Predictive validity of the Clinical Frailty Scale-España on the increase in dependency after hospital discharge

INTRODUCTION

The frailty present at hospital admission and the stressors to which patients are subjected during their stay may increase dependency at hospital discharge.

OBJECTIVES

To assess the predictive validity of the Clinical Frailty Scale-España (CFS-Es) on increased dependency at 3 and 12 months (m) after hospital discharge.

METHODOLOGY

Multicentre cohort study in 2020-2022. Including patients with >48 h stay in intensive care units (ICU) and non-COVID-19.

VARIABLES

pre-admission frailty (CFS-Es). Sex, age, days of stay (ICU and hospital), dependency on admission and at 3 m and 12 m after discharge (Barthel index), muscle weakness (Medical Research Council Scale sum score <48), hospital readmissions.

STATISTICS

descriptive and multivariate analysis.

RESULTS

254 cases were included. Thirty-nine per cent were women and the median [Q1-Q3] age was 67 [56-77] years. SAPS 3 on admission (median [Q1-Q3]): 62 [51-71] points. Frail patients on admission (CFS-Es 5-9): 58 (23%). Dependency on admission (n = 254) vs. 3 m after hospital discharge (n = 171) vs. 12 m after hospital discharge (n = 118): 1) Barthel 90-100: 82% vs. 68% vs. 65%. 2) Barthel 60-85: 15% vs. 15% vs. 20%. 3) Barthel 0-55: 3% vs. 17% vs. 15%. In the multivariate analysis, adjusted for the variables recorded, we observed that frail patients on admission (CFS-Es 5-9) are 2.8 times (95%CI: 1.03-7.58; p = 0.043) more likely to increase dependency (Barthel 90-100 to <90 or Barthel 85-60 to <60) at 3 m post-discharge (with respect to admission) and 3.5 times (95%CI: 1.18-10.30; p = 0.024) more likely to increase dependency at 12 m post-discharge. Furthermore, for each additional CFS-Es point there is a 1.6-fold (95%CI: 1.01-2.23; p = 0.016) greater chance of increased dependency in the 12 m following discharge.

CONCLUSIONS

CFS-Es at admission can predict increased dependency at 3 m and 12 m after hospital discharge.

Effectiveness of closed blood sampling systems in intensive care patients: a scoping review

BACKGROUND

Anemia associated with blood extraction for diagnostic purposes is a highly prevalent entity in intensive care units (ICU) for adults. The evidence recommends its prevention through different strategies, among which we can find the use of closed blood sampling systems (CBSS). Different experimental studies support the use of these devices.

OBJECTIVE

To identify knowledge gaps regarding the effectiveness of CBSS in ICU patients.

METHODS

Scoping review with search in PubMed, CINAHL, Embase, Cochrane Library and Joanna Briggs Institute databases, between September-2021 and September-2022. No time, language, or other limits were applied to ensure the recovery of all relevant studies. Gray literature sources: DART-Europe, OpenGrey and Google Scholar. Two researchers independently reviewed titles and abstracts and assessed full texts against the inclusion criteria. The following data was extracted for each study: design and sample, inclusion and exclusion criteria, variables, type of CBSS, results and conclusions.

RESULTS

18 articles were included in the final review, 11 clinical trials (RCTs) published between 1992 and 2014. Three systematic reviews were found, but they only analyzed the effect of CBSS in reducing blood loss, hemoglobin stabilization, and the need for transfusion. Five of the RCTs analyzed the risk of infection, one catheter complications, and two alterations in blood pressure readings.

CONCLUSIONS

The use of CBSS is recommended to reduce blood loss in ICUs. However, there are discrepancies about their ability to prevent anemia and/or the need for blood transfusion. Its use does not increase catheter-related infection rates or alter the measurement of mean arterial pressure.

Blood glucose monitoring in critically ill adult patients: type of sample and method of analysis. Systematic review and meta-analysis

INTRODUCTION

The clinical guideline for the management of sepsis, recommends using arterial blood samples for glycaemic control. A multicentre study in 86 Spanish intensive care units (ICU) revealed that 85.4% of ICUs used capillary puncture.

