Family centeredness of care: a cross-sectional study in intensive care units part of the European society of intensive care medicine

PURPOSE

To identify key components and variations in family-centered care practices.

METHODS

A cross-sectional study, conducted across ESICM members. Participating ICUs completed a questionnaire covering general ICU characteristics, visitation policies, team-family interactions, and end-of-life decision-making. The primary outcome, self-rated family-centeredness, was assessed using a visual analog scale. Additionally, respondents completed the Maslach Burnout Inventory and the Ethical Decision Making Climate Questionnaire to capture burnout dimensions and assess the ethical decision-making climate.

RESULTS

The response rate was 53% (respondents from 359/683 invited ICUs who actually open the email); participating healthcare professionals (HCPs) were from Europe (62%), Asia (9%), South America (6%), North America (5%), Middle East (4%), and Australia/New Zealand (4%). The importance of family-centeredness was ranked high, median 7 (IQR 6-8) of 10 on VAS. Significant differences were observed across quartiles of family centeredness, including in visitation policies availability of a waiting rooms, family rooms, family information leaflet, visiting hours, night visits, sleep in the ICU, and in team-family interactions, including daily information, routine day-3 conference, and willingness to empower nurses and relatives. Higher family centeredness correlated with family involvement in rounds, participation in patient care and end-of-life practices. Burnout symptoms (41% of respondents) were negatively associated with family-centeredness. Ethical climate and willingness to empower nurses were independent predictors of family centeredness.

CONCLUSIONS

This study emphasizes the need to prioritize healthcare providers' mental health for enhanced family-centered care. Further research is warranted to assess the impact of improving the ethical climate on family-centeredness.

Effect of odor treatment systems on bioaerosol microbial concentration and diversity from wastewater treatment plants

Biofiltration, activated carbon and chemical scrubbing are technologies used for odor control in wastewater treatment plants. These systems may also influence the airborne microbial load in treated air. The study objectives were to 1) evaluate the capacity of three odor control system technologies to reduce the airborne concentration of total bacteria, Legionella, L. pneumophila, non-tuberculous mycobacteria (NTM) and Cladosporium in winter and summer seasons and 2) to describe the microbial ecology of the biofiltration system and evaluate its impact on treated air microbial diversity. A reduction of the total bacterial concentration up to 25 times was observed after odor treatment. Quantification by qPCR revealed the presence of Legionella spp. in all air samples ranging between 26 and 1140 GC/m³, while L. pneumophila was not detected except for three samples below the limit of quantification. A significant increase of up to 25-fold of Legionella spp. was noticed at the outlet of two of the three treatment systems. NTM were ubiquitously detected before air treatment (up to 2500 GC/m³) and were significantly reduced by all 3 systems (up to 13-fold). Cladosporium was measured at low concentrations for each system (< 190 GC/m³), with 68 % of the air samples below the limit of detection. Biodiversity results revealed that biofiltration system is an active process that adapts to air pollutants over time. Legionella spp. were detected in significant abundance in the air once treated in winter (up to 27 %). Nevertheless, the abundance of protozoan hosts is low and does not explain the multiplication of Legionella spp. The season remains the most influential factor shaping biodiversity. In summer only, air biofiltration caused a significant enrichment of the biodiversity. Although odor control technologies are not designed for bacterial mitigation, findings from this study suggest their potential to reduce the abundance of some genera harboring pathogenic species.

Prevalence of skin pressure injury in critical care patients in the UK: results of a single-day point prevalence evaluation in adult critically ill patients

OBJECTIVES

Hospital-acquired pressure injuries (PIs) are a source of morbidity and mortality, and many are potentially preventable.

DESIGN

This study prospectively evaluated the prevalence and the associated factors of PIs in adult critical care patients admitted to intensive care units (ICU) in the UK.

SETTING

This service evaluation was part of a larger, international, single-day point prevalence study of PIs in adult ICU patients. Training was provided to healthcare givers using an electronic platform to ensure standardised recognition and staging of PIs across all sites.

PARTICIPANTS

The characteristics of the ICUs were recorded before the survey; deidentified patient data were collected using a case report form and uploaded onto a secure online platform.

