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Oxygenation practices in the adult ventilated patient: a retrospective audit
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
per 12hours are reported as mean (SD) and compared using the student t-test. One hundred patients were randomised with 96 completing the study (150 mls/min – 49; 250 mls/min – 47). Groups were well matched for baseline characteristics with the exception that patients in the 150 mls/min group were slightly heavier (83.5 vs. 75.8kg, p=0.039). Hours of treatment per 12hrs (n=854) was 6.3hrs (3.7) in the 150 mls/min group and 6.7hrs (3.9) in the 250ml/min group, p= 0.6. There was no difference between the two BFR groups for delta urea (-0.06 [0.015] vs. - 0.074 [0.01], p=0.42) or delta creatinine (-0.05 [0.01] vs. -0.08 [0.01], p=0.18). Independent variables associated with less reduction in serum urea and creatinine were a low haemoglobin, -0.01 [0.005], p= 0.002; 0.01 [0.005], p= 0.006) and less hours treated; -0.023 [0.001], p= 0.000; -0.02 [0.002], p= 0.001. No effect for body weight was found. BFR assessed for treatment time over 12 hour intervals did not influence solute control in patients with AKI, however haemoglobin and hours of treatment did affect control of both urea and creatinine. http://dx.doi.org/10.1016/j.aucc.2017.02.048 Compassion-satisfaction and compassion-fatigue in Australian intensive care units Samantha Jakimowicz ∗ , Lin Perry, Joanne Lewis Faculty of Health, University of Technology Sydney, Sydney, Australia Compassion-satisfaction and compassion-fatigue influence nurses’ decision to remain in nursing and may impact patient experience of ICU. It is important to gauge ICU nurses’ levels of compassion-satisfaction or fatigue, as workforce turnover is high and quality patient care is essential. The aim was to determine the extent and predictive factors of critical care nurses’ level of compassion-satisfaction and fatigue. A self-reported cross-sectional survey collected data from nurses of two adult Australian ICUs (n=117). The Professional Quality of Life Scale measured compassion-satisfaction, with compassion-fatigue as two subscales: burnout and secondary traumatic stress (STS). Scores of 22 or less were designated low, 23-41 average and 42 or above as high. Participants were mostly female, held post-graduate qualifications with a mean age of 42 years, 16 years experience and 9 years tenure. The mean (SD) score for compassion-satisfaction was 35.39 (6.00), burnout 25.47 (5.31) and STS 21.43 (4.64). Compassionsatisfaction levels significantly increased experience and tenure. With increasing age, years of tenure and practice burnout scores reduced significantly. Mid-career nurses had higher burnout scores than their colleagues [F(2,110)=4.11, p=.019]; post hoc test [p =.023, 95% CI [0.33, 5.55]. Nurses with a postgraduate qualification had significantly higher compassion-satisfaction scores (p=.027). Nurses at Site A had significantly higher compassion-satisfaction scores (p =.008) but lower STS scores (p=.025). High compassion-satisfaction and moderate to low fatigue are indicators of an effective workforce and may impact quality of patient care. Interventions targeting mid-career nurses and those without post-graduate qualifications are required to support these at risk groups. Further investigation is needed to understand different ways each unit supports their nurses by examining potential protective factors present at one site and possibly absent from the other. http://dx.doi.org/10.1016/j.aucc.2017.02.049
127
Patient-centred nursing and compassion in Australian intensive care units: mixed methods research Samantha Jakimowicz ∗ , Lin Perry, Joanne Lewis Faculty of Health, University of Technology Sydney, Sydney, Australia The aggressive, curative ICU setting may compromise patientcentred nursing (PCN). ICU nurses are expected to employ clinical expertise and compassionate nursing care; they are at high risk of anxiety and fatigue. Compassion-satisfaction and compassionfatigue influence nurses’ intention to leave; workforce turnover is high. The aim was to develop an explanatory framework for PCN and compassion-satisfaction or fatigue in ICU. We used a mixed methods explanatory sequential design and collected data from nurses of two adult ICUs using a self-reported cross-sectional survey (n=117). The Professional Quality of Life Scale was chosen. Grounded theory methods were used to examine 23 nurses’ experiences. Findings were integrated using a constructivist paradigm. Participants had average levels of compassion-satisfaction and fatigue. Compassion-satisfaction scores rose significantly with increasing experience and tenure. Burnout scores significantly reduced with increasing age, experience and tenure. Nurses at Site A had significantly higher compassion-satisfaction scores (p=.008) and lower STS scores (p=.025). The results indicate mid-career nurses and those without post-graduate