OBJECTIVE

To analyse the reliability of glycaemia by comparing different blood samples (arterial, venous, capillary) and instruments (glucometers, gasometers, central laboratory). Secondarily, to estimate the effect of confounding variables and the performance of measuring instruments as determined by different quality standards.

METHODOLOGY

Systematic review and meta-analysis with search in PubMed, CINAHL and Embase databases in September-2021 and September-2022, with no time or language limits. Grey literature sources: DART-Europe, OpenGrey and Google Scholar. Results summarised by qualitative (description of results, study characteristics) and quantitative (meta-analysis to assess standardised mean difference) synthesis. Methodological quality of articles assessed with Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2).

PROTOCOL

https://osf.io/ DOI 10.17605/OSF.IO/T8KYP.

RESULTS

A total of 32 articles and 5451 patients were included. No discrepancies were obtained between arterial glucometer vs laboratory samples [bias (95%CI): 0.01 (-0.12 to 0.14) mg/dL]. In contrast, arterial samples with a gasometer did significantly overestimate [bias (95%CI): 0.12 (0.01 to 0.24) mg/dL]. The same trend is seen in capillaries with a glucometer, although not significantly [bias (95%CI): 0.07 (--0.02 to 0.15) mg/dL]. There is discrepancy between studies on the effect of haematocrit and acid-base balance. The greatest consensus is on the poor agreement of glucometer with capillary vs laboratory samples in the presence of shock and vasopressor support, renal failure or during vitamin C treatment.

CONCLUSIONS

The evidence to date recommends the use of arterial blood with a blood glucose meter for better reliability of glycaemic analysis and less effect of possible confounding variables, frequently present in the critically ill adult patient.

[Streamlining of patient discharge and intra-hospital transfer processes using Lean methodology]

INTRODUCTION

The application of Lean methodology in the hospital environment can help to improve interprofessional communication and reduce non-value adding activities (waste).

OBJECTIVE

To determine the effectiveness of the implementation of a visual management tool, in the ability to reduce the number of trips, to determine the location of patients in real time in the process of intra-hospital transfers (ITH) and discharges in a hospital.

MATERIAL AND METHODS

Before-after study in a hospital internal medicine unit. Several time wastes due to unnecessary transfers were detected. A multiprofessional group was formed to design a visual management tool for the resolution of these identified problems. The opinion of the professionals on the tool was evaluated and variables of staff displacement and completion of the tool were measured before and after its implementation.

RESULTS

The personnel involved was trained. Completion of the tool improved over time, both in HIT and in discharges, reducing the number of trips.

CONCLUSIONS

The application of a visual management tool in care processes, including all the personnel involved is effective and saves waste.

The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study

OBJECTIVES

To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement.

METHOD

Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96 h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals).

RESULTS

A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P < .001) and with the provision of training for professionals (P = .020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r = -.431) and in the subgroup of patients with ETT (r = -.521).

CONCLUSIONS

Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.

[Update of the recommendations of the Pneumonia Zero project]

La pandemia por el SARS-Cov-2 ha impactado negativamente en la aplicación de las recomendaciones de Neumonía Zero y se ha acompañado de un incremento de las tasas de Neumonía asociada a ventilación mecánica (NAVM) en las unidades de cuidados intensivos de España. Con el objetivo de disminuir las tasas actuales a 7 episodios por 1000 días de VM, se han actualizado las recomendaciones del proyecto inicial.

Se identificaron, 27 medidas que se clasificaron en 12 medidas funcionales (posición semisentada, higiene estricta de manos, entrenamiento para manipular la vía aérea, valoración diaria de posible extubación, protocolización del destete, traqueostomía precoz, ventilación no invasiva, vigilancia microbiológica, cambio de tubuladuras, humidificación, fisioterapia respiratoria, nutrición enteral postpilórica), 7 mecánicas (control de la presión del neumotaponamiento, tubos con aspiración subglótica, nutrición con sondas de bajo calibre/en intestino delgado, aspiración de secreciones con circuitos cerrados/abiertos, filtros respiratorios, cepillado de dientes, técnicas de presión negativa en la aspiración de secreciones) y 8 farmacológicas (descontaminación selectiva digestiva, descontaminación orofaríngea, ciclo corto de antibióticos, higiene de boca con clorhexidina, antibióticos inhalados, rotación de antibióticos, probióticos, anticuerpos monoclonales).

