Comparing Outcomes of Critically Ill Patients in Intensive Care Units and General Wards: A Comprehensive Analysis

Background

The admission of critically ill patients to intensive care unit (ICU) plays a crucial role in reducing mortality. However, the scarcity of available ICU beds presents a significant challenge. In resource-limited settings, the outcomes of critically ill patients, particularly those who are not accepted for ICU admission, have been a topic of ongoing debate and contention.

Objective

This study aimed to explore the outcomes and factors associated with ICU admission and mortality among critically ill patients in Thailand.

Methods

This prospective cohort study enrolled critically ill adults indicated for medical ICU admission. Patients were followed for 28 days regardless of whether they were admitted to an ICU. Data on mortality, hospital length of stay, duration of organ support, and factors associated with mortality and ICU admission were collected.

Results

Of the 180 patients enrolled, 72 were admitted to ICUs, and 108 were cared for in general wards. The ICU group had a higher 28-day mortality rate (44.4% vs 20.4%; P=0.001), but other outcomes of interest were comparable. Multivariate analysis identified alteration of consciousness, norepinephrine use, and epinephrine use as independent predictors of 28-day mortality. Higher body mass index (BMI), higher APACHE II score, and acute kidney injury were predictive factors associated with ICU acceptance.

Conclusion

Among patients indicated for ICU admission, those who were admitted had a higher 28-day mortality rate. Higher mortality was associated with alteration of consciousness and vasopressor use. Patients who were sicker and had higher BMI were more likely to be admitted to an ICU.

The Effectiveness of NIV and CPAP Training on the Job in COVID-19 Acute Care Wards: A Nurses' Self-Assessment of Skills

Background: Noninvasive ventilation (NIV) in COVID-19 patients outside of intensive care unit (ICU) settings was a feasible support during the pandemic outbreak. The aim of this study was to assess the effectiveness of an “on the job” NIV training program provided to 66 nurses working in 3 COVID-19 wards in an Italian university hospital. Methods: A quasi-experimental longitudinal before−after study was designed. The NIV Team education program, provided by expert ICU nurses, included: 3 h sessions of training on the job during work-shifts about the management of helmet-continuous positive airway pressure (CPAP) Venturi systems, and NIV with oronasal and full-face masks. An eleven-item “brief skills self-report tool” was administered before and after the program to explore the perception of NIV education program attendees about their level of skills. Results: In total, 59 nurses responded to the questionnaire. There was an improvement in the skill levels of the management of Helmet-CPAP (median before training 2, inter-quartile range (IQR) 0−6; median after training 8, IQR 3−9; p < 0.0001), and mask-NIV (median before training 2, IQR 0−6; median after training 8, IQR 3−9; p < 0.0001). Conclusions: Training on the job performed by expert ICU nurses can be a valuable and fast means to implement new Helmet-CPAP and mask-NIV skills outside of ICUs.

Comparison of the Outcomes of Patients Starting Mechanical Ventilation in the General Ward Versus the Intensive Care Unit

OBJECTIVE

Mechanical ventilation is sometimes initiated in the general ward (GW) due to the shortage of intensive care unit (ICU) beds. We investigated whether invasive mechanical ventilation (MV) started in the GW affects the patient's prognosis compared with its initiation in the ICU.

METHODS

From January 2016 to December 2018, medical records of patients who started MV in the GW or ICU were collected. The 28-day mortality, ICU mortality, ventilator-free days, and complications related to the ventilator and the ventilator-free days were analyzed as outcomes.

RESULTS

A total of 673 patients were enrolled. Among these, 268 patients (39.8%) started MV in the GW and 405 patients (60.2%) started MV within 24 hours after admittance to the ICU. There was no difference in 28-day mortality between the 2 groups (27.2% versus 27.2%, P = 0.997). In addition, there was no difference between ventilator-related complication rates, ventilator-free days, or the length of hospital stay. A high Acute Physiology and Chronic Health Evaluation II score, the presence of solid tumor, the absence of chronic kidney diseases, and low platelet count were associated with higher 28-day mortality. However, the initiation of MV in the GW was not associated with an increase in 28-day mortality compared with the initiation in the ICU.

CONCLUSIONS

Starting MV in the GW was not a risk factor for 28-day mortality. Therefore, prompt application of a ventilator if medically indicated, regardless of the patient's location, is desirable if a skilled airway team and appropriate monitoring are available.

