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Post traumatic stress disorder in relatives of patients admitted to an intensive care unit
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 26 (2013) 81–98
Results: Twenty-nine nurses participated; a 47% response rate. Data analysis using Wilcoxon Signed Rank Test showed AEG diagnostic accuracy significantly improved 2 weeks post intervention (p = 0.006). No further improvement in accuracy occurred at 8 weeks (p = 0.28). Participants completed the education program between 02.30 a.m. and 9.00 p.m. on weekdays (n = 20) using a home personal computer (n = 25) over an average duration of 68 min. Eight participants initiated an AEG assessment in their clinical area during the study, with one participant changing a patient’s arrhythmia management due to newly acquired knowledge. Conclusions: Atrial electrogram diagnostic accuracy improved after completing the education program. Flexible delivery of education can facilitate ongoing nursing professional development beyond education during a clinical shift. This education mode is an evidence-based, cost effective and time efficient way of reaching large audiences to improve clinical knowledge and patient care. Acknowledgement: This study was supported by an Epworth Healthcare Research Scholarship. http://dx.doi.org/10.1016/j.aucc.2013.02.019 Is peripheral arterial waveform analysis continuous cardiac output monitoring useful with assessment of oxygenation status for patients on veno–venous extracorporeal membrane oxygenation? J. Breeding ∗ , P. Nair, N. Nguyen, H. Buscher, C. Frost, M. Gopal, R. Pye, S. Whittam St Vincent’s Hospital, Sydney, Australia Introduction: Patients on VV-ECMO have frequent changes in their oxygen saturations (SaO2 ). While increases in cardiac output (CO) are a common cause for desaturation, other causes need to be excluded. Pulmonary artery CO monitoring is not routinely undertaken due to associated risks. A less invasive CO monitoring device might assist. Objective: To conduct a 12 month single centre pilot study to evaluate the usefulness of peripheral arterial pulse analysis cardiac output (CO) monitoring in patients on V-V ECMO in assessing alterations in oxygenation status. Method: Eight adult patients on VV ECMO for severe respiratory failure were included. The device used was the Edwards FloTracTM Sensor with the VigileoTM Monitor. Data were analysed for individual patients as well as collectively, including the generation of box and scatter plots. Analysis focussed upon comparing the resultant oxygen saturations for different ranges of ECMO blood flow as a percentage of CO. Results: Individual patient data was variable. Pooled data demonstrated that when the ECMO blood flow increased as a percentage of CO, then the SaO2 increased. When the ECMO blood flow was ≥70% of CO, the median SaO2 was 96% (interquartile range 94–99; min–max 86–100). When ≤70% the median SaO2 was 92% (interquartile range 89–96, min–max 70–100). Discussion: The trend of the CO readings appeared to correlate with clinicians’ perceptions of CO changes although the absolute number did not always correlate. These trends allowed clinicians to readily identify a reason for a drop in SaO2 without further investigations. Conclusions: The device assists with guiding appropriate ECMO flows and troubleshooting episodes of arterial de-saturation taking into consideration potential pitfalls. http://dx.doi.org/10.1016/j.aucc.2013.02.020
87
The effect of feedback on compliance with the ventilator care bundle P. Lawrence-Baxter 1,∗ , P. Fulbrook 1,2,3 1
The Prince Charles Hospital, Australia Australian Catholic University, Australia 3 Australian College of Critical Care Nurses, Australia 2
Introduction: The ventilator care bundle (VCB) is a group of four evidence-based procedures (head of bed elevation; daily sedation hold and readiness to wean assessment; gastric ulcer prevention; deep vein thrombosis prophylaxis). Implemented as an ‘all or nothing’ strategy it may result in clinical outcome improvement. Aim: To measure the effect of audit and feedback on VCB compliance. Setting: two Queensland metropolitan general ICUs. Methods: Before–after design. De-identified data, relating to adult ventilated patients, were collected weekly, on a randomised day. Compliance was recorded simply, as ‘yes’ or ‘no’, and legitimate contraindications to each element were recorded as ‘yes’. Individual element, overall, and ‘all or nothing’ compliance with the VCB were calculated. In the second phase of the study, feedback about VCB compliance rates were provided to both ICUs and its effect on VCB compliance rates was measured. Results: Data were collected from 164 ‘before’ and 151 ‘after’ patient episodes. Overall VCB compliance increased from 89 to 91% and ‘all or nothing’ compliance increased from 65 to 68%. In one ICU, compliance with all four VCB elements increased whereas only two increased in the other. Both ICUs achieved 100% compliance with gastric ulcer prophylaxis for all 6 months of the second phase. Overall compliance was influenced by a significant fall in HOBE compliance in one ICU. Conclusions: Both ICUs’ overall VCB compliance rates were very good, and improved during the second 6 months. The relatively poor HOBE compliance is a cause of concern, but is consistent with the findings of previous research. http://dx.doi.org/10.1016/j.aucc.2013.02.021 Post traumatic stress disorder in relatives of patients admitted to an intensive care unit K. Sundararajan 1,∗ , M. Martin 2 , T.R. Sullivan 3 , M.J. Chapman 1 1