Cada medida se analizó de forma independiente, por al menos dos miembros del grupo de trabajo, mediante una revisión sistemática de la literatura y una revisión iterativa de las recomendaciones de las sociedades científicas y/o grupos de expertos.

Para la clasificación de la calidad de la evidencia y fuerza de las recomendaciones se siguió la propuesta del grupo GRADE. Para determinar el grado de recomendación, cada medida fue puntuada por todos los miembros del grupo de trabajo en relación con su efectividad, tolerabilidad y aplicabilidad en las UCI españolas a corto plazo de tiempo. Se solicitó el apoyo de expertos externos en alguna de las medidas que se revisaron. Se seleccionaron aquellas medidas que alcanzaron la máxima puntuación.

Care and treatments related to intensive care unit-acquired muscle weakness: A cohort study

BACKGROUND

Intensive care unit-acquired muscle weakness (ICUAW) has an incidence of 40-46%. Early mobilisation is known to be a protective factor.

OBJECTIVE

The aim of the study was to identify the incidence of ICUAW in Spain and to evaluate variables likely to contribute to the development of ICUAW.

METHODS

A 4-month, prospective observational multicentre cohort study was conducted on patients receiving invasive mechanical ventilation for at least 48 h. Data were collected from ICU day 3 until ICU discharge. The primary outcome was presence of ICUAW (diagnosed using the Medical Research Council [MRC] scale). The secondary outcome was nurse-patient ratio, physiotherapist availability, analgesia, sedation and delirium management, glycaemic control, and daily level of mobility during the ICU stay as per the ICU Mobility Scale. A logistic regression model was constructed based exclusively on days 3-5 of the ICU stay.

RESULTS

The data of 642 patients were analysed from 80 ICUs, accounting for 35% of all ICUs in Spain. The incidence of ICUAW was 58% (275 of 474 patients; 95% confidence interval [CI] [53-62]). The predictors for ICUAW were older age (odds ratio [OR] = 1.01; 95% CI [1.00-1.03]) and more days with renal replacement therapy (OR = 1.01; 95% CI [1.00-1.02]). The protective factors for ICUAW were male gender (OR = 0.58; 95% CI [0.38-0.89]), higher Barthel Index (showing prehospital functional independence) (OR = 0.97; 95% CI [0.95-0.99]), more days of being awake and cooperative (defined by a feasible MRC assessment) (OR = 0.98; 95% CI [0.97-0.99]), presence of delirium (OR = 0.98; 95% CI [0.97-0.99]), and more days with active mobilisation (ICU Mobility Scale ≥ 4) (OR = 0.98; 95% CI [0.97-0.99]).

CONCLUSIONS

The risk factors for ICUAW were functional dependence before admission, female gender, older age, and more days on renal replacement therapy. The protective factors for ICUAW were feasibility of MRC assessment, the presence of delirium, and being actively mobilised during the first 5 days in the ICU.

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD

AIMS

Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR.

METHOD

An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units.

RESULTS

One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium.

CONCLUSIONS

The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).

Effect of a training programme on blood culture contamination rate in critical care

Blood culture contamination can occur from extraction to processing; its rate should not exceed 3%.

OBJECTIVE

To evaluate the impact of a training programme on the rate of contaminated blood cultures after the implementation of sample extraction recommendations based on the best evidence.

METHOD

Prospective before-after study in a polyvalent intensive care unit with 18 beds. Two phases were established (January-June 2012, October 2012-October 2015) with a training period between them. Main recommendations: sterile technique, surgical mask, double skin disinfection (70° alcohol and 2% alcoholic chlorhexidine), 70° alcohol disinfection of culture flasks and injection of samples without changing needles. Including all blood cultures of patients with extraction request.