One-Year Follow up of Noninvasive Respiratory Support in General Wards

BACKGROUND

Noninvasive respiratory support (NRS) has been used to treat acute respiratory failure outside the ICU, but existing data have left many knowledge gaps for managing NRS in general wards. The primary objective of this study was to describe indications, duration of treatment, and outcomes of subjects treated with NRS outside the ICU. The secondary objective was to compare outcomes based on age < 80 or ≥ 80 y.

METHODS

This retrospective observational study was conducted at Maggiore della Carità University Hospital in Novara, Italy, and included all patients treated with noninvasive ventilation (NIV) or CPAP outside the ICU from November 2017 to October 2018, with 1 year of follow-up.

RESULTS

Of the 570 treatments performed, 383 subjects were analyzed, 136 NIV and 247 CPAP. Subjects' median (interquartile range [IQR]) age was 79 (72-85) y, and the main diagnoses of respiratory failure were cardiogenic pulmonary edema in 128 subjects (33%), pneumonia in 99 (26%), and COPD exacerbation in 52 (14%), with a median (IQR) treatment duration of 38 (16-74) h. Rapid response team visits lasted a median (IQR) 3 (2-6) d. Interface-related pressure lesions occurred in 13% of the subjects, in no case leading to definitive treatment discontinuation. Compared with the subjects ≥ 80 y old, the younger subjects had a median (IQR) longer hospitalization (16 [10-24] d vs 13 [9-20] d; P = .003) but slightly decreased in-hospital mortality (21% vs 30%; P = .061) and a decreased post-discharged 1-year mortality in hospital survivors (25% vs 41%; P = .002), differences observed only in the subjects treated with NIV.

CONCLUSIONS

In a real-life setting outside the ICU, NIV and CPAP managed by a rapid response team with a daily visit in collaboration with ward staff highly experienced in NRS allowed us to treat the subjects without major complications. Post-discharge 1-year mortality was higher in the subjects ≥ 80 y old treated with NIV for acute hypercapnic respiratory failure.

Parental experience of transition from a pediatric intensive care unit to a general ward: A Qualitative Study

AIM

To explore parental experience in transitioning from a pediatric intensive care unit to a general ward and to investigate parental involvement in caring for their critical illness children.

BACKGROUND

Parents have a major responsibility in caring for seriously ill children, but nursing staff fail to meet the expectations of parents regarding nursing care. Few studies have investigated the challenges and needs of Chinese parents during the transition from pediatric intensive care unit to general ward.

METHODS

Semi-structured interviews were conducted with 24 parents of children with critical illness in a pediatric hospital in Shanghai, mainland China to explore their views. Transcripts were entered into NVivo. Framework analysis was used to analyze the qualitative data.

RESULTS

Four themes were identified by data analysis: changes in the child during post pediatric intensive care unit periods; experiencing a wide range of emotions; factors involved in the transition; and suggestions for improving transitional care.

CONCLUSIONS

Due to the unmet needs of parents, a more flexible visiting policy and social media support were highly desirable. Getting accurate information, establishing family integrated care, and strengthening ward-based critical support services were also listed as important needs of parents caring for critically ill children.

IMPLICATIONS FOR NURSING MANAGEMENT

A profound understanding of parental experiences during the transitional period can help nursing staff to assess the effects on children and their families, improve ward-based intensive care, support parental participation, and improve visitation policies. Based on these findings, nurse managers can develop reasonable intervention programs in order to improve nursing quality and patient outcomes.

[The Impact of Critical Care Transition Programs (CCTPs) on Relocation Stress in Patients and Patient Families in the Intensive Care Unit]

The intensive care unit (ICU) is designed to care for patients with high disease severity who require critical care and close monitoring. Patients in the ICU may be transferred to the general ward for further treatment following recovery from the acute phase. Transferring from the ICU to the general ward after acute phase recovery is a stressful event that may stress both the patient and their family, potentially resulting in relocation stress syndrome (RSS). RSS has been found to be closely related to unplanned ICU readmissions, prolonged hospitalization, and adverse events, affecting recovery to health and family peace of mind. Furthermore, RSS may result in ineffective disease coping, feelings of uncertainty, and poor treatment response, leading to prolonged hospitalization, reduced trust in medical staff, and decreased happiness and quality of life. In recent years, the nursing profession has attached increasing importance to holistic health care. This has encouraged critical care teams to map out customized relocation plans for patients who are about to be transferred from the ICU that use standardized evaluation tools for transfers and elicit the situation and needs from patients or their family. Through the setting of care goals, shared decision making, and cross-unit support, enhanced communications among the medical team facilitate transition preparation and improve the quality and effect of intensive care.

