Impact of Standardized Multidisciplinary Critical Care Training on Confidence with Critical Illness and Attitudes Towards Interprofessional Education and Multidisciplinary Care

INTRODUCTION

The Fundamental Critical Care Support Course (FCCS) is a standardized multidisciplinary program designed to educate participants on the basics of identification and management of patients with critical illness. Our objective was to evaluate the effect of FCCS participation on confidence in the assessment and management of critically ill patients and attitudes towards multidisciplinary education and interprofessional care in a multidisciplinary group of participants.

METHODS

Participants enrolled in the FCCS course from May 2018 to November 2019 were solicited to participate in a series of surveys evaluating their course experience and confidence in critical care. Attitudes towards multidisciplinary education and interprofessional care were evaluated using the Student Perceptions of Interprofessional Clinical Education-Revised Instrument version 2 (SPICE-R2) tool. A prospective pre- and post-design with a self-report survey including retrospective pre-training assessment and a 3-month follow-up was conducted. Statistical analysis was performed using descriptive statics and non-parametric methods.

RESULTS

321 (97.9%) of the course participants enrolled in the study and completed the confidence survey and SPICE-R2 tool pre-course. Nurses (113, 35.4%) and physicians (110, 34.4%) made up the largest groups of participants, although physician assistants and paramedics were also well represented. Confidence in recognition and management of critical illness significantly improved across all studied domains after course completion, with the mean total confidence score improving from 32.96 pre-course to 41.10 post-course, P < 0.001. Attitudes towards multidisciplinary education and interprofessional care also improved (mean score 41.37 pre-course vs 42.71 post-course, P < 0.001), although pre-course numbers were higher than expected which limited the significance to only certain domains.

DISCUSSION

In a multidisciplinary group, completion of FCCS training led to increased confidence in all aspects of critical illness measured. A modest increase in attitudes regarding multidisciplinary education and interprofessional care was also demonstrated. Further study is needed to assess whether this increased confidence translates to improvements in patient care and outcomes.

Decreasing catheter colonization through the use of an antiseptic-impregnated catheter: a continuous quality improvement project

STUDY OBJECTIVES

To evaluate the use of an antiseptic-impregnated (chlorhexidine and silver sulfadiazine) catheter for the prevention of catheter colonization and catheter-related bloodstream infection (CR-BSI). Then, based on these findings, to implement changes in hospital policy and to assess their effect on a hospital service.

DESIGN

Prospective, randomized, controlled (phase I); prospective, concurrent data collection (phase II).

SETTING

Tertiary referral hospital with level 1 trauma center.

PATIENTS

Patients > 12 years of age with central venous catheters placed while they were in the emergency room, neurotrauma ICU, or medical/surgical ICU from May through December, 1995 (phase I). All patients > 12 years of age on the trauma service admitted from November 16, 1996, through November 15, 1997 (phase II).

INTERVENTIONS

Randomization table determined whether the patient would receive an antiseptic-impregnated catheter (AIC) or nonimpregnated catheter (NIC) (phase I). All removed or exchanged catheters were sent for semiquantitative culture. In phase II, only AICs were used; "length of time" and "fever" were discouraged as reasons for catheter exchange or removal; and only the tip was sent for culture.

MEASUREMENTS AND RESULTS

In phase I, there were 139 catheters placed in 60 patients in the NIC group and 98 catheters placed in 55 patients in the AIC group. Two catheters (2.0/100 catheters) in the AIC group were found to be colonized, compared with 25 (18.0/100 catheters) in the NIC group (p = 0.001). The catheter colonization rates were 2.27/1,000 catheter days (AIC) and 24.68/1,000 catheter days (NIC) (p < 0.001), while the CR-BSI rates were 1.14/1,000 catheter days (AIC) and 3.9.5/1,000 catheter days (NIC) (p = 0.31). The reason for each catheter removal/exchange was noted, and only "positive blood culture" was statistically significant overall. The tip segment was found to be positive more often than the intracutaneous segment. In phase II, there were 213 AICs placed in 101 patients. The colonization rate was 3.8/100 catheters (4.52/1,000 catheter days), and CR-BSI rate was 1.0/100 catheters (0.6/1,000 catheter days). The colonization rate for catheters left in place remained low for catheters left in place < 14 days (1.6/100 catheters). Only 11% of catheters were exchanged/removed for reason of "fever," as compared with 23% in phase I.

CONCLUSIONS

AICs significantly reduce the rate of central venous catheter colonization. In addition, the apparent protective effects of the catheter over time permit less frequent exchanges or removals of the catheters, decreasing both patient risk and hospital cost.

Management of renal trauma at a rural, level I trauma center

Appropriate management of renal trauma is controversial. Successful outcome and long term complication rates are not well defined. In an effort to evaluate management options, outcomes, and complications of renal injuries, we conducted a retrospective review of all trauma patients admitted to the trauma service from January 7, 1989 through August 31, 1995. Inpatient and outpatient charts were reviewed for type and mechanism of injury, radiologic studies utilized, method of treatment, and short and long term complications. Fifty-five patients were identified with renal injuries. Most injuries were parenchymal injuries due to blunt trauma. Only nine patients with renal artery injuries and four patients with collecting system injuries were identified. CT scan was the most commonly used study to identify renal injuries. All nine renal artery injuries were due to blunt trauma and were initially diagnosed by CT scan. Six were confirmed with arteriogram, and two with renal scans. Of the seven patients seen in follow-up (average 153 days), there were three complications: one patient with small bowel obstruction and two patients with hypertension. Among the 47 patients with parenchymal injuries, including 4 patients with collecting system injuries, there were 2 with complications: an intraoperative ureteral transection and a urinoma. Both complications were treated successfully with a ureteral stent. Five deaths occurred in the entire group; none were related to renal injury. Thirteen patients underwent laparotomy for associated injuries only. Eight patients underwent surgical treatment for their renal injury, including five nephrectomies. The nephrectomy rate among those patients who underwent laparotomy as part of their initial management was 20 per cent, versus 3 per cent for those patients initially managed nonoperatively. Thus, most renal injuries can be managed nonoperatively with a low incidence of complications. The incidence of long-term complications after renal artery injuries and the appropriate management of these patients deserves further study.

