A Survey of Rounding Practices in Canadian Adult Intensive Care Units

Objective

To describe rounding practices in Canadian adult Intensive Care Units (ICU) and identify opportunities for improvement.

Design

Mixed methods design. Cross sectional survey of Canadian Adult ICUs (n = 180) with purposefully sampled follow-up interviews (n = 7).

Measurements and Main Results

Medical directors representing 111 ICUs (62%) participated in the survey. Rounding practices varied across ICUs with the majority reporting the use of interprofessional rounds (81%) that employed an open (94%) and collaborative (86%) approach, occurred at the patient’s bedside (82%), and started at a standard time (79%) and standard location (56%). Most participants reported that patients (83%) and family members (67%) were welcome to attend rounds. Approximately half of ICUs (48%) used tools to facilitate rounds. Interruptions during rounds were reported to be common (i.e., ≥1 interruption for ≥50% of patients) in 46% of ICUs. Four themes were identified from qualitative analysis of participant responses to open-ended survey questions and interviews: multidisciplinarity, patient and family involvement, factors influencing productivity, and teaching and learning.

Conclusions

There is considerable variation in current rounding practices in Canadian medical/surgical ICUs. Opportunities exist to improve ICU rounds including ensuring the engagement of essential participants, clearly defining participant roles, establishing a standardized approach to the rounding process, minimizing interruptions, modifying the role of teaching, utilizing a structured rounding tool, and developing a metric for measuring rounding quality.     

Chest Radiography in Intensive Care Units

The role chest radiography plays in intensive care units (ICU) is unlike its role elsewhere because in the ICU a patient''s underlying disease is usually known. Furthermore, additional diseases that develop in the ICU—such as pneumonia, hemorrhage, edema, lung collapse and effusion—often are radiographically indistinguishable. Nevertheless, an ICU radiograph of the chest is valuable, mainly in identifying such complications as malpositioned intravenous catheters, Swan-Ganz catheters, pacemakers, nasogastric tubes, endotracheal tubes, chest tubes, and mediastinal tubes, and ectopic gas related to mechanical ventilation. Understanding the limitations of the portable ICU chest film in the diagnosis of specific diseases and being alert to possible iatrogenic complications will increase the usefulness of ICU chest radiography.     

重症监护病房鲍曼不动杆菌医院感染的调查分析

通过对重症监护病房内鲍曼不动杆菌医院感染的临床特征和耐药性调查分析,为临床更好地预防和治疗该细菌所引起的感染提供参考。对我院2009年1月至2011年12月重症监护病房鲍曼不动杆菌医院感染的107例患者进行回顾性调查。94例患者有严重的基础疾病,与感染相关的因素还包括侵入性操作、深静脉置管、环境污染及长期广谱抗菌药物的使用;药敏结果显示鲍曼不动杆菌几乎均为多重耐药,对碳青霉烯类抗菌药物的耐药率逐年升高,2011年为89.5%。缩短住院时间、加强病区环境和空气监控、尽量减少侵入性操作和合理使用抗生素、规范医疗护理操作、避免交叉感染是减少鲍曼不动杆菌感染发生的重要措施。     

Revisiting Unplanned Endotracheal Extubation and Disease Severity in Intensive Care Units

Most reports regarding unplanned extubation (UE) are case-control studies with matching age and disease severity. To avoid diminishing differences in matched factors, this study with only matching duration of mechanical ventilation aimed to re-examine the risk factors and the factors governing outcomes of UE in intensive care units (ICUs). This case-control study was conducted on 1,775 subjects intubated for mechanical ventilation. Thirty-seven (2.1%) subjects with UE were identified, and 156 non-UE subjects were randomly selected as the control group. Demographic data, acute Physiological and Chronic Health Evaluation II (APACHE II) scores, and outcomes of UE were compared between the two groups. Logistic regression analysis was used to identify the risk factors of UE. Milder disease, younger age, and higher Glasgow Coma Scale (GCS) scores with more frequently being physically restrained (all p<0.05) were related to UE. Logistic regression revealed that APACHE II score (odds ratio (OR) 0.91, p<0.01), respiratory infection (OR 0.24, p<0.01), physical restraint (OR 5.36, p<0.001), and certain specific diseases (OR 3.79–5.62, p<0.05) were related to UE. The UE patients had a lower ICU mortality rate (p<0.01) and a trend of lower in-hospital mortality rate (p = 0.08). Cox regression analysis revealed that in-hospital mortality was associated with APACHE II score, age, shock, and oxygen used, all of which were co-linear, but not UE. The results showed that milder disease with higher GCS scores thereby requiring a higher use of physical restraints were related to UE. Disease severity but not UE was associated with in-hospital mortality.     