PRIMARY AND SECONDARY OUTCOME MEASURES

Factors associated with ICU-acquired PIs in the UK were analysed descriptively and using mixed multiple logistic regression analysis.

RESULTS

Data from 1312 adult patients admitted to 94 UK ICUs were collected. The proportion of individuals with at least one PI was 16% (211 out of 1312 patients), of whom 8.8% (n=115/1312) acquired one or more PIs in the ICU and 7.3% (n=96/1312) prior to ICU admission. The total number of PIs was 311, of which 148 (47.6%) were acquired in the ICU. The location of majority of these PIs was the sacral area, followed by the heels. Braden score and prior length of ICU stay were associated with PI development.

CONCLUSIONS

The prevalence and the stage of severity of PIs were generally low in adult critically ill patients admitted to participating UK ICUs during the study period. However, PIs are a problem in an important minority of patients. Lower Braden score and longer length of ICU stay were associated with the development of injuries; most ICUs assess risk using tools which do not account for this.

TRIAL REGISTRATION NUMBER

NCT03270345.

Ten areas for ICU clinicians to be aware of to help retain nurses in the ICU

Shortage of nurses on the ICU is not a new phenomenon, but has been exacerbated by the COVID-19 pandemic. The underlying reasons are relatively well-recognized, and include excessive workload, moral distress, and perception of inappropriate care, leading to burnout and increased intent to leave, setting up a vicious circle whereby fewer nurses result in increased pressure and stress on those remaining. Nursing shortages impact patient care and quality-of-work life for all ICU staff and efforts should be made by management, nurse leaders, and ICU clinicians to understand and ameliorate the factors that lead nurses to leave. Here, we highlight 10 broad areas that ICU clinicians should be aware of that may improve quality of work-life and thus potentially help with critical care nurse retention.

Management and outcomes in critically ill nonagenarian versus octogenarian patients

Background

Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup and place a huge financial burden on health care resources despite the benefit being unclear. This leads to ethical problems. The present investigation assessed the differences in outcome between nonagenarian and octogenarian ICU patients.

Methods

We included 7900 acutely admitted older critically ill patients from two large, multinational studies. The primary outcome was 30-day-mortality, and the secondary outcome was ICU-mortality. Baseline characteristics consisted of frailty assessed by the Clinical Frailty Scale (CFS), ICU-management, and outcomes were compared between octogenarian (80–89.9 years) and nonagenarian (> 90 years) patients. We used multilevel logistic regression to evaluate differences between octogenarians and nonagenarians.

Results

The nonagenarians were 10% of the entire cohort. They experienced a higher percentage of frailty (58% vs 42%; p < 0.001), but lower SOFA scores at admission (6 + 5 vs. 7 + 6; p < 0.001). ICU-management strategies were different. Octogenarians required higher rates of organ support and nonagenarians received higher rates of life-sustaining treatment limitations (40% vs. 33%; p < 0.001). ICU mortality was comparable (27% vs. 27%; p = 0.973) but a higher 30-day-mortality (45% vs. 40%; p = 0.029) was seen in the nonagenarians. After multivariable adjustment nonagenarians had no significantly increased risk for 30-day-mortality (aOR 1.25 (95% CI 0.90–1.74; p = 0.19)).

Conclusion

After adjustment for confounders, nonagenarians demonstrated no higher 30-day mortality than octogenarian patients. In this study, being age 90 years or more is no particular risk factor for an adverse outcome. This should be considered– together with illness severity and pre-existing functional capacity - to effectively guide triage decisions.

Trial registration

NCT03134807 and NCT03370692.

Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs

BACKGROUND

Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear.

OBJECTIVE

To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function.

DESIGN

Prospective cohort study.

SETTING

241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019.

SUBJECTS

Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2.

METHODS

Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected.

RESULTS

Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001).

CONCLUSIONS

There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.

POS0067 HIGH DEGREE OF INTER-PATIENT HETEROGENEITY IN SYNOVIOCYTE HYPERPLASIA AND IMMUNE CELLS INFILTRATION IN THE SYNOVIUM OF JUVENILE IDIOPATHIC ARTHRITIS PATIENTS

Background:

Increasing evidence indicates that synovial tissue analysis can deliver pathophysiological insights but also individual clinically-relevant information in adult-onset inflammatory arthritides. Little is known about synovial pathology in juvenile idiopathic arthritis, especially regarding inter-patient variability of histopathological features.