Discipline of Acute Care Medicine, University of Adelaide, Australia Traumatic Injuries Psychology Service, Royal Adelaide Hospital, Australia 3 Data Management and Analysis Centre, University of Adelaide, Australia 2
Background: There is a high risk of Post Traumatic Stress Disorder (PTSD) in relatives of intensive care unit (ICU) patients Aims: To determine the incidence and predictors of symptoms of PTSD in the relatives of an Australian critically ill population. Methods: One hundred and eight consecutive patients, staying >48 h in a mixed, level 3 ICU were identified. Eight were excluded because next of kin contact details were unavailable. On day 3 of admission their next of kin were contacted, consent was sought, and, if given, a phone questionnaire using Hospital Anxiety and Depression Scale, Impact of Event Scale Revised (IES-R), Short-Form General Health Survey, Royal Adelaide Hospital-ICU Family Satisfaction Survey, was performed 90 days post discharge from ICU. An IES-R score of >8.5 was used to define moderate, and >19 was used to define severe PTSD symptoms. Results: Thirty-seven subjects refused to participate. Thus a total of 63 family members were included, 49 of patients who survived. The incidence of PTSD symptoms was 49.21% (CI 36.38%,
88
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 26 (2013) 81–98
62.11%) for moderate and 7.94% (CI 2.63%, 17.56%) for severe. The anxiety score was found to be a significant predictor of moderate PTSD symptoms, with a one unit increase in the anxiety score being associated with a 12% increase in the risk of PTSD (relative risk = 1.12; 95% CI 1.06, 1.19; p = 0.0001). Conclusion: Many family members of ICU patients had PTSD symptoms. High anxiety scores were a significant predictor for developing moderate but not severe PTSD symptoms. http://dx.doi.org/10.1016/j.aucc.2013.02.022 Continuous veno-venous hemofiltration versus slow extended dialysis in acute renal failure critically ill patients with the use of cystatin c as an early biomarker for acute kidney injury H. Elkady Blacktown Hospital, Australia Introduction: Acute renal failure is a common complication of critical illness, which is associated with high mortality and has a separate independent effect on the risk of death. Objectives: To compare renal recovery and patient survival in critically ill patients developing acute renal failure using two modalities of continuous renal replacement therapy which were continuous venovenous hemofiltration and slow extended daily dialysis and to evaluate the prognostic value of serum Cystatin C in patients with acute renal failure. Methods: Prospective randomized controlled trial done on 20 adult critical patients with acute renal failure divided into 2 groups; Group A: 10 patients received CVVH, Group B: 10 patients received SLED with relevant investigations and measurements obtained through the time of the study, serum cystatin C was obtained at time of inclusion and after the end of renal replacement therapy. Patients with chronic renal insufficiency or obstructive uropathy were excluded. Results: Both groups were matched at the time of the inclusion to study. Results had been showing significant increase of MAP after therapy in SLED group, no significant difference between both groups in mortality, ICU LOS or renal recovery, Serum cystatin C was lower in CVVH group after therapy. Conclusions: 1. CVVH and SLED provided adequate hemodynamic stability, they were comparable regarding the incidence of complications, without significant difference in survival or renal recovery. 2. Early initiation of RRT was associated with better survival and restoration of renal functions. 3. SLED is a promising RRT that combines excellent detoxification and cardiovascular tolerability, even in severely ill patients. http://dx.doi.org/10.1016/j.aucc.2013.02.023 Estimation of fluid status changes after cardiac surgery fluid balance chart or electronic bed weight? A. Schneider 1,2,∗ , C. Thorpe 1 , K. Dellbridge 1 , G. Matalanis 1,2 , R. Bellomo 1,2 1 2
Warringal Private Hospital, Australia Austin Health, Australia
Introduction: Evaluating fluid status changes in the intensive care unit (ICU) is difficult. Previous studies have demonstrated a poor correlation between fluid balance (FB) and changes in body weight (BW) obtained with hospital beds. However, these studies included heterogeneous patients and low protocol observance.
