Effect of ICU care bundles on long-term patient-relevant outcomes: a scoping review

Extending the interval for changing flushing solutions for central venous and arterial line systems in the intensive care unit: An evidence-based quality improvement project

BACKGROUND

Central venous lines (CVLs) and arterial lines (ALs) are commonly used for patients in the intensive care units (ICUs) to facilitate the administration of medications and haemodynamic monitoring. In an ICU in Queensland, Australia (AU), saline (sodium chloride 0.9%) flush bags used for these lines were routinely changed every 24 h following organizational policy that all intravenous fluid bags are to be changed within a 24-h period.

AIM

This quality improvement (QI) project aimed to evaluate current practice guided by the Plan-Do-Study-Act (PDSA) model of QI and implementation science. Benchmarking practices with other ICUs was conducted.

STUDY DESIGN

A narrative literature review focused on evaluating the safe interval for changing flush solutions every 24 h was performed using EBSCO Medline, CINAHL, Cochrane Library, Embase and Google Scholar databases for citations up to November 2022. Bloodstream infection rates attributed to CVLs and/or ALs were monitored. Economic analysis was performed. End-user feedback was sought. A change of practice was implemented for a 1-year study period (March 2023 - March 2024) to extend dwell times of flushing solutions for CVLs and ALs from every 24 h to every 96 h.

RESULTS

One-year post-implementation, no bloodstream infections were linked to CVLs or ALs. A simplified economic analysis was performed based on costs of 0.9% sodium chloride 500-mL fluid bags, which revealed that changing the fluid bags once every 96 h resulted in a per patient saving of AU$3.21 for any individual AL or CVL and up to AU$6.42 per patient where both an AL and CVL are in situ, based on fluid bag cost at AU$1.07 per bag. This saving excludes potential savings from reduced nursing time, infection-related costs and recycling costs.

CONCLUSION

A sustainable practice change based on evidence was implemented in the local ICU. The use of the PDSA model of the QI process and the principles of implementation science strengthened the buy-in and implementation of the project.

RELEVANCE TO CLINICAL PRACTICE

This practice change was examined through lenses of evidence-based practice, environmental sustainability (minimizing environmental footprint by limiting plastic bag usage), patient safety, cost minimization, and reduced nursing workload.

Creating a Culture of an Awake and Walking Intensive Care Unit: In-Hospital Strategies to Mitigate Post-Intensive Care Syndrome

The ABCDEF bundle and Awake and Walking intensive care unit (ICU) approach aim to prevent the long-term consequences of critical illness (ie, post-intensive care syndrome) by promoting patient wakefulness, cognition, and mobility. Humanizing the ICU experience is the key, preserving patients' function and autonomy. Successful implementation requires cultivating an ICU culture focused on avoiding sedatives and initiating prompt mobilization, addressing organizational barriers through tailored strategies. Overall, these patient-centered, mobility-focused models offer a holistic solution to the complex challenge of preventing post-intensive care syndrome and supporting critical illness survivors.

Health Equity in the Care of Adult Critical Illness Survivors

There is evidence that people who fare worse in recovery do so, not only because of their illness, but also because of social and structural determinants. For example, food insecurity and poor nutrition, unemployment, poverty, social isolation and loneliness, limited social support, and poor access to medical care represent marked obstacles to recovery. Those who experience social or structural disadvantage have a poor start to their critical illness journey and are more vulnerable to adverse material conditions that contribute to and worsen their health outcomes.