qualifications are at higher risk of compassion-fatigue. Facilitative themes to compassionsatisfaction include: colleagues; understanding; time; education; and collaboration. Communication around treatment plans, lack of management support and pressured patient flow impedes nurses’ ability to fulfil their role and may cause ethical dilemma. High compassion-satisfaction and low fatigue augments PCN and a healthy workforce. ICU nurses experience compassionsatisfaction when supported in achieving and maintaining patients’ biomedical stability and providing compassionate care. Barriers to nurses’ providing PCN may challenge compassion-satisfaction. The complex nature of ICU nursing and fatigue for some nurses substantiates establishment of early interventions to enhance compassion-satisfaction. http://dx.doi.org/10.1016/j.aucc.2017.02.050 Oxygenation practices in the adult ventilated patient: a retrospective audit Rachel Longhurst Calvery Hospital, Canberra Prolonged exposure to a high FiO2 has been linked to significant ramifications, and therefore the lowest possible FiO2 to maintain normoxemia is likely warranted. The aim was to examine the timeframes fraction of inspired oxygen (FiO2 ) was weaned in relation to oxygen saturations (SpO2 ) and partial pressure of oxygen (PaO2 ) and whether target parameters were provided by the medical team. A retrospective clinical audit was conducted from 15 adult ventilated patients presenting with a variety of illnesses, examining
- Time taken to achieve an FiO2 of ≤.60 - Parameters provided by the ICU medical team for weaning - SpO2 and PaO2 in relation to FiO2
128
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
For a FiO2 less than .60: timeframe = 1 to 16hours. The average being 6.5hours. In nine cases the target SpO2 only was the only target provided. In three cases the PaO2 only. In two cases no parameters were provided and in one case both SpO2 and PaO2 were provided. The SpO2 was examined in each of the patients in comparison to their set FiO2 . In 88% of cases the SpO2 sat between 95-100% continuously, indicating the patient could be weaned from their set FiO2 many hours before they actually were. Blood gases were also examined. Often the patient’s PaO2 was greater than 80mmHg and weaning still did not occur. Timing of the FiO2 wean was mostly in conjunction with an ABG being attended with a resulting PaO2 reading ≥ 80mmHg (even when documented PaO2 goal was 60mmHg). Two main issues were identified: the giving of more O2 than needed for much longer than required; and a disconnection between nursing and medical methods of weaning FiO2 . http://dx.doi.org/10.1016/j.aucc.2017.02.051 Implementation of the critical care pain observation tool increases frequency of pain assessment for non-communicative icu patients Margaret Phillips a,∗ , Vijo Kuruvilla a , Michael Bailey b a
Intensive Care Unit, Royal Darwin Hospital, Darwin Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia b
Pain is a common stressor for ICU patients. In the absence of an observational pain tool, pain is inadequately assessed in non-communicative patients, and self-report tools may be used inappropriately. The Critical Care Pain Observation Tool (CPOT) is the most reliable tool currently available to assess pain in these patients. We investigated whether implementation of the CPOT in one Australian ICU could increase frequency of appropriate pain assessments, and if this would have a flow on effect to administration of analgesia and sedation. Conducted as a before and after study comprising three phases, in phase one, we performed a rapidly retrospective chart audit on 441 adult ICU patient charts, over 49 days. Data collected included frequency and type of pain assessments, sedation and analgesia administered, and bedside nurse-perceived pain issues. In phase two, new policy and guideline documents were released, and ICU Charts were redesigned to incorporate the CPOT. All ICU nursing staff attended an education session on pain assessment and correct use of the CPOT. After a washout period, the chart audit was repeated, capturing 344 charts over 43 days. Mean total assessments in 24hours increased from 6.1 to 8.0 for communicative, 3.0 to 8.7 for non-communicative, and 5.1 to 9.1 for transitioning patients. For non-communicative patients, there was a significant increase in observational assessments including the CPOT (1.7 to 8.3), and a decrease in inappropriate use of selfreport tools (1.3 to 0.2). We also observed significant increases in paracetamol, opiates, propofol, patient controlled analgesia, modified-release opiates, and neuropathic pain agents. Implementation of the CPOT using standardised education and resources has improved nurses’ abilities to appropriately assess pain. Administration of analgesia has increased, and the pattern of
