blood-stream infections. Study Objectives The objectives of our quality initiative (QI) were to assess: 1. The quality of the securement device. 2. Documentation of insertion and management of the CVC. 3. CVC tip termination from an x-ray. Methods Using a convenient sample we performed a clinical audit using a statewide electronic quality system; Governance, Evidence, Knowledge and Outcome (GEKO). A case report form was devised and underpinned with face validity and relevant current literature. We selected a pragmatic sample of 50 patients. Results The mean age was 60 +/- 14.7 years and the male gender accounted for 60% of our study population. Five-lumen CVCs were inserted in 80% of patients with 84% of CVCs located on the patient’s right side. Over 50% were inserted high up in the internal jugular (IJ) vein. 100% of CVCs were sutured in place. The edges of the dressings were loose in 40% with an additional border fixation found in 68%. Our specific CVC clinical information system portal was completed in 86% of patients. However, all required fields were not completed in 86%. Over 50% of the CVC tip termination
Discipline of Acute Care Medicine, University of Adelaide b National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes c Intensive Care Unit, Royal Adelaide Hospital, Adelaide d Menzies Health Institute of Queensland, Gold Coast e Nuclear Medicine and Bone Densitometry, Royal Adelaide Hospital f Discipline of Medicine, University of Adelaide, Adelaide, Australia g Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Canada Winner: Best Allied Health Paper sponsored by
Patients with a traumatic brain injury (TBI) admitted to intensive care are at risk of muscle wasting but this has not previously been quantified. The aims were (1) to describe changes in body composition over the entire hospitalisation and at 3-months from admission and (2) to assess the relationship between body composition and self-reported quality of life (QoL) measurements. Body composition measurements were performed weekly throughout hospitalisation and at 3-months: subjective global assessment (SGA), bodyweight and ultrasound-derived quadriceps muscle layer thickness (QMLT). Health-related QoL and functional outcome was assessed 3-months post-ICU admission using the Short-Form-36 Version 2 (SF-36v2) and dichotomised Glasgow Outcome Scale-Extended (GOS-E). Thirty-seven patients (45.3 (15.8) years, 87% male) were studied. Median ICU and hospital length of stays were 13.4 [IQR: 6.4-17.9] and 37.8 [19.4-52.4] days, respectively. Patients had significant weight loss in hospital (4.9 (7.7) %; p=0.001) and more patients were classified as malnourished via the SGA at hospital discharge than admission (12 vs 5 patients; p=0.005). For patients that had QMLT measured more than once (n=28) the mean baseline measurement
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
was 1.78 (0.72) cm and proximate measurement was 1.59 (0.57) cm, with a decrease of 3.91 (33.06) % between these time-points. The mean within-patient standard deviation was 0.14 (0.12) cm. SF36v2 Physical Component Score at 3-months was correlated with QMLT and BMI at hospital discharge (r=0.536, n=22; r=-0.440, n=22) and QMLT at 3-months (r=0.658, n=11). There were strong correlations between GOS and QMLT at hospital discharge (r=0.595, n=23) and 3-months (r=0.642, n=12). In general, head-injured patients admitted to ICU lose muscle mass in hospital and quadriceps muscle thickness at hospital discharge is associated with a reduction in functional status at 3 months. http://dx.doi.org/10.1016/j.aucc.2017.02.011 Lost in translation? Interpreting universal pressure injury prevention guidelines into a practical reference for intensive care Jane-Louise Cook a,∗ , Fiona Coyer a,b , Amanda Vann b , Jill Campbell a,c , Greg McNamara b a
Queensland University of Technology Intensive Care Services c Skin Integrity Services, Royal Brisbane and Women’s Hospital, Brisbane, Australia b
