E Patrick, S McKechnie, I Ausa, L Frost, W Arumemi-Ikhide. 23. First use of .... S Knight, R Frank, T Thomas. 83. ... M Thomasâ¡, J Soar§, J Nolan~, J Bengerâ¡+¶.
Clinical Practice Poster Presentations Each poster has been given a number. This relates to its poster board number. 1.
Survey of management of cardiac arrest survivors in UK intensive care units AH Ford, T Clark, K Shelley, EC Reynolds, C Ross, L Simmonds, M Thomas, J Soar, J Nolan, J Benger
2. Improving the quality of documentation during intra-hospital transfer of level three patients A Bartram, G Gibbon, A Howatson
3. A bundle of care to reduce catheter-related blood stream infection in a general ICU L Bates, A Griffiths, C Lamont, A Hall
4. Just pregnant or critically unwell? Four-year review of obstetric patients admitted to a district general intensive care unit A Cavalier, B Bray
5. Internet-based feedback improves departmental teaching A J Clarkin
6. Tracheostomy in a neurosciences intensive care: a two-year prospective observation B Millette, S Raby, D Shlugman, H Madder
7.
Complications related to tracheostomy tube change outside intensive care: evaluation of our practice B Kathiresan, T Quinnell, K Slack
8. Pre-morbid performance status and intensive care outcome B Sloan, B Besteiro-Grandio, L Eyre
9. ICU blood test profiles — do we need to test everything? C Kaye
10. Not ready for the ward — A feasibility study for the development of a bridging facility between high dependency care and the ward CV Higenbottam, H Harvey, R Browne, A Barrios
11. Does a high standardised mortality ratio indicate poor quality care? Retrospective analysis of ICNARC coding method and Apache II scoring with case record review C V Higenbottam, J F Bion
12. Patient feedback from intensive care patients, what can it tell us and what are the implications for revalidation? C Heath, TE Sams, S Bonner, J Mullenheim
13. An audit of temporary tracheostomy practice — introduction of a hospital care pathway to improve tracheostomy care C Dixon, R Lathey, C Sri-Chandana
14. Kinetic glomerular filtration rate (KeGFR) may predict need for renal replacement therapy CD Newson
15. An audit of ICS core standards in a neurosciences intensive care unit D Wood, B Millette, S Raby
16. Austerity in the NHS: small changes can make a difference D Fawkes, K Kiff
17. Rethinking and redesigning ICU escalation pathways for critically unwell patients D Katarey, A Curtis
18. Comparison of two methods of controlled temperature management after out-of-hospital cardiac arrest H Hendra, D Hall
19. Vancomycin infusion audit D Macrosson, A Crosby, J Roberts, A Wallis
20. A review of elective surgical patients admitted postoperatively to the intensive care unit E Senver, R Maeda, R Howard-Griffin
21. Critical care outreach Boussignac CPAP: an interim CPAP service evaluation E Senver, L Carpenter, R Lloyd
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22. Lung protective ventilation in mechanically ventilated theatre patients E Patrick, S McKechnie, I Ausa, L Frost, W Arumemi-Ikhide
23. First use of veno-venous membrane gas exchange in a district general hospital EA Quinn, AD Walder
24. Critical care outreach — delivering high-flow nasal oxygen therapy on the wards E Helme, C Ruse, R Loveridge
25. Early onset pneumonia post cardiac arrest in the era of normothermia SWARM
26. Variation in antibiotic therapy for pneumococcal septicaemia: a case series E Howells, E Nelson
27. Safer fluid prescribing — a foundation doctor-led quality improvement project EC Reynolds, D Paul, J Andersson, T Bull, R Hair, K Trivedi, H Eisenhauer, M Davies, A Nishimura, D Maggs, J Lloyd, S Clapham, A Jetley, B Plumb
28. Hantavirus cardiopulmonary syndrome secondary to Choclo virus: a case report EC King, SC West, TO Brougham, LJ Herbert, AQA Teo, SL Todhunter, B Bovill, EJ Aarons, JM Brown
29. Aetiology and outcome of critically ill patients undergoing renal replacement therapy: a retrospective study F Khan, S Mohamed, J Szafranski
30. Chest injury and intensive care: outcomes from a major trauma centre IT Smith, R Lowsby, N Bhuiyan
31. Diagnosing death: a prospective audit of knowledge and practice in diagnosing and certifying death IJ Whitehead, JC Wright, S Bonner
32. Introducing citrate anticoagulation for CRRT — interim report I Otahal, P Havalda, S Miles
33. The Kingston perioperative optimisation pathway: a quality improvement project M Rojo, JW Zwaal
34. Use of inhaled nitric oxide in intensive care for the management of severe acute respiratory distress syndrome in haemoncological patients J Pennington, K Sprigge, J Mawby, S Cone, J Down
35. How is your unit using the new ICS core standards? A “gap analysis” in Oxford J Strachan, S McKechnie
36. Safety monitoring for propofol infusion: are we doing enough? JL Gross, A Prasad, M Kadr, AA Radia
37. A sustained progressive reduction in the acquisition of MRSA colonisation across an 18-bedded level 3 mixed neurosurgical and general intensive care unit A Neumann, M Ghrew, E Parkin, E Boxall, S Chinari, J Naisbitt
38. Zero Clostridium difficile acquisition in an 18-bedded level 3 mixed neurosurgical and general intensive care unit: a three-year quality improvement clinical practice intervention E Parkin, A Neumann, E Boxall, A Jeans, J Naisbitt
39. Increasing the likelihood of awakening from coma through auditory stimulation J Daltrozzo, CM Conway