Objectives:

To assess the heterogeneity of main synovial features (synoviocyte hyperplasia and immune cells infiltration) in juvenile idiopathic arthritis (JIA) patients and a cohort of young adults (<30 years old) with early rheumatoid arthritis (RA).

Methods:

Synovial biopsies were sampled using needle arthroscopy or ultra-sound (US) guided biopsy during intra-articular joint injection. Tissue was embedded in paraffin then sections were stained with hematoxylin and eosin. Synoviocyte hyperplasia (SH) and immune cells infiltration (ICI) was assessed by an experienced pathologist on a 0 – 3 scale where 0 represents the absence of the feature and 3 the highest level.

Results:

34 JIA patients (age (median ±SD): 15.5±6.47 years, oligo-articular JIA n=28/34, polyarticular JIA n=6/34, ANA-RF-ACPA positivity=56%-10%-3%) and 22 RA (age (median ±SD): 24.3±2.6 years, ANA-RF-ACPA positivity=10%-36%-32%) patients were included. Synovial tissue was obtained from knee (n=49/56), wrist (n=4/56) or metacarpophalangeal/intercarpophalangeal joints (n=3/56), using US guided biopsy in 27% of patients and needle arthroscopy in 73%.

Individual scores of SH and ICI were correlated in both JIA (Spearman’s r=0.503, p value=0.0024) and RA (Spearman’s r=0.636, p value=0.0015). There was no significant difference in SH and ICI scores between the 2 groups (SH score (Q25-Q50-Q75) in JIA= 0.5-1.125-2 and in RA = 0.75-2-2; ICI score (Q25-Q50-Q75) in JIA= 1-2-2 and in RA = 0.75-2-2.25). Intra-group variability of the two assessed features was comparable between the 2 groups (SH coefficient of variation: 72.2% for JIA and 68.2% for RA; ICI coefficient of variation: 52.2% for JIA and 71.2% for RA). Within JIA patients, there was no significant difference in SH/ICI scores between groups based on ANA positivity, oligo or polyarticular involvement nor ongoing treatment.

Conclusion:

Studying main histological features of synovitis, we found no difference between JIA and young RA patients. Furthermore, we report a similar degree of inter-patient heterogeneity in synovial pathological features of JIA and RA patients. These variations were not explained by common clinical characteristics. Whether they relate to different molecular signatures as suggested in adult RA will be further investigated using bulk tissue RNA sequencing.

Acknowledgements:

This work was funded in part by Cap48 (RTBF). Clément Triaille is funded by the Fonds National de la Recherche Scientifique (FNRS, Communauté française de Belgique) and Fondation Saint-Luc (Cliniques Universitaires Saint-Luc).

Disclosure of Interests:

Clément Triaille: None declared, Cécile Boulanger: None declared, Tatiana Sokolova: None declared, Laurent Meric de Bellefon: None declared, Adrien Nzeusseu Toukap: None declared, Christine Galant: None declared, Nisha Limaye: None declared, Bernard Lauwerys Employee of: currently employed at UCB Biopharma, Patrick Durez: None declared.

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

PURPOSE

Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients.

METHODS

International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis.

RESULTS

Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9-27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6-16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score < 19, ICU stay > 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2-1.8), stage II (OR 1.6; 95% CI 1.4-1.9), and stage III or worse (OR 2.8; 95% CI 2.3-3.3).

CONCLUSION

Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat.

The quality of intensive care unit nurse handover related to end of life: a descriptive comparative international study

BACKGROUND

Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it.

OBJECTIVE

The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries.

DESIGN

This was a descriptive comparative study.

SETTINGS

The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units).

PARTICIPANTS

A convenience sample of 157 handovers was studied.

METHODS

Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors.