医院感染阴沟肠杆菌的耐药性及基因型分析

了解中南大学湘雅三医院重症监护病房(ICU)医院感染阴沟肠杆菌的耐药谱及分子流行病学特征,指导临床合理用药。基因分型采用优化反应体系的随机扩增多态性DNA(RAPD)法,耐药分析选用K-B法。RAPD分型将28株阴沟肠杆菌分为11种株型,耐药谱则将其分为12种不同的耐药型。基因分型和耐药分析显示ICU有多重耐药的阴沟肠杆菌株爆发流行现象,它为控制阴沟肠杆菌的医院内感染、追踪传染原、切断传播途径提供遗传学信息,指导临床医生选用敏感有效的抗生素。     

重症监护病房常见非发酵菌分布及耐药性分析

分析医院重症监护病房非发酵菌感染的耐药情况,以指导临床合理使用抗菌药物。回顾性分析2009~2010年医院自重症监护病房分离的非发酵菌,对其检出率及药敏结果进行统计分析。共检出96株非发酵菌,检出率为19.79%,分离率居前4位的依次为铜绿假单胞菌（46.88%）、鲍氏不动杆菌（21.88%）、嗜麦芽寡养单胞菌（15.63%）、洋葱伯克霍尔德菌（10.42%）;4种常见的非发酵菌对常用的抗菌药物耐药性均较高,头孢哌酮/舒巴坦等含酶抑制剂的复合型抗菌药物对非发酵菌有较高的敏感性。医院重症监护病房非发酵菌检出率高且耐药性强,应加强临床细菌学的检测,按照药敏试验结果合理用药。     

Differences in Clinical Outcomes According to Weaning Classifications in Medical Intensive Care Units

Background

Although the weaning classification based on the difficulty and duration of the weaning process has been evaluated in the different type of intensive care units (ICUs), little is known about clinical outcomes and validity among the three groups in medical ICU. The objectives of this study were to evaluate the clinical relevance of weaning classification and its association with hospital mortality in a medical ICU with a protocol-based weaning program.

Methods

All consecutive patients admitted to the medical ICU and requiring mechanical ventilation (MV) for more than 24 hours were prospectively registered and screened for weaning readiness by a standardized weaning program between July 2010 and June 2013. Baseline characteristics and outcomes were compared across weaning classifications.

Results

During the study period, a total of 680 patients were weaned according to the standardized weaning protocol. Of these, 457 (67%) were classified as simple weaning, 136 (20%) as difficult weaning, and 87 (13%) as prolonged weaning. Ventilator-free days within 28 days decreased significantly from simple to difficult to prolonged weaning groups (P < 0.001, test for trends). In addition, reintubation within 48 hours after extubation (P < 0.001) and need for tracheostomy during the weaning process (P < 0.001) increased significantly across weaning groups. Finally, ICU (P < 0.001), post-ICU (P = 0.001), and hospital (P < 0.001) mortalities significantly increased across weaning groups. In a multiple logistic regression model, prolonged weaning but not difficult weaning was still independently associated with ICU (adjusted OR 8.265, 95% CI 3.484–19.605, P < 0.001), and post-ICU (adjusted OR 3.180, 95% CI 1.349–7.497, P = 0.005), and hospital (adjusted OR 5.528, 95% CI 2.801–10.910, P < 0.001) mortalities.

Conclusions

Weaning classification based on the difficulty and duration of the weaning process may provide prognostic information for mechanically ventilated patients who undergo the weaning process.     

Molecular Characterization of Vancomycin-Resistant Enterococcus faecium Isolated from Intensive Care Units

To assess the molecular characterization of disseminated vancomycin-resistant enterococci (VRE) in the intensive care units, 546 enterococci isolates were collected from different clinical samples in a prospective observational study. The results showed that a total number of 33 isolates (6 %) were resistant to vancomycin. Most of the VRE isolates 11 (34 %) were isolated from intensive care units (ICUs). 18 (55 %) VRE isolates were obtained from urinary tract infections. The results from pulsed-field gel electrophoresis showed five common types (CT) and 13 single types (ST) among the VRE isolates. The analysis showed two and one major CTs and ST among the ICUs isolates, respectively. Tn1546 transposon was analyzed using ClaI-digested long PCR (L-PCR) RFLP followed by sequencing. The results showed the presence of two different lineages of transposon among the two clonal groups. Lineage 1 with the arrangement of Tn1546 prototype in the first clonal group and the second lineage with 13 kb harboring two insertion sequences, IS1216 V and IS1542. DNA hybridization showed that vanA gene in all VRE isolates, with an exception of one isolate, was present in the same location on the genome. Overall, the results suggest that a few VRE clonal types were disseminated in ICUs in hospitals in Iran which were able to transfer their vanA with high conjugation frequency.     

Animal-Assisted Therapy and Depression in Adult College Students

Abstract

This study investigated the effects of animal-assisted therapy (A-AT) on self-reported depression in a college population. Forty-four participants were selected on the basis of scores on the Beck Depression Inventory (BDI). They then were assigned to one of three groups: A-AT in conjunction with psychotherapy (directive group), A-AT only (nondirective group), and control. Standardized regressed BDI posttest scores were used as dependent variables in one-way analysis of variance with treatment as the independent variable. Results revealed significant differences among groups, F(2,41)=3.69, p<.05. Duncan's Multiple Ranges Test indicated that standardized regressed BDI post-test scores differed significantly between nondirective (M=5.67) and control groups (M=10.18).     