Effects of early rehabilitation on functional outcomes in patients after coronary artery bypass graft surgery: a randomized controlled trial

Objective

This study evaluated the effectiveness, feasibility, and safety of early rehabilitation for patients after coronary artery bypass graft (CABG) surgery.

Methods

In a three-arm randomized controlled trial, patients who underwent CABG from January 2018 to June 2018 were randomly assigned to one of three groups: (i) usual care (UC group); (ii) UC + single general ward rehabilitation (SGR group); and (iii) UC + general ward rehabilitation and intensive care unit (ICU) rehabilitation (IGR group). The primary outcome was the Barthel Index scores.

Results

The Barthel Index score for UC (75.3 ± 12.1) was significantly lower than that of both SGR (86.2 ± 14.1) and IGR (89.1 ± 15.5). There was no significant difference in the Barthel Index scores between the SGR and IGR groups. Statistically significant differences were found in the length of ICU stay and post-operative hospital stay but not in post-operative pulmonary complications (PPC) or atrial fibrillation between the three groups.

Conclusion

Early rehabilitation implemented during ICU stay and on the general ward resulted in significant improvements in functional independence and could be a safe part of routine care post-CABG.

Effects of MBSR therapy on negative emotions, fatigue, and sleep quality in "post-ICU patients": A randomized controlled clinical trial protocol

BACKGROUND

Survivors of intensive care unit (ICU) transfer to the common ward are often accompanied by psychological distress, negative emotions, fatigue, and sleep disturbances that affect recovery. Mindfulness-based stress reduction (MBSR) has achieved reliable results in improving physical and mental health. However, no clinical study has been conducted to evaluate the effects of MBSR on negative emotions, fatigue and sleep quality of patients who survived ICU and were transferred to general wards.

METHODS

This is a prospective randomized controlled trial (RCT) examining the effects of MBSR on negative emotions, fatigue, and sleep quality in inpatients transferred from ICU to general ward. Participants were randomly divided into the treatment group and the control group in a ratio of 1:1. On the basis of the same nursing plan and health education, the treatment group received MBSR therapy, while the control group received no other interventions, and all the patients were followed up for 3 months after 2 weeks of continuous treatment. The indicators included negative mood indicators [Self-rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS)], fatigue index [Fatigue Severity Scale (FSS) and Brief Fatigue Inventory (BFI)], and sleep quality index [Pittsburgh Sleep Quality Index (PSQI)]. Finally, SPSS 20.0 software was used for statistical analysis of the data.

DISCUSSION

This study will evaluate the effects of MBSR on negative emotions, fatigue, and sleep quality in hospitalized patients transferred from ICU to general ward. The results of this study will provide a reference for MBSR to improve psychological distress in ICU survivors transferred to general ward.

TRIAL REGISTRATION

This study protocol was registered in the Open Science Framework (OSF) (registration number: DOI 10.17605/OSF.IO/PD7SU).

Hospital Admission to a Window-Side Bed Does Not Prevent Delirium: A Retrospective Cohort Study of Older Medical Inpatients in General Wards

Background: Delirium in older inpatients is a serious problem. The presence of a window in the intensive care unit has been reported to improve delirium. However, no study has investigated whether window-side bed placement is also effective for delirium prevention in a general ward. Objectives: This study aims to clarify the association between admission to a window-side bed and delirium development in older patients in a general ward. Design: This research is designed as a retrospective cohort study of older patients admitted to the internal medicine departments of Shinshu University Hospital, Japan. Participants: The inclusion criteria were the following: (1) admitted to hospital internal medicine departments between April 2009 and December 2018, (2) older than 75 years, (3) admitted to a multi-patient room in a general ward, and (4) unplanned admission. The number of eligible patients was 1,556. Exposure: This study is a comparison of 495 patients assigned to a window-side bed (window group) with 1,061 patients assigned to a non-window-side bed (non-window group). When patients were transferred to the other type bed after admission, observation was censored. Main Measures: The main outcome of interest was "delirium with event" (e.g., the use of medication or physical restraint for delirium) within 14 days after admission as surveyed by medical chart review in a blinded manner. Key Results: The patients had a median age of 80 years and 38.1% were female. The main outcome was recorded in 36 patients in the window group (10.7 per thousand person-days) and 84 in the non-window group (11.7 per thousand person-days). Log-rank testing showed no significant difference between the groups (p = 0.78). Multivariate analysis with Cox regression modeling also revealed no significant association for the window group with main outcome development (adjusted hazard ratio 0.90, 95% confidence interval of 0.61-1.34). Conclusions: Admission to a window-side bed did not prevent delirium development in older patients admitted to a general ward.