RESULTS

The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154)=25.97, p=<.001; unit: F(6,150)=58.24, p=<.001), for the end of life subscale (country: F(2, 154)=28.23, p<.001; unit: F(6,150)=25.25, p=<.001), the family communication subscale (country: F(2,154)=15.04, p=<.001; unit: F(6,150)=27.38, p=<.001), the family needs subscale (F(2,154)=22.33, p=<.001; unit: F(6,150)=42.45, p=<.001) but only for units on the process subscale (F(6,150)=8.98, p=<.001. The total handover score was higher if the oncoming RN did not know the patient (F(1,155)=6.51, p=<.05), if the patient was expected to die during the shift (F(1,155)=89.67, p=<.01) and if the family were present (F(1,155)=25.81, p=<.01).

CONCLUSIONS

Practices of end-of-life-handover communication vary greatly between units. However, room for improvement exists in all areas in all of the units studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool.

Non-therapeutic omission of medications in acutely ill patients

AIMS AND OBJECTIVES

To examine documentation of medication administration in medical and surgical patients.

STUDY OBJECTIVES

(1) Determine the point prevalence of non-therapeutic medication omissions; (2) identify documented reasons for non-therapeutic medication omissions; (3) examine the relationship between length of stay and medication omissions; and (4) explore the impact of outlier status (e.g. medical patients managed on surgical wards) on medication administration.

BACKGROUND

Acutely ill patients are particularly sensitive to health care errors. We previously identified a 26% rate of non-therapeutic medication omissions in patients admitted unexpectedly to intensive care unit (ICU) from medical and surgical wards.

DESIGN

A point prevalence survey of 162 medical and surgical patients across four sites in the South West of England.

METHOD

Data collected included: all instances of, and reasons for, non-therapeutic medication omission. We also recorded whether the patient was an 'outlier' and examined nursing documentation where no reason for medication omission was given on the drug chart.

RESULTS

The number of patients who missed at least one medication was high across all sites (n = 129/162; 79.6%, range 60-88%), with a total of 1077 doses omitted. Patients who were outliers (e.g. surgical patients on a medical ward) were more likely to miss medications (100% versus 74%, p < 0.001). The most common missed medications were analgesia and anti-inflammatory drugs (28%, 299/1077); 203 of these were due to patient refusal.

CONCLUSIONS

The extent of medications omitted for non-therapeutic reasons in medical and surgical patients is of concern. None were recorded as an adverse drug event; however, the extent of omitted or refused medications suggests the need for a review of prescribing and drug administration processes. These findings have important implications for the role of ICU outreach and liaison services, for example, including medication management in the monitoring of patients pre/post-ICU admission and support/education provided for ward staff.

RELEVANCE TO CLINICAL PRACTICE

Detailed analysis of medication records suggests a number of areas of medication administration that would benefit from review.

How to measure and record vital signs to ensure detection of deteriorating patients

This article aims to provide registered nurses with knowledge, skills and practical advice to improve the assessment, recording and reporting of patient observations. Using guidance from Patient Safety First's intervention on reducing harm from deterioration, common issues forward staff are illustrated and practical advice is given.

Normal pregnancy in a woman with nesidioblastosis treated with somatostatin analog octreotide

OBJECTIVE

We report the case of a 36-yr-old woman with nesidioblastosis treated throughout pregnancy with high doses of octreotide. We studied the course of blood glucose, foetal growth and development.

METHODS

Blood samples were obtained every month throughout pregnancy and taken at birth from the umbilical cord. Sonography was performed repeatedly to monitor foetal growth.

RESULTS

The daily dose of octreotide was adapted to blood glucose levels: a dose of 1000 microg was infused during the first part of pregnancy, then it was decreased step by step during the last trimester of gestation. An elective cesarean section was performed at 32 weeks of gestation. High octreotide concentrations were obtained during the first part of gestation (range 2888-5021 pg/ml). During the third trimester of pregnancy blood glucose increased despite high insulin levels attesting physiological insulin-resistance. Plasma levels of placental GH and IGF-1 levels were similar to those observed in a normal pregnancy. Despite the presence of octreotide in the umbilical cord, TSH, free T4, PRL and pituitary GH concentrations were normal at birth. The female newborn (weight 3520 g, length 52 cm) had no malformation, and presented with normal postnatal development.

CONCLUSION

Our study demonstrates that: 1) octreotide treatment can be effective in controlling endogenous hyperinsulinism during pregnancy; 2) octreotide does not affect physiological changes during pregnancy such as insulin-resistance or placental GH level; 3) exposure of the foetus to octreotide throughout pregnancy does not induce any malformation and does not affect foetal development.