[Post-Intensive Care Syndrome: functional impairments of critical illness survivors]

With a decrease in mortality of critically ill patients in recent years, intensive care medicine research has shifted its focus on functional impairments of intensive care units (ICU) survivors. ICU survivorship is characterized by long-term impairments of cognition, mental health, and physical health. Since 2012, these impairments have been summarized with the umbrella term Post-Intensive Care Syndrome (PICS). Mental health impairments frequently entail new are aggravated symptoms of depression, anxiety, and posttraumatic stress disorder. Beyond impairments in the three PICS domains, critical illness survivors frequently suffer from chronic pain, dysphagia, and nutritional deficiencies. Furthermore, they have a higher risk for osteoporosis, bone fractures, and diabetes mellitus. Taken together, these sequelae reduce their health-related quality of life. Additionally, ICU survivors are challenged by social problems such as isolation, economic problems such as treatment costs and lost earnings, and return to previous employment. Yet, patients and caregivers have described post-ICU care as inadequate and fragmented. ICU follow-up clinics could improve post-ICU care, but there is insufficient evidence for their effectiveness. Thus far, large high-quality trials with multicomponent and interdisciplinary post-ICU interventions have mostly failed to improve patient outcomes. Hence, preventing PICS and minimizing risk factors by optimizing ICU care is crucial, e.g. by implementing the ABCDE bundle. Future studies need to identify effective components of post-ICU recovery interventions and determine which patient populations may benefit most from ICU recovery services.

Quality improvement collaborative for improving patient care delivery in Argentine public health sector intensive care units

BACKGROUND

The demand for healthcare services during the COVID-19 pandemic was excessive for less-resourced settings, with intensive care units (ICUs) taking the heaviest toll.

OBJECTIVE

The aim was to achieve adequate personal protective equipment (PPE) use in 90% of patient encounters, to reach 90% compliance with objectives of patient flow (OPF) and to provide emotional support tools to 90% of healthcare workers (HCWs).

METHODS

We conducted a quasi-experimental study with an interrupted time-series design in 14 ICUs in Argentina. We randomly selected adult critically ill patients admitted from July 2020 to July 2021 and active HCWs in the same period. We implemented a quality improvement collaborative (QIC) with a baseline phase (BP) and an intervention phase (IP). The QIC included learning sessions, periods of action and improvement cycles (plan-do-study-act) virtually coached by experts via platform web-based activities. The main study outcomes encompassed the following elements: proper utilisation of PPE, compliance with nine specific OPF using daily goal sheets through direct observations and utilisation of a web-based tool for tracking emotional well-being among HCWs.

RESULTS

We collected 7341 observations of PPE use (977 in BP and 6364 in IP) with an improvement in adequate use from 58.4% to 71.9% (RR 1.2, 95% CI 1.17 to 1.29, p<0.001). We observed 7428 patient encounters to evaluate compliance with 9 OPF (879 in BP and 6549 in IP) with an improvement in compliance from 53.9% to 67% (RR 1.24, 95% CI 1.17 to 1.32, p<0.001). The results showed that HCWs did not use the support tool for self-mental health evaluation as much as expected.

CONCLUSION

A QIC was effective in improving healthcare processes and adequate PPE use, even in the context of a pandemic, indicating the possibility of expanding QIC networks nationwide to improve overall healthcare delivery. The limited reception of emotional support tools requires further analyses.

Effects of cluster nursing interventions on the prevention of pressure ulcers in intensive care units patients: A meta-analysis

A meta-analysis was conducted to comprehensively evaluate the impact of cluster nursing interventions on the prevention of pressure ulcers (PUs) in intensive care unit (ICU) patients. Computer searches were performed in databases including Embase, Google Scholar, Cochrane Library, PubMed, Wanfang and China National Knowledge Infrastructure for randomized controlled trials (RCTs) implementing cluster nursing interventions for PUs prevention in ICU patients, with the search period covering the database inception to November 2023. Two researchers independently screened the literature, extracted data and conducted quality assessments. Stata 17.0 software was employed for data analysis. Overall, 17 RCTs involving 1463 ICU patients were included. The analysis showed that compared with conventional nursing, cluster nursing interventions significantly reduced the incidence of PUs (odds ratio: 0.24, 95% confidence intervals [CI]: 0.17-0.34, p < 0.001) and also significantly improved the levels of anxiety (standardized mean difference [SMD]: -1.39, 95% CI: -1.57 to 1.22, p < 0.001) and depression (SMD: -1.64, 95% CI: -2.02 to 1.26, p < 0.001) in ICU patients. This study indicates that the application of cluster nursing interventions in ICU patients can effectively reduce the incidence of PUs, as well as improve patients' anxiety and depression levels, thereby enhancing their quality of life, which is worth clinical promotion and application.