'From Expert to Novice', Perceptions of General Ward Nurses on Deployment to Outbreak Intensive Care Units during the COVID-19 Pandemic: A Qualitative Descriptive Study

AIMS AND OBJECTIVES

This study aimed to explore the perceived preparedness and psychosocial well-being of general ward nurses prior to their deployment into the outbreak intensive care units (ICUs) during the COVID-19 pandemic.

BACKGROUND

With the surge in COVID-19 cases requiring ICU care, non-ICU nurses maybe deployed into the ICUs. Having experienced through SARS, hospitals in Singapore instituted upskilling programs to secure general ward nurses' competency in providing critical care nursing. However, no studies have explored the perceptions of general ward nurses on deployment into the ICUs during the COVID-19 pandemic.

DESIGN

Qualitative descriptive study.

METHODS

The study was conducted at Singapore's epicentre of COVID-19 management. Five focus groups were conducted following purposive sampling of 30 general ward nurses identified for outbreak ICU deployment. Focus groups were audio-recorded, transcribed verbatim and data thematically analysed. This study was conducted and reported in accordance with the COREQ checklist.

RESULTS

Three salient themes arose, exemplifying the transition from clinical experts in the general wards to practising novices in the outbreak ICUs. Firstly, 'Into the deep end of the pool' described general ward nurses' feelings of anxiety and stress associated with higher exposure risk and expanded responsibilities to nurse critically ill patients. Secondly, 'Preparing for "war"' illustrated deployed nurses' need for clear communication and essential critical care nursing training. Lastly, 'Call of duty' affirmed the nurses' personal and professional commitment to embrace this transition into the ICUs, and their desire for greater psychosocial support.

CONCLUSION

The study findings highlight that though general ward nurses perceived their impending ICU deployment positively, they require ongoing support to facilitate a smoother transition.

RELEVANCE TO CLINICAL PRACTICE

Findings provided an evidence base to improve the preparedness of general ward nurses deployed into the ICUs during the COVID-19 pandemic within key areas of training, information dissemination and psychosocial resilience.

Comparison of Risk Factors of Falling for Psychiatric Inpatients and General Ward Inpatients Who Had Fallen

BACKGROUND

For psychiatric patients, the issue of falling is complex.

OBJECTIVE

The objective of this study was to compare the risk factors for falling in psychiatric inpatients and general ward inpatients who had fallen.

METHODS

The researchers first derived official fall records for 122 psychiatric inpatients and then selected 122 psychiatric inpatients who had not fallen as well as 122 general ward patients who had fallen, matched for gender, age, and length of hospital stay at the time of the fall incident.

RESULTS

After controlling other variables, multinomial logistic regression analysis revealed that psychiatric inpatients who had fallen and had dizziness (odds ratio [OR] = 7.11, p < .001), had an unsteady gait (OR = 1.97, p = .030), or were not using aids (OR = 0.42, p = .042) were at greater risk of falling than those who had not fallen. The researchers also found that general ward inpatients who had fallen and had higher Charlson Comorbidity Index scores (OR = 1.77, p < .001), were clear-headed (OR = 27.15, p = .001), had dizziness (OR = 11.55, p < .001), were unable to walk (OR = 64.28, p < .001), or were using aids (OR = 3.86, p = .001) were at greater risk of falling than those who had not fallen before.

CONCLUSIONS

The causes of falling among psychiatric inpatients and general ward inpatients are different. Medical personnel should understand the medications and attributes of patients for an accurate assessment of their risk factors for falling and thus implement fall prevention measures and health education to reduce falls.

