Variability of structures in German intensive care units – a representative, nationwide analysis

The role of compression in large scale data transfer and storage of typical biomedical signals at hospitals

In modern hospitals, monitoring patients' vital signs and other biomedical signals is standard practice. With the advent of data-driven healthcare, Internet of medical things, wearable technologies, and machine learning, we expect this to accelerate and to be used in new and promising ways, including early warning systems and precision diagnostics. Hence, we see an ever-increasing need for retrieving, storing, and managing the large amount of biomedical signal data generated. The popularity of standards, such as HL7 FHIR for interoperability and data transfer, have also resulted in their use as a data storage model, which is inefficient. This article raises concern about the inefficiency of using FHIR for storage of biomedical signals and instead highlights the possibility of a sustainable storage based on data compression. Most reported efforts have focused on ECG signals; however, many other typical biomedical signals are understudied. In this article, we are considering arterial blood pressure, photoplethysmography, and respiration. We focus on simple lossless compression with low implementation complexity, low compression delay, and good compression ratios suitable for wide adoption. Our results show that it is easy to obtain a compression ratio of 2.7:1 for arterial blood pressure, 2.9:1 for photoplethysmography, and 4.1:1 for respiration.

Epidemiology, management, and outcome of infection, sepsis, and septic shock in a German emergency department (EpiSEP study)

BACKGROUND

The adjacent conditions infection, sepsis, and septic shock are among the most common causes of treatment in the emergency department (ED). Most available data come from intensive care units (ICU) and include nosocomial infections acquired during hospitalization. Epidemiological data from German EDs are not yet available, although the ED is one of the first points of contact for patients. The aim of this study was to investigate the epidemiology, causes, diagnosis, mortality, and treatment of patients with infections in the ED.

MATERIALS AND METHODS

In this retrospective, single-center observational study, routinely collected data from the patient data management system and from the hospital information system were analyzed. All adult patients who presented to the ED in connection with an infection during the study period from 01/01 to 28/02/2019 were included. Exclusion criteria were age ≤ 17 years and incomplete records. Three groups (I. Infection, II. Sepsis, and III. Septic shock) were defined according to SEPSIS-3 definitions.

RESULTS

During the study period, a total of 6,607 patients were treated in the ED. Of these patients, 19.3% (n = 1,278) had an infection (mean age 56 ± 23 years, 50% female). The sites of infection were distributed as follows: Respiratory tract 35%, genitourinary tract 18%, maxillofacial/ears/nose/throat 14%, intraabdominal 13%, soft tissues 10%, central nervous system 1%, other cause 3%, or unknown cause 6%. Infection only, sepsis and septic shock were present in 86, 10, and 3%, respectively. There were significant differences in vital signs as well as in the various emergency sepsis scores across the predefined groups [I vs. II vs. III: SOFA (pts.): 1 ± 1 vs. 4 ± 2 vs. 7 ± 3 (p < 0.0001), systolic blood pressure (mmHg): 137 ± 25 vs. 128 ± 32 vs. 107 ± 34 (p < 0.05), heart rate (bpm): 92 ± 18 vs. 99 ± 23 vs. 113 ± 30 (p < 0.05), respiratory rate (min-1): 18 ± 4 vs. 20 ± 7 vs. 24 ± 10 (p < 0.05)]. In the three groups, blood cultures were obtained in 34, 81, and 86%, of cases, respectively and antibiotics were administered in the ED in 50, 89, and 86%, of cases respectively. The 30-day mortality rate in the three groups was 1.6, 12.0, and 38.1%, respectively.

CONCLUSION

This study is the first to show the incidence, management, and outcome of patients classified as infection, sepsis, and septic shock in a German ED. The findings of our real-world data are important for quality management and enable the optimization of treatment pathways for patients with infectious diseases.

The Austrian ICU survey : A questionnaire-based evaluation of intensive care medicine in Austria

Background

While structures of intensive care medicine in Austria are well defined, data on organisational and medical practice in intensive care units (ICUs) have not been systematically evaluated.