sedation has altered. These findings are likely to signify improved patient comfort, mitigating the adverse effects of pain. http://dx.doi.org/10.1016/j.aucc.2017.02.052 Relationship between severe hypercalcemia and mortality in post-liver transplant patients: a retrospective case-control study Kanaki Sakai e,∗ , Naoya Iguchi a , Hirotsugu Iwatani b , Akinori Uchiyama c , Yuji Fujino d a
Systems Neurophysiology Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia b Nephrology, National Hospital Organization Osaka National Hospital, Osaka c Intensive Care Unit, Osaka University Hospital d Department of Anesthesiology & Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan e Shintakeo Hospital, Japan Introduction There are a few case reports of hypercalcemia after liver transplantation. However, no study has investigated the relationship between hypercalcemia and prognosis in post -liver transplant patients. Objective Our objective was to determine whether a correlation exists between severe hypercalcemia and prognosis in post-liver transplant patients. Methods We enrolled 29 adult patients (age>15) receiving liver transplantation at the Osaka University Hospital between January 2013 and December 2014. We defined ‘post-liver transplant severe hypercalcemia (PLTH)’ as albumin-corrected serum calcium concentration level >11.0 mg/dL for at least 7days. Baseline characteristics (age, sex, BMI, MELD score and so on), donor factors (living or cadaveric, ABO matched or incompatible and GV/SLV), operative factors (operative time, volume of blood loss, ischemic time and so on) and postoperative course were recorded. Results PLTH occurred 7patients (24.1%). PLTH was diagnosed at postoperative day 24 (median, interquartile range 12-34). There were no significant differences in baseline characteristics, donor factors and operative factors between 2 groups. Blood transfusion volume during postoperative 28 days was higher in PLTH group than in no-PTLH group. The incidence of serious arrhythmia was higher in PLTH group than in no-PLTH group (57.1% vs 4.6%; p=0.0013). The need for renal replacement therapy and plasma exchange was higher in PLTH group than in no-PLTH group (100.0 vs 22.7%; p=0.0003 and 71.4 vs 18.2%; p=0.0080, respectively). The mortality rate was significantly higher in PLTH group (71.4%) than in noPLTH group (4.5%; p = 0.0002), and there were similar results for the length of ICU stay and hospital stay. Conclusion Our study suggested that PLTH was associated with poor prognosis. It would be a future target of our study whether an aggressive calcium management might lead to a better prognosis or not in liver transplantation. http://dx.doi.org/10.1016/j.aucc.2017.02.053
per 12hours are reported as mean (SD) and compared using the student t-test. One hundred patients were randomised with 96 completing the study (150 mls/min – 49; 250 mls/min – 47). Groups were well matched for baseline characteristics with the exception that patients in the 150 mls/min group were slightly heavier (83.5 vs. 75.8kg, p=0.039). Hours of treatment per 12hrs (n=854) was 6.3hrs (3.7) in the 150 mls/min group and 6.7hrs (3.9) in the 250ml/min group, p= 0.6. There was no difference between the two BFR groups for delta urea (-0.06 [0.015] vs. - 0.074 [0.01], p=0.42) or delta creatinine (-0.05 [0.01] vs. -0.08 [0.01], p=0.18). Independent variables associated with less reduction in serum urea and creatinine were a low haemoglobin, -0.01 [0.005], p= 0.002; 0.01 [0.005], p= 0.006) and less hours treated; -0.023 [0.001], p= 0.000; -0.02 [0.002], p= 0.001. No effect for body weight was found. BFR assessed for treatment time over 12 hour intervals did not influence solute control in patients with AKI, however haemoglobin and hours of treatment did affect control of both urea and creatinine. http://dx.doi.org/10.1016/j.aucc.2017.02.048 Compassion-satisfaction and compassion-fatigue in Australian intensive care units Samantha Jakimowicz ∗ , Lin Perry, Joanne Lewis Faculty of Health, University of Technology Sydney, Sydney, Australia Compassion-satisfaction and compassion-fatigue influence nurses’ decision to remain in nursing and may impact patient experience of ICU. It is important to gauge ICU nurses’ levels of compassion-satisfaction or fatigue, as workforce turnover is high and quality patient care is essential. The aim was to determine the extent and predictive factors of critical care nurses’ level of compassion-satisfaction and fatigue. A self-reported cross-sectional survey collected data from nurses of two adult Australian ICUs (n=117). The Professional Quality of Life Scale measured compassion-satisfaction, with compassion-fatigue as two subscales: burnout and secondary traumatic stress (STS). Scores of 22 or less were designated low, 23-41 average and 42 or above as high. Participants were mostly female, held post-graduate qualifications with a mean age of 42 years, 16 years experience and 9 years tenure. The mean (SD) score for compassion-satisfaction was 35.39 (6.00), burnout 25.47 (5.31) and STS 21.43 (4.64). Compassionsatisfaction levels significantly