Velocity-based target flow rate for high-flow nasal cannula oxygen therapy

BACKGROUND

The aim of this study was to assess retrospectively whether the average inspiratory flow velocity-based initial flow rate in high-flow nasal cannula (HFNC) therapy could be well tolerated and safely used for infants and children hospitalized with moderate to severe respiratory failure.

METHODS

Thirty-three patients without underlying diseases (22 males; 67%), hospitalized to receive HFNC therapy for infection-related respiratory failure, were analyzed. The median age was 2 months (interquartile range, 1 month to 1 year). Patients with dyspnea and carbon dioxide partial pressure (pCO₂ ) >50 mmHg or venous blood pH <7.320, combined with pulse oximetry arterial oxygen saturation <92%, were included. We set target flow rates calculated from the average inspiratory flow velocity, starting at the actual initial flow rates, and these were subsequently adjusted if necessary.

RESULTS

One patient could not tolerate the cannula. Of the remaining 32 patients, 81% (n = 26) had an actual initial flow rate within 1 L of the target flow rate; these patients were evaluated for changes in the fraction of inspired oxygen (FITarget flow rate tableO₂ ), pH, and pCO₂ values after 24 h. Three patients required a higher fraction of inspired oxygen, one showed a persistent pH < 7.320, and seven exhibited pCO₂ >50 mmHg. No patient required non-invasive positive-pressure ventilation, and one required intubation. Pneumothorax was not reported in any patient.

CONCLUSIONS

The average inspiratory flow velocity-based initial flow rate was well-tolerated without sedation, and there were no severe complications. Starting at this flow rate would improve the use of HFNC therapy in the pediatric ward, possibly reducing the need for more invasive modes of ventilation.

Cost Effectiveness of Different Initial Antimicrobial Regimens for Elderly Community-Acquired Pneumonia Patients in General Ward

Purpose

The cost-effectiveness of different guideline-concordant antimicrobial regimens for elderly patients with community-acquired pneumonia (CAP) was rarely discussed. This study attempts to explore the most appropriate cost-effectiveness of guideline-concordant antimicrobial regimen for elderly patients with CAP in general wards.

Patients and Methods

This was a multicenter, retrospective, 4:2:1 matched study enrolling 511 elderly patients with CAP hospitalized in general wards. Two hundred ninety-two patients prescribed with β-lactam monotherapy (group A), 146 patients prescribed with fluoroquinolone monotherapy (group B) and 73 patients prescribed with β-lactam/macrolide combination therapy (group C). Clinical outcomes and medical costs were analyzed by χ² test for categorical variables or Kruskal–Wallis H-test for continuous variables.

Results

There were no statistical differences in imaging features, etiology and complications during hospitalization among these three groups. The rates of clinical failure occurrence, in-hospital mortality, 30-day mortality and 60-day mortality also had no significant differences among group A, B and C patients; however, the median length of stay (LOS) in group A patients was 12.0 days, which was significantly higher than that in group B and C patients (both 10.0 days, p<0.02). The median total, drug, and antibiotic costs for one elderly CAP episode in group B patients were RMB 10368.4, RMB 3874.8, and RMB 1796.3, respectively, which were significantly lower than those in group A and C patients (p<0.01).

Conclusion

Non-inferiority of clinical failure occurrence and short-term mortality was observed in different guideline-concordant antimicrobial regimens for elderly patients with CAP in general wards; however, the median LOS and hospitalization-associated costs for one elderly CAP episode with fluoroquinolone monotherapy were significantly lowest, and this strategy was considered to be the most cost-effective strategy in general wards.

Prevalence of neuropathic pain in terminally ill patients with cancer admitted to a general ward: a prospective observational study

Objectives

To determine the prevalence of neuropathic pain among terminally ill patients with cancer admitted to a general ward, using the International Association for the Study of Pain algorithm.

Methods

This prospective observational study was conducted at a tertiary care center. We enrolled terminally ill patients with cancer admitted to the general ward between September 2018 and September 2019. On the day of consultation with our palliative care team, pain management clinicians examined and diagnosed neuropathic pain using the International Association for the Study of Pain diagnostic criteria.

Results

A total of 108 patients were enrolled during the study period. The median age was 69 years (interquartile range [IQR] 58.3–76.8 years), 72 patients (66.7%) were men, and the median survival time was 33 days (IQR 14.3–62 days). Of the 108 patients, 33 (30.6%) had neuropathic pain. Patients with neuropathic pain had more severe pain than those without neuropathic pain.