In vitro cationic lipid-mediated gene delivery with fluorinated glycerophosphoethanolamine helper lipids

There is a need for the development of nonviral gene transfer systems with improved and original properties. "Fluorinated" lipoplexes are such candidates, as supported by the remarkably higher in vitro and in vivo transfection potency found for such fluorinated lipoplexes as compared with conventional ones or even with PEI-based polyplexes (Boussif, O., Gaucheron, J., Boulanger, C., Santaella, C., Kolbe, H. V. J., Vierling, P. (2001) Enhanced in vitro and in vivo cationic lipid-mediated gene delivery with a fluorinated glycerophosphoethanolamine helper lipid. J. Gene Med. 3, 109-114). Here, we describe the synthesis of fluorinated glycerophosphoethanolamines (F-PEs), close analogues of dioleoylphosphatidylethanolamine (DOPE), and report on their lipid helper properties vs that of DOPE, as in vitro gene transfer components of fluorinated lipoplexes based on pcTG90, DOGS (Transfectam), or DOTAP. To evaluate the contribution of the F-PEs to in vitro lipoplex-mediated gene transfer, we examined the effect of including the F-PEs in lipoplexes formulated with these cationic lipids (CL) for various CL:DOPE:F-PE molar ratios [1:(1 - x):x with x = 0, 0.5 and 1; 1:(2 - y):y with y = 0, 1, 1.5, and 2], and various N/P ratios (from 10 to 0.8, N = number of CL amines, P = number of DNA phosphates). Irrespective of the F-PE chemical structure, of the colipid F-PE:DOPE composition, and of the N/P ratio, comparable transfection levels to those of their respective control DOPE lipoplexes were most frequently obtained when using one of the F-PEs as colipid of DOGS, pcTG90, or DOTAP in place of part of or of all DOPE. However, a large proportion of DOGS-based lipoplexes were found to display a higher transfection efficiency when formulated with the F-PEs rather than with DOPE alone while the opposite tendency was evidenced for the DOTAP-based lipoplexes. The present work indicates that "fluorinated" lipoplexes formulated with fluorinated helper lipids and conventional cationic lipids are very attractive candidates for gene delivery. It confirms further that lipophobicity and restricted miscibility of the lipoplex lipids with the endogenous lipids does not preclude efficient gene transfer and expression. Their transfection potency is rather attributable to their unique lipophobic and hydrophobic character (resulting from the formulation of DNA with fluorinated lipids), thus preventing to some extent DNA from interactions with lipophilic and hydrophilic biocompounds, and from degradation.

[Mechanical and functional predictive factors for restenosis and arterial remodeling after experimental angioplasty]

Arterial remodelling plays an important part in post-angioplasty restenosis but the physiopathology of this process is not fully understood. Abundant collagen synthesis and endothelial dysfunction have been demonstrated after angioplasty, but their role in restenosis and remodelling has not been studied. The aim of this study was therefore to assess endothelial function and collagen with respect to the severity of restenosis and the type of arterial remodelling. Atherosclerosis was induced by an association of endothelial abrasion and a high cholesterol diet in the femoral arteries of 22 white New Zealand rabbits. Four weeks later, angioplasty was performed. The acetylcholine endothelium-dependant vasomotricity (expressed as % inhibition of contraction to phenylephrine), collagen and morphology were assessed 28 days after angioplasty. The change in acetylcholine endothelium-dependant vasomotricity was greater in severe restenosis (r = 0.61, p = 0.02). Endothelium-dependant relaxation was not significantly altered when remodelling was expansive and very abnormal when it was constrictive (35.5 +/- 13.0 vs 3.7 +/- 7.9%; p = 0.04). Restenosis was associated with an increase in collagen (r = 0.69, p = 0.004). The density of collagen was significantly higher in constrictive remodelling than in expansive remodelling (34.5 +/- 4.5 vs 18.2 +/- 4.7%; p = 0.03). Endothelial dysfunction and collagen accumulation are correlated with the severity of restenosis and with constrictive remodelling after angioplasty in an experimental model.