Objectives: We sought to compare fluid balance estimates obtained by these two methods in cardiac surgery patients. Methods: All patients admitted to the Warringal Private ICU after cardiac surgery over a 7 month period were weighed twice daily (1200 and 2400 h) using electronic weighing beds (HillRomTM (Batesville, USA)). Differences in BW and FB between two consecutive twelve hours periods were compared. Additionally, the last weight before discharge was compared with that obtained on a regular scale on ward admission. Results: We obtained data in 83 consecutive patients. In total 319/425 (72.5%) BW values were obtained. We excluded 8 values (one for faulty bed calibration and seven for BW changes > 10 kg) and 179 pairs were analysed. The 12 h changes in BW and corresponding FB were only weakly correlated (r = 0.30, p < 0.001). On Bland–Altman plot, the limits of agreement were wide (−3.5 to 3.7 litres). These findings persisted after correction for insensible fluid losses and restriction to intubated patients. There was excellent correlation (r = 0.98) between weights obtained on ICU discharge and on ward admission. Conclusion: Even in a study setting, the correlation between changes in body weights and fluid balance was weak. Further studies are required to establish the reasons for this discrepancy. http://dx.doi.org/10.1016/j.aucc.2013.02.024
Adult Critical Care Posters Drawing the line: Behaviours and attitudes for fostering a safe and positive ICU culture C.N. Duncan Intensive Care Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia Winner: Best Nursing Poster Prize sponsored by Australian Catholic University
Introduction: In 2011 the Safety Attitudes Questionnaire (SAQ) was performed in the Sir Charles Gairdner Hospital Intensive Care Unit (ICU). Whilst survey results indicate a positive safety climate, we did not score as positively as comparable ICUs nationally and internationally. Anecdotal reports by nursing staff indicate unwillingness to address inappropriate or unsafe practice with peers, preferring instead to report to the Nurse Manager or Clinical Nurse Specialist. Objectives: • To determine attitudes and behaviours employees believe generate a safe and positive ICU culture. • To provide a framework for the cultural orientation of new nursing employees to the ICU. Methods: 113 nurses (76.3% nursing employees in ICU) participated in round table discussions. Nurses were asked to identify attitudes or behaviours that they felt were “Above or Below the Line”. Real-time discourse analysis was performed to identify attitudes or behaviours that generate a positive and safe ICU culture. Results: Comments were thematically coded into five domains: • • • • •
Teamwork, Honesty and ethics, Respect and caring, Excellence, Accountability.
Results: Twenty-nine nurses participated; a 47% response rate. Data analysis using Wilcoxon Signed Rank Test showed AEG diagnostic accuracy significantly improved 2 weeks post intervention (p = 0.006). No further improvement in accuracy occurred at 8 weeks (p = 0.28). Participants completed the education program between 02.30 a.m. and 9.00 p.m. on weekdays (n = 20) using a home personal computer (n = 25) over an average duration of 68 min. Eight participants initiated an AEG assessment in their clinical area during the study, with one participant changing a patient’s arrhythmia management due to newly acquired knowledge. Conclusions: Atrial electrogram diagnostic accuracy improved after completing the education program. Flexible delivery of education can facilitate ongoing nursing professional development beyond education during a clinical shift. This education mode is an evidence-based, cost effective and time efficient way of reaching large audiences to improve clinical knowledge and patient care. Acknowledgement: This study was supported by an Epworth Healthcare Research Scholarship. http://dx.doi.org/10.1016/j.aucc.2013.02.019 Is peripheral arterial waveform analysis continuous cardiac output monitoring useful with assessment of oxygenation status for patients on veno–venous extracorporeal membrane oxygenation? J. Breeding ∗ , P. Nair, N. Nguyen, H. Buscher, C. Frost, M. Gopal, R. Pye, S. Whittam St Vincent’s Hospital, Sydney, Australia Introduction: Patients on VV-ECMO have frequent changes in their oxygen saturations (SaO2 ). While increases in cardiac output (CO) are a common cause for desaturation, other causes need to be excluded. Pulmonary artery CO monitoring is not routinely undertaken due to associated risks. A less invasive CO monitoring device might assist. Objective: To conduct a 12 month single centre pilot study to evaluate the usefulness of peripheral arterial pulse analysis cardiac output (CO) monitoring in patients on V-V ECMO in assessing alterations in oxygenation status. Method: Eight adult patients on VV ECMO for severe respiratory failure were included. The device used was the Edwards FloTracTM Sensor with the VigileoTM Monitor. Data were analysed for individual patients as well as collectively, including the generation of box and scatter plots. Analysis focussed upon comparing