Conclusions

The prevalence of neuropathic pain in terminally ill patients with cancer admitted to a Japanese general ward was 30.6%. Further studies are warranted to elucidate whether the accurate diagnosis of neuropathic pain can improve pain control and/or patient conditions.

Developing and testing a Korean patient classification system for general wards based on nursing intensity

Aim

To develop a new general wards patient classification tool based on the nursing intensity level that reflects patients’ clinical characteristics and indirect nursing activities.

Design

A cross‐sectional design was adopted. This methodological study developed a patient classification system to sort general ward patients based on the intensity of their nursing needs and verified the validity and reliability of this classification system.

Methods

Thirteen experts verified the tools’ content validity. Data collectors and head nurses classified 150 patients from two hospitals with four general wards and various nurse staffing levels. Inter‐rater reliability was analysed. Staff nurses classified 846 patients following the Korean patient classification system on nursing intensity scores that reflected patients’ clinical status. Content validity was verified based on the classification results. Using K‐group cluster analysis, score ranges for four groups were identified.

Results

The developed tool includes 8 domains, (symptom management, infection control, nutrition and medication, personal hygiene and secretion, activity, sleep and rest, guidance in nursing/emotional support, nursing activity planning and coordination, indirect activity), 24 subdomains, 66 nursing activities and 124 criteria. Inter‐rater reliability showed high agreement.

Actual Situations and Factors Related to Nursing Activities in Supporting the Transition to Homecare Settings for End-Stage Cancer Patients in General Wards in Japan

This study aimed to investigate actual situations of nursing activities in supporting the transition to homecare settings for end-stage cancer patients and to determine factors related to executing such nursing activities from the perspectives of communication skills and interprofessional collaboration. A cross-sectional study was conducted with 513 nurses who worked at designated cancer care hospitals in Japan. A total of 318 valid responses were obtained (valid response rate: 62.0%). Scores for nursing activities were higher for the following items: sharing information regarding the transition to homecare settings, intentionally engaging with patients after their medical conditions were explained, providing care for families, and understanding a patient's will about the transition to homecare settings. On the other hand, scores were lower for items that were related to guiding juniors and self-improvement. A multiple regression analysis was performed with nursing activities as the dependent variable. 8 factors related to nursing activities were determined: experience in supporting the transition to homecare settings as a primary nurse, contribution to a team (Team Approach Assessment Scale [TAAS]), years of nursing experience, function of a team (TAAS), regulation of interpersonal relationship (ENDCOREs communication skills scale), experience of participation in homecare nursing education or seminars, verbal communication skills for good communication (End-of-life Care Nurses' Communication Skills scale), and educational background. Future challenges include developing an educational program based on the results of the present study and promoting educational intervention studies.

Relationship between first mobilization following the onset of stroke and clinical outcomes in patients with ischemic stroke in the general ward of a hospital: A cohort study

OBJECTIVE

The purpose of this study was to compare the effects of first mobilization following a stroke with independently performing the activities of daily living at discharge in acute phase ischemic stroke patients in a general ward of a hospital.

METHODS

A total of 158 patients with ischemic strokes were admitted to a general ward from June 1, 2014 to March 31, 2015. Of the 158 patients, 53 met the study's eligibility criteria. First mobilization was defined as the transfer of a patient from the bed to a wheelchair by a rehabilitation therapist. A favorable primary outcome at discharge was defined as a modified Rankin Scale score of < 3. The outcome was analyzed using the proportional hazards analysis and receiver operating characteristic curves.

RESULTS

The age of the participants was 78.2 ± 11.7 years, stroke severity evaluated by the National Institutes of Health Stroke Scale scores on admission was 14.3 ± 10.6 points, and first mobilization of this population was 6.4 ± 5.2 days. Thirteen [25%] patients had a favorable outcome. Hazards analysis showed a favorable outcome due to first mobilization (adjusted hazards ratio 0.80, 95% confidence interval 0.65-0.98; p < 0.05). The cutoff point for first mobilization to produce a favorable outcome was 6.5 days after the stroke onset (area under the curve 0.729; p < 0.05).

CONCLUSION

As seen in stroke units, early first mobilization is associated with improved clinical outcomes in ischemic stroke patients admitted to a general ward.