increased experience and tenure. With increasing age, years of tenure and practice burnout scores reduced significantly. Mid-career nurses had higher burnout scores than their colleagues [F(2,110)=4.11, p=.019]; post hoc test [p =.023, 95% CI [0.33, 5.55]. Nurses with a postgraduate qualification had significantly higher compassion-satisfaction scores (p=.027). Nurses at Site A had significantly higher compassion-satisfaction scores (p =.008) but lower STS scores (p=.025). High compassion-satisfaction and moderate to low fatigue are indicators of an effective workforce and may impact quality of patient care. Interventions targeting mid-career nurses and those without post-graduate qualifications are required to support these at risk groups. Further investigation is needed to understand different ways each unit supports their nurses by examining potential protective factors present at one site and possibly absent from the other. http://dx.doi.org/10.1016/j.aucc.2017.02.049
127
Patient-centred nursing and compassion in Australian intensive care units: mixed methods research Samantha Jakimowicz ∗ , Lin Perry, Joanne Lewis Faculty of Health, University of Technology Sydney, Sydney, Australia The aggressive, curative ICU setting may compromise patientcentred nursing (PCN). ICU nurses are expected to employ clinical expertise and compassionate nursing care; they are at high risk of anxiety and fatigue. Compassion-satisfaction and compassionfatigue influence nurses’ intention to leave; workforce turnover is high. The aim was to develop an explanatory framework for PCN and compassion-satisfaction or fatigue in ICU. We used a mixed methods explanatory sequential design and collected data from nurses of two adult ICUs using a self-reported cross-sectional survey (n=117). The Professional Quality of Life Scale was chosen. Grounded theory methods were used to examine 23 nurses’ experiences. Findings were integrated using a constructivist paradigm. Participants had average levels of compassion-satisfaction and fatigue. Compassion-satisfaction scores rose significantly with increasing experience and tenure. Burnout scores significantly reduced with increasing age, experience and tenure. Nurses at Site A had significantly higher compassion-satisfaction scores (p=.008) and lower STS scores (p=.025). The results indicate mid-career nurses and those without post-graduate qualifications are at higher risk of compassion-fatigue. Facilitative themes to compassionsatisfaction include: colleagues; understanding; time; education; and collaboration. Communication around treatment plans, lack of management support and pressured patient flow impedes nurses’ ability to fulfil their role and may cause ethical dilemma. High compassion-satisfaction and low fatigue augments PCN and a healthy workforce. ICU nurses experience compassionsatisfaction when supported in achieving and maintaining patients’ biomedical stability and providing compassionate care. Barriers to nurses’ providing PCN may challenge compassion-satisfaction. The complex nature of ICU nursing and fatigue for some nurses substantiates establishment of early interventions to enhance compassion-satisfaction. http://dx.doi.org/10.1016/j.aucc.2017.02.050 Oxygenation practices in the adult ventilated patient: a retrospective audit Rachel Longhurst Calvery Hospital, Canberra Prolonged exposure to a high FiO2 has been linked to significant ramifications, and therefore the lowest possible FiO2 to maintain normoxemia is likely warranted. The aim was to examine the timeframes fraction of inspired oxygen (FiO2 ) was weaned in relation to oxygen saturations (SpO2 ) and partial pressure of oxygen (PaO2 ) and whether target parameters were provided by the medical team. A retrospective clinical audit was conducted from 15 adult ventilated patients presenting with a variety of illnesses, examining
- Time taken to achieve an FiO2 of ≤.60 - Parameters provided by the ICU medical team for weaning - SpO2 and PaO2 in relation to FiO2
128
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
For a FiO2 less than .60: timeframe = 1 to 16hours. The average being 6.5hours. In nine cases the target SpO2 only was the only target provided. In three cases the PaO2 only. In two cases no parameters were provided and in one case both SpO2 and PaO2 were provided. The SpO2 was examined in each of the patients in comparison to their set FiO2 . In 88% of cases the SpO2 sat between 95-100% continuously, indicating the patient could be weaned from their set FiO2 many hours before they actually were. Blood gases were also examined. Often the patient’s PaO2 was greater than 80mmHg and weaning still did not occur. Timing of the FiO2 wean was mostly in conjunction with an ABG being attended with a resulting PaO2 reading ≥ 80mmHg (even when documented PaO2 goal was 60mmHg). Two main issues were identified: the giving of more O2 than needed for much longer than required; and a disconnection between nursing and medical methods of weaning FiO2 . http://dx.doi.org/10.1016/j.aucc.2017.02.051 Implementation of the critical care pain observation tool increases frequency of pain assessment for non-communicative icu patients Margaret Phillips a,∗ , Vijo Kuruvilla a , Michael Bailey b a