重症监护病房的病原调查及耐药性监测研究

目的调查浙江中医药大学附属第一医院重症监护病房（ICU）临床分离株的病原分布及细菌耐药状况,并与非ICU相比较,观察二者的区别,为临床用药提供有效的参考价值。方法收集该院2010年1月至2011年6月临床送检的各类标本,采用VITEK-2 compact全自动微生物鉴定仪,用GPI、GNI、ANC、YST鉴定卡、AST—GN13、AST—GP67药敏卡进行菌株的鉴定和药敏,根据美国临床实验室标准化协会（CLSI2010）制定的指导原则,判断细菌的耐药率。结果共计分离到2341株细菌,其中ICU有505株占21．6％,非ICU有1836株占78．4％。在ICU分离到的细菌中,革兰阳性菌占23．2％（117／505）;非发酵菌占47．3％（239／505）。在非ICU中,革兰阳性菌占34．4％（632／1836）;非发酵菌20．2％（371／1836）。ICU前3位细菌分别为鲍曼不动杆菌、肺炎克雷伯杆菌、洋葱伯克霍尔德菌。非ICU前3位依次为大肠埃希菌、金黄色葡萄球菌、铜绿假单胞菌。非发酵菌中,铜绿假单胞菌和鲍曼不动杆菌对哌拉西林／他唑巴坦、头孢他啶、头孢吡肟、亚胺培南、美洛培南的耐药率,ICU和非ICU差异有统计学意义（P〈0．05）。亚胺培南对ICU铜绿假单胞中的MIC50是非ICU的8倍,MIC。值相当。ICU与非ICU分离的葡萄球菌属细菌对头孢唑啉、环丙沙星、左旋氧氟沙星的耐药率差异有统计学意义（P〈0．05）。ICU和非ICU葡萄球菌对利奈唑胺、万古霉素、替考拉宁全部敏感。结论ICU患者分离的细菌以革兰阴性菌为主,其中又以非发酵菌占大多数。非ICU患者分离的革兰阳性菌比例明显要比ICU高。在主要的致病菌中,ICU的耐药率明显高于非ICU。     

Predisposing Risk Factors for Delirium in Living Donor Liver Transplantation Patients in Intensive Care Units

Background

Delirium is one of the main causes of increased length of intensive care unit (ICU) stay among patients who have undergone living donor liver transplantation (LDLT). We aimed to evaluate risk factors for delirium after LDLT as well as to investigate whether delirium impacts the length of ICU and hospital stay.

Methods

Seventy-eight patients who underwent LDLT during the period January 2010 to December 2012 at a single medical center were enrolled. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scale was used to diagnose delirium. Preoperative, postoperative, and hematologic factors were included as potential risk factors for developing delirium.

Results

During the study period, delirium was diagnosed in 37 (47.4%) patients after LDLT. The mean onset of symptoms occurred 7.0±5.5 days after surgery and the mean duration of symptoms was 5.0±2.6 days. The length of stay in the ICU for patients with delirium (39.8±28.1 days) was significantly longer than that for patients without delirium (29.3±19.0 days) (p<0.05). Risk factors associated with delirium included history of alcohol abuse [odds ratio (OR) = 6.40, 95% confidence interval (CI): 1.85–22.06], preoperative hepatic encephalopathy (OR = 4.45, 95% CI: 1.36–14.51), APACHE II score ≥16 (OR = 1.73, 95% CI: 1.71–2.56), and duration of endotracheal intubation ≥5 days (OR = 1.81, 95% CI: 1.52–2.23).

Conclusions

History of alcohol abuse, preoperative hepatic encephalopathy, APACHE II scores ≥16 and endotracheal intubation ≥5 days were predictive of developing delirium in the ICU following liver transplantation surgery and were associated with increased length of ICU and hospital stay.     

Fungal Microbiota in Air-Conditioning Installed in Both Adult and Neonatal Intensive Treatment Units and Their Impact in Two University Hospitals of the Central Western Region,Mato Grosso,Brazil

To evaluate fungal microbiota in air-conditioning units installed in intensive care units in two university hospitals in Cuiaba city, Mato Grosso, central western region of Brazil, 525 solid environmental samples were collected, 285 from Hospital A and 240 from Hospital B. Collections were performed using sterile swabs on air-conditioning unit components: cooling coils, ventilators, and filters. Mycelial fungi identification was achieved by observation of the macroscopic and micromorphological characteristics in different culture mediums (maize meal, oatmeal and potato dextrose agars and malt extract) using the Ridell technique. Eleven genera and 27 distinct species belonging to the hyphomycetes and ascomycetes classes were isolated and identified. The most frequently detected genera in both hospitals were Aspergillus spp, Penicillium spp, and Cladosporium spp. Values for colony-forming units per gram were 64 and 75%, well above the limits recommended by Health Ministry resolution 176/00 at the locations selected for analysis in Hospitals A and B, respectively. In conclusion, evaluation of fungal microbiota in the air-conditioning units indirectly determined that the air quality was compromised in both university hospitals analyzed, which constitutes a risk factor for the acquisition of infection in the intensive care units.