A multicomponent intervention program to Prevent and Reduce AgItation and phySical rEstraint use in the ICU (PRAISE): study protocol for a multicenter, stepped-wedge, cluster randomized controlled trial

BACKGROUND

Physical restraints remain to be commonly used in agitated intensive care unit (ICU) patients worldwide, despite a lack of evidence on efficacy and safety and reports of detrimental short and long-term consequences, such as prolonged delirium and a longer ICU length of stay. Physical restraint minimization approaches have focused mainly on educational strategies and other non-pharmacological interventions. Combining these interventions with goal-directed light sedation therapy if needed may play an important contributory role in further reducing the use of physical restraints. The aim of the study is to determine the effectiveness of a multicomponent intervention (MCI) program, combining person-centered non-pharmacological interventions with goal-directed light sedation, compared to physical restraints.

METHODS

A multicenter stepped-wedge cluster randomized controlled trial will be conducted in six Dutch ICUs. A power calculation based total of 480 (expected to become) agitated adult patients will be included in 26 months with a subsequent 2-year follow-up. Patients included in the control period will receive standard care with the current agitation management protocol including physical restraints. Patients included in the intervention period will be treated with the MCI program, consisting of four components, without physical restraints: education of ICU professionals, identification of patients at risk for agitation, formulation of a multidisciplinary person-centered care plan including non-pharmacological and medical interventions, and protocolized goal-directed light sedation using dexmedetomidine. Primary outcome is the number of days alive and outside of the ICU within 28 days after ICU admission. Secondary outcomes include length of hospital stay; 3-, 12-, and 24-month post-ICU quality of life; physical (fatigue, frailty, new physical problems), mental (anxiety, depression, and post-traumatic stress disorder), and cognitive health; and 1-year cost-effectiveness. A process evaluation will be conducted.

DISCUSSION

This will be the first multicenter randomized controlled trial determining the effect of a combination of non-pharmacological interventions and light sedation using dexmedetomidine compared to physical restraints in agitated ICU patients. The results of this study, including long-term patient-centered outcomes, will provide relevant insights to aid ICU professionals in the management of agitated patients.

TRIAL REGISTRATION

NCT05783505, registration date 23 March 2023.

Biomarkers of neuropsychiatric dysfunction in intensive care unit survivors: a prospective cohort study

OBJECTIVE

To assess factors associated with long-term neuropsychiatric outcomes, including biomarkers measured after discharge from the intensive care unit.

METHODS

A prospective cohort study was performed with 65 intensive care unit survivors. The cognitive evaluation was performed through the Mini-Mental State Examination, the symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale, and posttraumatic stress disorder was evaluated using the Impact of Event Scale-6. Plasma levels of amyloid-beta (1-42) [Aβ (1-42)], Aβ (1-40), interleukin (IL)-10, IL-6, IL-33, IL-4, IL-5, tumor necrosis factor alpha, C-reactive protein, and brain-derived neurotrophic factor were measured at intensive care unit discharge.

RESULTS

Of the variables associated with intensive care, only delirium was independently related to the occurrence of long-term cognitive impairment. In addition, higher levels of IL-10 and IL-6 were associated with cognitive dysfunction. Only IL-6 was independently associated with depression. Mechanical ventilation, IL-33 levels, and C-reactive protein levels were independently associated with anxiety. No variables were independently associated with posttraumatic stress disorder.

CONCLUSION

Cognitive dysfunction, as well as symptoms of depression, anxiety, and posttraumatic stress disorder, are present in patients who survive a critical illness, and some of these outcomes are associated with the levels of inflammatory biomarkers measured at discharge from the intensive care unit.