Intensive Care Unit, Royal Darwin Hospital, Darwin Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia b
Pain is a common stressor for ICU patients. In the absence of an observational pain tool, pain is inadequately assessed in non-communicative patients, and self-report tools may be used inappropriately. The Critical Care Pain Observation Tool (CPOT) is the most reliable tool currently available to assess pain in these patients. We investigated whether implementation of the CPOT in one Australian ICU could increase frequency of appropriate pain assessments, and if this would have a flow on effect to administration of analgesia and sedation. Conducted as a before and after study comprising three phases, in phase one, we performed a rapidly retrospective chart audit on 441 adult ICU patient charts, over 49 days. Data collected included frequency and type of pain assessments, sedation and analgesia administered, and bedside nurse-perceived pain issues. In phase two, new policy and guideline documents were released, and ICU Charts were redesigned to incorporate the CPOT. All ICU nursing staff attended an education session on pain assessment and correct use of the CPOT. After a washout period, the chart audit was repeated, capturing 344 charts over 43 days. Mean total assessments in 24hours increased from 6.1 to 8.0 for communicative, 3.0 to 8.7 for non-communicative, and 5.1 to 9.1 for transitioning patients. For non-communicative patients, there was a significant increase in observational assessments including the CPOT (1.7 to 8.3), and a decrease in inappropriate use of selfreport tools (1.3 to 0.2). We also observed significant increases in paracetamol, opiates, propofol, patient controlled analgesia, modified-release opiates, and neuropathic pain agents. Implementation of the CPOT using standardised education and resources has improved nurses’ abilities to appropriately assess pain. Administration of analgesia has increased, and the pattern of
sedation has altered. These findings are likely to signify improved patient comfort, mitigating the adverse effects of pain. http://dx.doi.org/10.1016/j.aucc.2017.02.052 Relationship between severe hypercalcemia and mortality in post-liver transplant patients: a retrospective case-control study Kanaki Sakai e,∗ , Naoya Iguchi a , Hirotsugu Iwatani b , Akinori Uchiyama c , Yuji Fujino d a
Systems Neurophysiology Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia b Nephrology, National Hospital Organization Osaka National Hospital, Osaka c Intensive Care Unit, Osaka University Hospital d Department of Anesthesiology & Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan e Shintakeo Hospital, Japan Introduction There are a few case reports of hypercalcemia after liver transplantation. However, no study has investigated the relationship between hypercalcemia and prognosis in post -liver transplant patients. Objective Our objective was to determine whether a correlation exists between severe hypercalcemia and prognosis in post-liver transplant patients. Methods We enrolled 29 adult patients (age>15) receiving liver transplantation at the Osaka University Hospital between January 2013 and December 2014. We defined ‘post-liver transplant severe hypercalcemia (PLTH)’ as albumin-corrected serum calcium concentration level >11.0 mg/dL for at least 7days. Baseline characteristics (age, sex, BMI, MELD score and so on), donor factors (living or cadaveric, ABO matched or incompatible and GV/SLV), operative factors (operative time, volume of blood loss, ischemic time and so on) and postoperative course were recorded. Results PLTH occurred 7patients (24.1%). PLTH was diagnosed at postoperative day 24 (median, interquartile range 12-34). There were no significant differences in baseline characteristics, donor factors and operative factors between 2 groups. Blood transfusion volume during postoperative 28 days was higher in PLTH group than in no-PTLH group. The incidence of serious arrhythmia was higher in PLTH group than in no-PLTH group (57.1% vs 4.6%; p=0.0013). The need for renal replacement therapy and plasma exchange was higher in PLTH group than in no-PLTH group (100.0 vs 22.7%; p=0.0003 and 71.4 vs 18.2%; p=0.0080, respectively). The mortality rate was significantly higher in PLTH group (71.4%) than in noPLTH group (4.5%; p = 0.0002), and there were similar results for the length of ICU stay and hospital stay. Conclusion Our study suggested that PLTH was associated with poor prognosis. It would be a future target of our study whether an aggressive calcium management might lead to a better prognosis or not in liver transplantation. http://dx.doi.org/10.1016/j.aucc.2017.02.053