Methods

In this explorative survey, organisational and medical details of ICUs in Austria were collected using an online questionnaire consisting of 147 questions.

Results

Out of 249 registered ICUs 73 (29.3%) responded, 60 were adult, 10 pediatric/neonatal ICUs and 19, 25 and 16 ICUs were located in level I, II and III hospitals, respectively. Of the respondents 89% reported that the ICU director was board-certified in intensive care medicine. Consultants were constantly present in 78% of ICUs during routine working hours and in 45% during nights and weekends. The nurse:bed ratio varied between 1:1 and 1:2 in 74% during day shifts and 60% during night shifts. Routine physiotherapist rounds were reported to take place daily except weekends in 67% of ICUs. Common monitoring techniques were reported to be in routine or occasional use in 85% and 83% of ICUs, respectively. The majority of ICUs provided daily visiting hours ranging between 2–12 h. Waiting rooms for relatives were available in 66% and an electronic documentation system in 66% of ICUs. Written protocols were available in 70% of ICUs.

Conclusion

The Austrian ICU survey suggests that ICUs in Austria are clearly structured, well-organized and well-equipped and have a high nurse:bed ratio. In view of the relatively low return rate we cannot exclude that a selection bias has led to overestimation of the survey findings.

Supplementary Information

The online version of this article (10.1007/s00508-021-02002-x) contains supplementary material, which is available to authorized users.

Outcomes sensitive to critical care nurse staffing levels: A systematic review

OBJECTIVE

To determine associations between variations in registered nurse staffing levels in adult critical care units and outcomes such as patient, nurse, organisational and family outcomes.

METHODS

We published and adhered to a protocol, stored in an open access repository and searched for quantitative studies written in the English language and held in CINAHL Plus, MEDLINE, PsycINFO, SCOPUS and NDLTD databases up to July 2020. Three authors independently extracted data and critically appraised papers meeting the inclusion criteria. Results are summarised in tables and discussed in terms of strength of internal validity. A detailed review of the two most commonly measured outcomes, patient mortality and nosocomial infection, is also presented.

RESULTS

Our search returned 7960 titles after duplicates were removed; 55 studies met the inclusion criteria. Studies with strong internal validity report significant associations between lower levels of critical care nurse staffing and increased odds of both patient mortality (1.24-3.50 times greater) and nosocomial infection (3.28-3.60 times greater), increased hospital costs, lower nurse-perceived quality of care and lower family satisfaction. Meta-analysis was not feasible because of the wide variation in how both staffing and outcomes were measured.

CONCLUSIONS

A large number of studies including several with high internal validity provide evidence that higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However, inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to translate findings into recommendation for safe staffing in critical care.

Importance of acute cardiac care registries at the national level

Improving organization and patient care quality in intensive care units is increasingly important as intensive care unit diagnostic and therapeutic procedures account for a growing proportion of hospital services. We identified the lack of comprehensive national and international registries available in the contemporary literature. This paper aims to describe and analyze cardiac intensive care unit (CICU) network at the national level in Croatia and its comparison with more developed countries. Thirty-four representatives from all Croatian acute hospitals (response rate of 100%) filled in a web based questionnaire on CICU organization and competence during September and October 2016. Organization and available technical procedures for health care in general, and especially in very expensive CICU treatment, highly depends on gross domestic product (GDP) per capita. That is why one could expect that Croatia, with the second lowest GDP among European Union countries and 4.7 CICU per million inhabitants will have worse results in this field in comparison with most of these countries. Results such as one nurse responsible for a mean of 2.7 CICU patients, 52% of cardiologists among physicians during working hours but 37% during night shifts, 24/7 transesophageal echocardiography in only 26.5% of CICUs, one-third without therapeutic hypothermia, and 23.5% without extracorporeal membrane oxygenation treatment are some of these results, revealing much room for improvement. This representative, nationwide sample of Croatian CICUs also demonstrated considerable variation of key elements of structures with respect to hospital size, academic status and financial issues, as well as a trend towards current guidelines. This kind of investigation is very important for proposing standards, reimbursement master plan, or quality assessment of the national health system.