the resultant oxygen saturations for different ranges of ECMO blood flow as a percentage of CO. Results: Individual patient data was variable. Pooled data demonstrated that when the ECMO blood flow increased as a percentage of CO, then the SaO2 increased. When the ECMO blood flow was ≥70% of CO, the median SaO2 was 96% (interquartile range 94–99; min–max 86–100). When ≤70% the median SaO2 was 92% (interquartile range 89–96, min–max 70–100). Discussion: The trend of the CO readings appeared to correlate with clinicians’ perceptions of CO changes although the absolute number did not always correlate. These trends allowed clinicians to readily identify a reason for a drop in SaO2 without further investigations. Conclusions: The device assists with guiding appropriate ECMO flows and troubleshooting episodes of arterial de-saturation taking into consideration potential pitfalls. http://dx.doi.org/10.1016/j.aucc.2013.02.020
87
The effect of feedback on compliance with the ventilator care bundle P. Lawrence-Baxter 1,∗ , P. Fulbrook 1,2,3 1
The Prince Charles Hospital, Australia Australian Catholic University, Australia 3 Australian College of Critical Care Nurses, Australia 2
Introduction: The ventilator care bundle (VCB) is a group of four evidence-based procedures (head of bed elevation; daily sedation hold and readiness to wean assessment; gastric ulcer prevention; deep vein thrombosis prophylaxis). Implemented as an ‘all or nothing’ strategy it may result in clinical outcome improvement. Aim: To measure the effect of audit and feedback on VCB compliance. Setting: two Queensland metropolitan general ICUs. Methods: Before–after design. De-identified data, relating to adult ventilated patients, were collected weekly, on a randomised day. Compliance was recorded simply, as ‘yes’ or ‘no’, and legitimate contraindications to each element were recorded as ‘yes’. Individual element, overall, and ‘all or nothing’ compliance with the VCB were calculated. In the second phase of the study, feedback about VCB compliance rates were provided to both ICUs and its effect on VCB compliance rates was measured. Results: Data were collected from 164 ‘before’ and 151 ‘after’ patient episodes. Overall VCB compliance increased from 89 to 91% and ‘all or nothing’ compliance increased from 65 to 68%. In one ICU, compliance with all four VCB elements increased whereas only two increased in the other. Both ICUs achieved 100% compliance with gastric ulcer prophylaxis for all 6 months of the second phase. Overall compliance was influenced by a significant fall in HOBE compliance in one ICU. Conclusions: Both ICUs’ overall VCB compliance rates were very good, and improved during the second 6 months. The relatively poor HOBE compliance is a cause of concern, but is consistent with the findings of previous research. http://dx.doi.org/10.1016/j.aucc.2013.02.021 Post traumatic stress disorder in relatives of patients admitted to an intensive care unit K. Sundararajan 1,∗ , M. Martin 2 , T.R. Sullivan 3 , M.J. Chapman 1 1
Discipline of Acute Care Medicine, University of Adelaide, Australia Traumatic Injuries Psychology Service, Royal Adelaide Hospital, Australia 3 Data Management and Analysis Centre, University of Adelaide, Australia 2
Background: There is a high risk of Post Traumatic Stress Disorder (PTSD) in relatives of intensive care unit (ICU) patients Aims: To determine the incidence and predictors of symptoms of PTSD in the relatives of an Australian critically ill population. Methods: One hundred and eight consecutive patients, staying >48 h in a mixed, level 3 ICU were identified. Eight were excluded because next of kin contact details were unavailable. On day 3 of admission their next of kin were contacted, consent was sought, and, if given, a phone questionnaire using Hospital Anxiety and Depression Scale, Impact of Event Scale Revised (IES-R), Short-Form General Health Survey, Royal Adelaide Hospital-ICU Family Satisfaction Survey, was performed 90 days post discharge from ICU. An IES-R score of >8.5 was used to define moderate, and >19 was used to define severe PTSD symptoms. Results: Thirty-seven subjects refused to participate. Thus a total of 63 family members were included, 49 of patients who survived. The incidence of PTSD symptoms was 49.21% (CI 36.38%,
88
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 26 (2013) 81–98