[Cancer Family Care Learning Materials for Japanese General Ward Nurses]

Families of cancer patients are also subject to care, and early intervention is necessary. In general hospital wards, nurses have difficulty in performing satisfactory nursing care for families of cancer patients due to limited time to get involved. Their priority is to provide essential care for patients, thus it is inevitable that they cannot offer intervention for patients' families. In recent years, overtime work by nurses has been regarded as a problem, and implementation of in-service education within the working hours is recommended. Based on these backgrounds, we developed "Learning materials for nurses, with a view to standardized care for the families of cancer patients hospitalized in general wards". In this paper, we report on this learning program and the development process.

Frequency of vital sign measurement among intubated patients in the general ward and nurses' attitudes toward vital sign measurement

Purpose

The lack of recognition of respiratory distress may result in emergency tracheal intubation in the general ward. However, few studies have examined the differences in the frequency of vital sign measurement between patients with and without emergency tracheal intubation in the general ward. Thus, this study aimed to investigate the differences in the frequency of vital sign measurements between patients with and without emergency tracheal intubation.

Patients and methods

This is a single-center, retrospective, observational study of unplanned intensive care unit (ICU) admissions from the general wards between December 2015 and February 2017. This study included patients with emergency medical intubations in the general ward who were then transferred to the ICU. Vital signs measured within 24 hours prior to ICU admission were compared between patients who did and did not require emergency tracheal intubation in the general ward. A survey was also conducted to explore the nurses' attitudes toward vital sign measurements.

Results

Compared with other vital signs, the respiratory rate was significantly less frequently measured. Moreover, the frequency of respiratory rate measurement was lower in the 38 patients who were intubated than in the 102 patients who were not intubated in the general ward (P=0.07). The survey revealed that 54% of the participating nurses considered assessment of the respiratory rate as the most troublesome nursing task and ~15% of nurses did not routinely measure respiratory rates.

Conclusion

Respiratory rate was less frequently assessed in deteriorating patients in the general ward, possibly because it was considered a troublesome task.

Mechanical Ventilation-Related Safety Incidents in General Care Wards and ICU Settings

BACKGROUND

Although the ICU is the most appropriate place to care for mechanically ventilated patients, a considerable number are ventilated in general medical care wards all over the world. However, adverse events focusing on mechanically ventilated patients in general care have not been explored.

METHODS

Data from the Japan Council for Quality Health Care database were analyzed. Patient safety incidents from January 2010 to November 2017 regarding mechanical ventilation were collected, and comparisons of patient safety incidents between ICUs/high care units (HCUs) and general care wards were made.

RESULTS

We identified 261 adverse events (with at least 20 adverse events resulting in death) and 702 near-miss events related to mechanical ventilation in Japan between 2010 and 2017. Furthermore, among all adverse events, 19% (49 of 261 events) caused serious harm (residual disability or death). Human-factor issues were most frequent in both ICU/HCU and general care settings (55% and 53%, respectively), while knowledge-based errors were higher in the general care setting.

CONCLUSIONS

Human-factor issues were the most frequent reasons in both settings, while knowledge-based error rates were higher in general care. Our results suggest that proper education and training is needed to minimize patient safety incidents in facilities without respiratory therapists.

Differences in distribution and drug sensitivity of pathogens in lower respiratory tract infections between general wards and RICU

BACKGROUND

Lower respiratory tract infections (LRTIs) are common among patients in hospitals worldwide, especially in patients over the age of 60. This study investigates the differences in distribution and drug sensitivity of pathogens in LRTIs.

METHODS

The clinical and laboratory data of 4,762 LRTI patients in the general ward and respiratory intensive care unit (RICU) of Xiangya Hospital (Changsha) were retrospectively analyzed.