Bacterial sepsis : Diagnostics and calculated antibiotic therapy

The mortality of patients with sepsis and septic shock is still unacceptably high. An effective calculated antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed infection and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account during the selection of anti-infective treatment. Many pathophysiologic alterations influence the pharmacokinetics (PK) of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of β‑lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM, but for continuous infusion, TDM is generally necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug-resistant (MDR) pathogens in the intensive care unit. For effective treatment, antibiotic stewardship teams (ABS teams) are becoming more established. Interdisciplinary cooperation of the ABS team with infectious disease (ID) specialists, microbiologists, and clinical pharmacists leads not only to rational administration of antibiotics, but also has a positive influence on treatment outcome. The gold standards for pathogen identification are still culture-based detection and microbiologic resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction(PCR)-based procedures for pathogen identification and resistance determination are currently only an adjunct to routine sepsis diagnostics, due to the limited number of studies, high costs, and limited availability. In complicated septic courses with multiple anti-infective therapies or recurrent sepsis, PCR-based procedures can be used in addition to treatment monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically (still) absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation). (Contribution available free of charge by "Free Access" [ https://link.springer.com/article/10.1007/s00101-017-0396-z ].).

[Bacterial sepsis : Diagnostics and calculated antibiotic therapy]

The mortality of patients with sepsis and septic shock is still unacceptably high. An effective antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed focus and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account for selection of anti-infection treatment. Many pathophysiological alterations influence the pharmacokinetics of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of beta-lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM but for continuous infusion TDM is basically necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug resistant pathogens (MDR) in the intensive care unit. For effective treatment antibiotic stewardship teams (ABS team) are becoming more established. Interdisciplinary cooperation of the ABS team with infectiologists, microbiologists and clinical pharmacists leads not only to a rational administration of antibiotics but also has a positive influence on the outcome. The gold standards for pathogen detection are still culture-based detection and microbiological resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction (PCR)-based procedures for pathogen identification and resistance determination, are currently only an adjunct to routine sepsis diagnostics due to the limited number of studies, high costs and limited availability. In complicated septic courses with multiple anti-infective treatment or recurrent sepsis, PCR-based procedures can be used in addition to therapy monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation).

Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study

Background

Despite the central role of nurses in intensive care, a relationship between intensive care nurse workload/staffing ratios and survival has not been clearly established. We determined whether there is a threshold workload/staffing ratio above which the probability of hospital survival is reduced and then modeled the relationship between exposure to inadequate staffing at any stage of a patient’s ICU stay and risk-adjusted hospital survival.

Methods

Retrospective analysis of prospectively collected data from a cohort of adult patients admitted to two multi-disciplinary Intensive Care Units was performed. The nursing workload [measured using the Therapeutic Intervention Scoring System (TISS-76)] for all patients in the ICU during each day to average number of bedside nurses per shift on that day (workload/nurse) ratio, severity of illness (using Acute Physiology and Chronic Health Evaluation III) and hospital survival were analysed using net-benefit regression methodology and logistic regression.

Results

A total of 894 separate admissions, representing 845 patients, were analysed. Our analysis shows that there was a 95% probability that survival to hospital discharge was more likely to occur when the maximum workload-to-nurse ratio was <40 and a more than 95% chance that death was more likely to occur when the ratio was >52. Patients exposed to a high workload/nurse ratio (≥52) for ≥1 day during their ICU stay had lower risk-adjusted odds of survival to hospital discharge compared to patients never exposed to a high ratio (odds ratio 0.35, 95% CI 0.16–0.79).