VARIABLES

demographic, severity, pathology, reason for admission, stay and results of blood cultures (negative, positive and contaminated). Basic descriptive statistics: mean (standard deviation), median (interquartile range) and percentage (95% confidence interval). Calculated contamination rates per 100 blood cultures extracted. Bivariate analysis between periods.

RESULTS

Four hundred and eight patients were included. Eight hundred and forty-one blood cultures were taken, 33 of which were contaminated. In the demographic variables, severity, diagnosis and stay of patients with contaminated samples, no differences were observed from those with uncontaminated samples. Pre-training vs post-training contamination rates: 14 vs 5.6 per 100 blood cultures extracted (P=.00003).

CONCLUSION

An evidence-based training programme reduced the contamination of samples. It is necessary to continue working on the planning of activities and care to improve the detection of pollutants and prevent contamination of samples.

[Validating the Spanish version of the Nursing Activities Score]

INTRODUCTION

Validating workload scores ensures that they are appropriate for the purpose for which they were developed.

OBJECTIVE

To validate the Nursing Activities Score (NAS) Spanish version.

METHODOLOGY

Observational and prospective study. 1,045 patients who were admitted to a medical-surgical unit and a serious burns unit in 2006 were included. The nurse in charge assessed patient workloads by Nine Equivalent of Nursing Manpower use Score and NAS. To assess the internal consistency of the measurements of NAS, item-test correlations, Cronbach's α and Cronbach's α corrected by omitting each of the items were calculated. The intraobserver and interobserver reliability were assessed with the intraclass correlation coefficient by viewing recordings and Kappa (interobserver reliability) was estimated. For the analysis of internal validity, a factorial principal components analysis was performed. Convergent validity was assessed using the Spearman correlation coefficient values obtained from the Nine Equivalent of Nursing Manpower use Score and Spanish-NAS scales.

RESULTS

For internal consistency, 164 questionnaires were analysed and a Cronbach's α of 0.373 was calculated. The intraclass correlation coefficient for intraobserver reliability estimate was 0.837 (95% IC: 0.466-0.950) and 0.662 (95% IC: 0.033-0.882) for interobserver reliability. The estimated kappa was 0.371. For internal validity, exploratory factor analysis showed that the first item explained 58.9% of the variance of the questionnaire. For convergent validity 1006 questionnaires were included and a Spearman correlation coefficient of 0.746 was observed.

CONCLUSIONS

The psychometric properties of Spanish-NAS are acceptable.

[Reliability of the measurement of glucose at the bedside of critical patients]

INTRODUCTION

The objective of this study is to measure the reliability of three measurement methods at the bedside of the patient, of glucose in the critical patient compared with the measurement of glucose in the central laboratory.

MATERIAL AND METHODS

Observational, perspective study developed in a polyvalent unit of 18 beds for four months. Patients who had arterial catheter were included. Eight samples obtained at the patient's bedside were compared with the plasma glucose (gold Standard): three in capillary blood, four in arterial blood and one in arterial blood gases from a syringe. The measurements at bedside were conducted with reactive strips MediSense Optium Plus and glucometer MediSense Optium. A comparison was made of the means used in the Student's T test and Bland and Altman analysis.

RESULTS

We obtained 630 samples in 70 patients. Mean glucose (SD) in mg/dl was: a) capillary samples: 149 (38), 149 (35), 147 (37); b) arterial samples: 140 (34), 142 (35), 143 (35), 142 (34); arterial gas sample syringe: 143 (33); c) plasma glucose: 138(33). There were significant differences (p < 0.001) between plasma glucose and capillary samples but not with arterial samples (p=0.2). In the arterial samples, the presence of some factors, such as vasoactive drugs, glycated solution perfusion, insulin perfusion and plasma concentration of hemoglobin, increase error and dispersion regarding the gold standard.

CONCLUSIONS

The measurement of glucose at bedside in critical patients is more reliable in arterial samples than in capillary ones.