International guidelines for pressure injury prevention (PIP) apply equally to all general and specialty nursing areas. However, intensive care unit (ICU) patients are a unique population due to their severity of illness. Not only are these patients susceptible to pressure injuries (PIs) over bony prominences, they are at increased risk for medical device-related pressure injuries from chemical restraint, physical restrictions, and the many invasive procedures they undergo. The juxtaposition of urgent life-saving interventions with the adherence to best practice PIP guidelines poses problems for nursing staff who constantly juggle these priorities. In our ICU these challenges were highlighted during the weekly skin integrity nursing rounds and from analysis of the integument-related patient incident reports. To develop an evidence-based, clinical guideline that integrates PIP strategies into a tertiary intensive care context as a strategy to reduce PI prevalence. A survey of nurses’ perceptions of barriers, enablers and attitudes towards pressure injury prevention and skin integrity care was conducted in combination with focus groups. The need for an ICU-specific guideline was identified. Collaboration with the ICU nursing leadership and medical team, hospital skin integrity service and quality and safety unit, resulted in the development of a clinical guideline with simplification of the PI risk assessment categories, clarification of PIP strategies in ICU and documentation recommendations to improve consistency and minimise skin disruptions. An ongoing reduction in the prevalence and incidence of PIs in the ICU occurred that was evidenced by weekly PIP prevalence audits from 16% to 9% over 6 months and other reporting measures. Implementation of a standardised, evidence-based approach to PIP and skin integrity optimisation with expert collaboration and explicit interpretation in an intensive care context should be considered in order to achieve sustained PI reduction.
113
End-of-life-care in the ICU: a qualitative meta-synthesis investigating the experiences and perceptions of the patients family Alysia Coventry a,∗ , Elizabeth McInnes b , John Resenberg c , Rosemary Ford d a
School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne b School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney c School of Nursing, Queensland University of Technology, Brisbane d School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Ballarat, Australia End-of-life-care (EOLC) practices in the ICU, vary considerably in the absence of evidence-based clinical guidelines. Families are optimally positioned to identify important domains of EOLC, but their views are often overlooked. A systematic review and meta-synthesis was conducted to identify the experiences and perceptions of families of adult intensive care patients on the adequacy of EOLC, following withdrawal of life-support. Qualitative studies published between January 2005 and May 2016 that addressed this phenomenon were eligible for inclusion. A comprehensive search was used in 28 databases. Critical appraisal, data extraction, data synthesis and ConQual were conducted using the guidelines of the Joanna Briggs Institute with the addition of a thematic analysis. Critical appraisal and ConQual were used to rate the confidence of the synthesised findings. Twelve studies met the inclusion criteria; none were excluded after critical appraisal. Data analysis and meta-synthesis resulted in 23 categories and five synthesised findings: (1) communication; (2) care of the patient; (3) promoting a peaceful death and dying environment; (4) caring behaviours and support of the family; and (5) bereavement care. The synthesised findings have demonstrated families have unmet needs for support, communication and care after the withdrawal of life-support and death of a patient in the ICU. Also, despite the psychological reactions associated with grief and loss, death in the ICU can be a positive experience for families. There is an opportunity for healthcare teams to align care and support with the values, needs and wishes of families during EOLC. The delivery of timely EOLC that is compassionate, individualised and involves effective communication may also promote a more patient and family-centred death and dying environment. As no studies were eligible for inclusion from Australasia, a study from this region could further inform policy and guideline development in this area. http://dx.doi.org/10.1016/j.aucc.2017.02.013 Are Australian ICU patients more overweight than the general population, and is it important: a single site observational study? Diane Dennis a,∗ , Chrianna Bharat b , Timothy Paterson c , Adele Clair a , Tracy Hebden-Todd a , Emily Brough c , Wendy Jacob a a
Sir Charles Gairdner Hospital, Nedlands, WA University of Western Australia c Western Australian Neuroscience Research Institute (WANRI) b
http://dx.doi.org/10.1016/j.aucc.2017.02.012
Obesity is a world-wide health issue in developed nations and although national population data are available for many countries, little pertains to hospitalised populations, particularly those who are critically ill requiring expensive care. The objective of this study