62.11%) for moderate and 7.94% (CI 2.63%, 17.56%) for severe. The anxiety score was found to be a significant predictor of moderate PTSD symptoms, with a one unit increase in the anxiety score being associated with a 12% increase in the risk of PTSD (relative risk = 1.12; 95% CI 1.06, 1.19; p = 0.0001). Conclusion: Many family members of ICU patients had PTSD symptoms. High anxiety scores were a significant predictor for developing moderate but not severe PTSD symptoms. http://dx.doi.org/10.1016/j.aucc.2013.02.022 Continuous veno-venous hemofiltration versus slow extended dialysis in acute renal failure critically ill patients with the use of cystatin c as an early biomarker for acute kidney injury H. Elkady Blacktown Hospital, Australia Introduction: Acute renal failure is a common complication of critical illness, which is associated with high mortality and has a separate independent effect on the risk of death. Objectives: To compare renal recovery and patient survival in critically ill patients developing acute renal failure using two modalities of continuous renal replacement therapy which were continuous venovenous hemofiltration and slow extended daily dialysis and to evaluate the prognostic value of serum Cystatin C in patients with acute renal failure. Methods: Prospective randomized controlled trial done on 20 adult critical patients with acute renal failure divided into 2 groups; Group A: 10 patients received CVVH, Group B: 10 patients received SLED with relevant investigations and measurements obtained through the time of the study, serum cystatin C was obtained at time of inclusion and after the end of renal replacement therapy. Patients with chronic renal insufficiency or obstructive uropathy were excluded. Results: Both groups were matched at the time of the inclusion to study. Results had been showing significant increase of MAP after therapy in SLED group, no significant difference between both groups in mortality, ICU LOS or renal recovery, Serum cystatin C was lower in CVVH group after therapy. Conclusions: 1. CVVH and SLED provided adequate hemodynamic stability, they were comparable regarding the incidence of complications, without significant difference in survival or renal recovery. 2. Early initiation of RRT was associated with better survival and restoration of renal functions. 3. SLED is a promising RRT that combines excellent detoxification and cardiovascular tolerability, even in severely ill patients. http://dx.doi.org/10.1016/j.aucc.2013.02.023 Estimation of fluid status changes after cardiac surgery fluid balance chart or electronic bed weight? A. Schneider 1,2,∗ , C. Thorpe 1 , K. Dellbridge 1 , G. Matalanis 1,2 , R. Bellomo 1,2 1 2
Warringal Private Hospital, Australia Austin Health, Australia
Introduction: Evaluating fluid status changes in the intensive care unit (ICU) is difficult. Previous studies have demonstrated a poor correlation between fluid balance (FB) and changes in body weight (BW) obtained with hospital beds. However, these studies included heterogeneous patients and low protocol observance.
Objectives: We sought to compare fluid balance estimates obtained by these two methods in cardiac surgery patients. Methods: All patients admitted to the Warringal Private ICU after cardiac surgery over a 7 month period were weighed twice daily (1200 and 2400 h) using electronic weighing beds (HillRomTM (Batesville, USA)). Differences in BW and FB between two consecutive twelve hours periods were compared. Additionally, the last weight before discharge was compared with that obtained on a regular scale on ward admission. Results: We obtained data in 83 consecutive patients. In total 319/425 (72.5%) BW values were obtained. We excluded 8 values (one for faulty bed calibration and seven for BW changes > 10 kg) and 179 pairs were analysed. The 12 h changes in BW and corresponding FB were only weakly correlated (r = 0.30, p < 0.001). On Bland–Altman plot, the limits of agreement were wide (−3.5 to 3.7 litres). These findings persisted after correction for insensible fluid losses and restriction to intubated patients. There was excellent correlation (r = 0.98) between weights obtained on ICU discharge and on ward admission. Conclusion: Even in a study setting, the correlation between changes in body weights and fluid balance was weak. Further studies are required to establish the reasons for this discrepancy. http://dx.doi.org/10.1016/j.aucc.2013.02.024
Adult Critical Care Posters Drawing the line: Behaviours and attitudes for fostering a safe and positive ICU culture C.N. Duncan Intensive Care Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia Winner: Best Nursing Poster Prize sponsored by Australian Catholic University
Introduction: In 2011 the Safety Attitudes Questionnaire (SAQ) was performed in the Sir Charles Gairdner Hospital Intensive Care Unit (ICU). Whilst survey results indicate a positive safety climate, we did not score as positively as comparable ICUs nationally and internationally. Anecdotal reports by nursing staff indicate unwillingness to address inappropriate or unsafe practice with peers, preferring instead to report to the Nurse Manager or Clinical Nurse Specialist. Objectives: • To determine attitudes and behaviours employees believe generate a safe and positive ICU culture. • To provide a framework for the cultural orientation of new nursing employees to the ICU. Methods: 113 nurses (76.3% nursing employees in ICU) participated in round table discussions. Nurses were asked to identify attitudes or behaviours that they felt were “Above or Below the Line”. Real-time discourse analysis was performed to identify attitudes or behaviours that generate a positive and safe ICU culture. Results: Comments were thematically coded into five domains: • • • • •
Teamwork, Honesty and ethics, Respect and caring, Excellence, Accountability.