Management of splenic trauma at a rural, Level I trauma center

The spleen is the most commonly injured organ in blunt abdominal trauma. There remains much controversy in the diagnosis and management of the injured spleen, with a recent trend toward nonoperative management. A 5-year period was reviewed at a rural, Level I trauma center to address issues of operative versus nonoperative management. During this time period, there were 136 patients identified as having trauma to the spleen. Most (95%) were the result of blunt trauma, and a majority of these were from motor vehicle accidents. Computed tomography was the most frequent method of diagnosis. Approximately half of the patients underwent immediate operative intervention. Of those initially observed, 10 patients (16%) eventually were operated on. Most of the cases were due to underestimation of the severity of the splenic injury, and most received blood transfusion. This experience suggests that observation for splenic trauma is appropriate in many cases, as long as the surgeon is certain the spleen is not actively bleeding and the patient will not require blood transfusion.

Laparoscopic examination of the traumatized spleen with blood salvage for autotransfusion

The management of splenic trauma presents a dilemma to the surgeon, who must weigh the risks of operative versus nonoperative management. Laparoscopy has been used increasingly for trauma cases to decrease the morbidity associated with standard laparotomy. Autotransfusion of the patient's shed blood has also become widespread to decrease the risks associated with transfusion. We describe the case of a 15-year-old male with blunt splenic trauma, in which laparoscopy was used to examine the spleen to ascertain the need for operative treatment, to look for other intra-abdominal injuries, and to salvage intraperitoneal blood for autotransfusion. In this case, laparoscopy determined that laparotomy would be nontherapeutic, and that autotransfusion could obviate the need for banked-blood transfusion.

Spontaneous migration of subcutaneous central venous catheters

Along with the increasing use of central venous catheters have come an increasing number of complications. Although many are discovered at the time of insertion, others can occur at a later time. If unrecognized, problems may ensue. We describe two cases of spontaneous migration of subcutaneous venous access catheters to illustrate the importance of early recognition and treatment. In one case, the patient was asymptomatic at the time the migration was discovered, and the catheter was removed. However, in the second case, the patient required hospitalization for sepsis following clot formation around a catheter whose tip was in the internal jugular vein. Migration of a central venous catheter can lead to a number of cardiovascular, neurologic, and infectious complications. Although a number of methods of nonoperative intervention have been used to correct the position of central venous catheters, it is difficult to fix a subcutaneous port, because the entire device is implanted under the skin. Removal and replacement are usually required, especially if the catheter is not in the ideal location after initial placement.

The role of ultrasonography in blunt abdominal trauma: a prospective study

The evaluation of blunt abdominal trauma (BAT) can be difficult because of the subtle manifestations of the injuries and because assessment is hampered by altered neurologic status. Short of laparotomy, CT and diagnostic peritoneal lavage provided the best means of accurately diagnosing intra-abdominal injury. Ultrasound (US) has recently been introduced into trauma centers in the United States as a quick, cheap, and safe method to make the diagnosis of BAT. After theoretical and practical training, one attending surgeon and one chief resident began performing trauma ultrasounds at a rural, Level 1 trauma center. The US was performed concurrent with initial resuscitation and prior to other studies. The US was then correlated with the other tests. Of the 82 tests performed, 79 correlated with other methods of diagnosis. Overall, US was 88 per cent sensitive, 98 per cent specific, and 96 per cent accurate in diagnosing intra-abdominal injuries. There were no operative sequelae to patients whose injury was missed by US. We conclude that: 1) US can be used as the initial method of diagnosis of BAT and 2) surgeons are able to perform the examination accurately.

Endometriosis of the colon. Its diagnosis and management

Cases of endometriosis of the colon were examined in a retrospective fashion to illustrate the problems in diagnosis and management of this disease entity. Nine patients were identified from 1956 to 1988; their average age was 41 years. Common presenting symptoms were abdominal pain, diarrhea, constipation, tenesmus, small caliber stools, abdominal distention, and blood per rectum. Bowel symptoms were cyclic in four of the nine patients, and seven had a history of gynecologic complaints. Barium enema was performed in six patients and endoscopy in five patients. All cases involved the sigmoid or rectosigmoid colon. In no case was the diagnosis established endoscopically. Surgical procedures included resection with primary anastomosis (6 patients), and resection with sigmoid endcolostomy and Hartmann's pouch (3 patients). In only one case was full-thickness colonic wall involvement noted. One patient had an adenocarcinoma of the colon adjacent to the area of endometriosis. Our data indicate that the diagnosis of endometriosis of the colon should be considered in women with colonic symptoms, especially with an associated history of dysmenorrhea or cyclic changes in bowel habits. Surgical resection offers the best chance for relief of symptoms.