RESULTS

The infection rate of Gram-negative bacteria was significantly higher than that of Gram-positive bacteria in both the general ward and RICU (P<0.05). The incidence of Gram-negative bacteria infection was significantly higher in the RICU than in the general ward (P<0.05), whereas the incidence of Gram-positive bacteria infection is less in the RICU than in the general ward (P<0.05). In the general ward, the incidence of Gram-negative bacteria infection significantly increased (P<0.05) over time, whereas the incidence of Gram-positive bacteria infection significantly decreased from 1996 to 2011 (P<0.05). In the RICU, the incidence of Gram-positive bacteria infection decreased, while Gram-negative bacteria infections increased without statistical significance (P>0.05). Staphylococcus pneumoniae and Staphylococcus aureus were found to be the predominant Gram-positive strains in the general ward (34.70-41.18%) and RICU (41.66-54.87%), respectively (P>0.05). Pseudomonas aeruginosa and Acinetobacter baumannii were the predominant gram negative strains in the general ward (19.17-21.09%) and RICU (29.60-33.88%), respectively (P>0.05). Streptococcus pneumoniae is sensitive to most antibiotics with a sensitivity of more than 70%. Staphylococcus aureus is highly sensitive to vancomycin (100%), linezolid (100%), chloramphenicol (74.36-82.19%), doxycycline (69.57-77.33%), and sulfamethoprim (67.83-72.46%); however, its sensitivity to other antibiotics is low and decreased each year. Sensitivity of Pseudomonas aeruginosa to most β-lactam, aminoglycoside, and quinolone group antibiotics decreased each year.

CONCLUSIONS

The distribution and drug sensitivity of LRTI pathogens exhibit a high divergence between the general ward and RICU. Streptococcus pneumoniae may not be the predominant pathogen in LRTIs in some areas of China.

Does noninvasive ventilation delivery in the ward provide early effective ventilation?

BACKGROUND

Although noninvasive ventilation (NIV) is increasingly used in general wards, limited information exists about its ability to provide effective ventilation in this setting. We aim to evaluate NIV delivered in the ward by assessing (1) overall time of application and occurrence of adverse events and (2) differences between daytime and nighttime NIV application.

METHODS

We studied subjects with hypercapnic acute hypercapnic respiratory failure not fulfilling strict criteria for ICU admission, and excluded those who interrupted NIV prior to 48 h. Time spent on NIV, presence and extent of air leaks, and occurrence of desaturations were assessed for the overall study period, and compared between daytime and nighttime.

RESULTS

We enrolled 42 subjects, 25 of whom received NIV for at least 48 h and were included in the data analysis. NIV was successful for 20 subjects, who did not reach criteria for ICU admission. Both PaCO2 and pH significantly improved on average after 2 h and at the end of the study period. NIV was applied for 64.5% of the overall study period and had absent or compensated air leaks for 62.3% of the overall 48-h period. NIV was applied for 55.8% of daytime and for 79.3% of nighttime (P < .01). Effective NIV application was significantly longer overnight (76.9%) than during daytime (53.2%) (P < .01).

CONCLUSIONS

In selected subjects with hypercapnic acute respiratory failure not fulfilling criteria for ICU admission, the application of NIV in the ward is feasible; in addition, NIV can be safely administered overnight.

Clinical outcomes of witnessed and monitored cases of in-hospital cardiac arrest in the general ward of a university hospital in Korea

BACKGROUND

There are few studies of the epidemiology and clinical outcomes of patients with in-hospital cardiac arrest (IHCA) in a general hospital ward.

OBJECTIVE

To investigate the clinical outcomes of IHCA cases that occurred in the general ward of a university hospital and that were witnessed and/or monitored.

METHODS

We prospectively gathered data on all IHCAs in the general ward of Asan Medical Center, Seoul, South Korea, that were recorded by the Medical Emergency Team between March 2008 and February 2010. The main outcomes included survival to hospital discharge, incidence of IHCA, and prognostic factors related to hospital mortality. We also investigated preventable cases.

RESULTS

We identified 238 index cases of IHCA. The average incidence of IHCA was 0.145 IHCAs per 1,000 patient admissions. Survival to hospital discharge was 19% (46 cases), 66% of which were due to non-cardiac causes, and 77% were due to medical illnesses. The most common first documented rhythm was pulseless electrical activity (38%). Two hundred three cases (85.3%) of IHCA were witnessed at the event; 135 cases (56.7%) were monitored at the event. Non-witnessed cases, monitored cases, night onset, medical illness, metastatic cancer, intubation, and long duration of cardiopulmonary resuscitation were significantly associated with hospital mortality. We identified 91 preventable cases (38%). Respiratory insufficiency (37 cases, 41%) was one of major cause of preventable IHCA.

CONCLUSIONS

Witnessed IHCAs in the general ward had a higher rate of survival to hospital discharge; however, monitored cases had a lower rate of survival to hospital discharge. Respiratory insufficiency was a major preventable cause of IHCA. In consideration of the preventable IHCAs, further studies should be performed on monitoring practices in general wards.