Conclusions

Exposing critically ill patients to high workload/staffing ratios is associated with a substantial reduction in the odds of survival.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0269-2) contains supplementary material, which is available to authorized users.

[Methods for endotracheal tube fixation. Results of a survey of intensive care nurses]

There are a wide variety of strategies and methods used in securing and managing the oral endotracheal tube and mouth and oral care in German clinical intensive care nursing for mechanically ventilated patients. There are no nationally recognized guidelines or recommendations on this topic. A survey among intensive care nurses identified the most widely used nursing strategies and methods. Regarding the results of the survey and international literature findings, the commonly used strategies and methods are discussed. Following these discussions, there are recommendations for improving nursing care of orally intubated patients in intensive care, including the aspects of evidence identified, currently used methods and patient needs. Also included are aspects of patient safety, potential complications and quality-orientated nursing care within a system having limited overall nursing care resources.

The impact of staffing on central venous catheter-associated bloodstream infections in preterm neonates - results of nation-wide cohort study in Germany

Background

Very low birthweight (VLBW) newborns on neonatal intensive care units (NICU) are at increased risk for developing central venous catheter-associated bloodstream infections (CVC BSI). In addition to the established intrinsic risk factors of VLBW newborns, it is still not clear which process and structure parameters within NICUs influence the prevalence of CVC BSI.

Methods

The study population consisted of VLBW newborns from NICUs that participated in the German nosocomial infection surveillance system for preterm infants (NEO-KISS) from January 2008 to June 2009. Structure and process parameters of NICUs were obtained by a questionnaire-based enquiry. Patient based date and the occurrence of BSI derived from the NEO-KISS database. The association between the requested parameters and the occurrance of CVC BSI and laboratory-confirmed BSI was analyzed by generalized estimating equations.

Results

We analyzed data on 5,586 VLBW infants from 108 NICUs and found 954 BSI cases in 847 infants. Of all BSI cases, 414 (43%) were CVC-associated. The pooled incidence density of CVC BSI was 8.3 per 1,000 CVC days. The pooled CVC utilization ratio was 24.3 CVC-days per 100 patient days. A low realized staffing rate lead to an increased risk of CVC BSI (OR 1.47; p=0.008) and also of laboratory-confirmed CVC BSI (OR 1.78; p=0.028).

Conclusions

Our findings show that low levels of realized staffing are associated with increased rates of CVC BSI on NICUs. Further studies are necessary to determine a threshold that should not be undercut.

[Influence of personnel staffing on patient care and nursing in German intensive care units. Descriptive study on aspects of patient safety and stress indicators of nursing]

In this article selected results of a descriptive study on personnel staffing and patient care in German intensive care units are presented and discussed. The main focus is on comparing features of personnel staffing with indicators of the job situation and patient care. The study is based on a standardized survey of nursing managers from 535 intensive care units carried out in 2011. The results show that a low nurse-patient ratio in intensive care units has a tendency to cause higher risks in patient care and also in other stress indicator situations, such as absenteeism.

[Safety in intensive care medicine. Can we learn from aviation?]

Safety is of extraordinary value in commercial aviation. Therefore, sophisticated and complex systems have been developed to ensure safe operation. Within this system, the pilots are of specific concern: they form the human-machine interface and have a special responsibility in controlling and monitoring all aircraft systems. In order to prepare pilots for their challenging task, specific selection of suitable candidates is crucial. In addition, for every commercial pilot regulatory requirements demand a certain number of simulator training sessions and check flights to be completed at prespecified intervals. In contrast, career choice for intensive care medicine most likely depends on personal reasons rather than eligibility or aptitude. In intensive care medicine, auditing, licensing, or mandatory training are largely nonexistent. Although knowledge of risk management and safety culture in aviation can be transferred to the intensive care unit, the diversity of corporate culture and tradition of leadership and training will represent a barrier for the direct transfer of standards or procedures. To accomplish this challenging task, the analysis of appropriate fields of action with regard to structural requirements and the process of change are essential.