40. Do no harm? The perils of infection control J Breeze, E Smithson, L Poole
41. Not all cirrhotics are equal: acute-on-chronic liver failure in the ICU J Millar, J McPeake, R Fulton, J Kinsella
42. The use of therapeutic hypothermia following cardiac arrest at Basingstoke and North Hampshire Hospital J Cassell, J Kinsella, K Oliver
43. Attitudes to co-enrolment on intensive care: nursing opinions reviewed KM Wilkinson, M Bland, A Krige
44. Sitting patients out of bed in intensive care: a focus group evaluation of physiotherapists’ experiences and culture L Osman, A Curtis, G Cork
45. A strategy for quality improvement on ICU M Powell, G Randhawa, B Sloan, A Breen
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46. Teaching acute illness management in Uganda M Jackson, S Whiting, S Cook, L Byrne-Davis, J Hart, H Slattery, R McCarthy, G Yuill, M Surgenor, A Stevens, G Byrne
47. Abstract withdrawn
48. Emergency management of tracheostomy (EMT) box: a patient safety initiative M McAlindon
49. Management of tracheostomy on intensive care at QEHB M McAlindon, R O’Leary, J Sinnott, L Allen, N Abeysinghe
50. Root cause analysis for all intensive care admissions: a useful tool for improving care of the deteriorating patient? M McEvoy, T Hirst, J Wood, A Gerrard
51. Non-invasive ocular microtremor measurement technology for rapid assessment of comatose patients in intensive care M Norkus, D Coakley, G Boyle
52. Should all high-risk elective surgeries have cardio-pulmonary exercise testing as part of preoperative assessment? G Bagchi, N Santana-Vaz, B John, L Linhartova, E Parkes, B Chakraborty, R Mukherjee
53. Effect of a weekly ventilation multidisciplinary meeting on respiratory patients’ journey through intensive care — a retrospective observational study N Santana-Vaz, B Chakraborty, K Morley, G Raghuraman, R Mukherjee
54. Patients being ventilated with a cuff-inflated tracheostomy can safely be fed an oral diet N Ledlie, T Cobby
55. CPET in colorectal patients: it’s more than just an anaerobic threshold NR Plummer, C Slawinski, D Richardson, T Owen, S Laha, A Jadav
56. Trainee working patterns — referrals to the ICU K Arulkumaran, N Arulkumaran
57. Speciality involvement and consultant review in intensive care: audit of practice against ICS core standards for intensive care units guideline N Fahmy, C Iwegbu , C Barrot, GPS Bawa
58. Time for admission to intensive care: audit of practice against ICS core standards for intensive care units guideline N Fahmy, C Barrot, C Iwegbu, GPS Bawa
59. Obstetric intensive care admissions to a Scottish tertiary referral centre: a five-year review O Robinson, M Beatty, A Wise
60. The impact of being an obstetric and intensive care tertiary referral centre O Robinson, M Beatty, A Wise
61. One-year outcome of intensive care patients with chronic liver disease, including possible prognostic factors O Oxenham, A Kuravi, W Malein
62. Developing and implementing an intensive care unit airway alert P Austin, S Cole
63. Quality indicators in Scotland: developing and implementing a family experience survey P Austin, S Crofts, S Cole
64. Documentation of ceilings of care in the intensive care unit P Shepherd, P Alexander
65. Tracheostomy training for foundation doctors PD Frank, J Sharpley
66. Improving the patient journey of unscheduled ward admissions to the intensive care unit PS Parulekar, E Bodenham, V Halai, V Brown, P Anderson
67. Audit on the use of ideal body weight in calculating lung protective tidal volumes RK Basra, G Packer, C Bassford
68. Improving the safety of airway management for intensive care patients across the Greater Manchester region R Frank, R Hine, L Bates, on behalf of Greater Manchester Critical Care Network RICON Airway group The State of the Art 2014 Meeting
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69. Factors associated with 180-day mortality in patients with non-haematological malignancy admitted to ICU R Fisher, L Starsmore, C Dangoisse, T Manickavasagar, S McGrath, F Chatterjee, C Whiteley, S Crichton, M Ostermann
70. Difficult airway management on the intensive care unit — a multidisciplinary approach to improving patient safety R Briscoe, D Fabbroni, J Horn, S Hale
71. Electrode placement for five-lead electrocardiogram monitoring R Harris, R Wenstone, L Poole
72. An audit into end-of-life care in a district general intensive care unit R Loveridge, A Goodwin, S Surapaneni
73. Improving antimicrobial stewardship in intensive care: the impact of introducing procalcitonin testing in two district general hospital intensive care units C Williams, T Woodward, C Brookes, N Patel, P Moore, R Orme
74. Chest X-ray interpretation in UK intensive care units: a 2014 survey R Spiritoso, T Pirani, S Patel, J Martin, S Singh
75. Acute kidney injury diagnostic alerts and outcomes of patients presenting to the emergency department R Haines, L Oliver, C Kirwan, K Ahmad, J Prowle
76. Platypnoea orthodeoxia syndrome: a case of postoperative hypoxaemia S Scott, M Wayman
77. Six-year audit of outcome of patients with haematological malignancy admitted to intensive care S Taylor, M Singh, I Grant, K Raveendran
78. A review of tracheostomy practice in a teaching hospital intensive care unit L Poole, L Bethell, A Roberts, S Harwood
79. Lipid emulsion therapy: successful use in complex non-local anaesthetic drug overdose S Kabadayi, S Flood, P Jackson, A Padmakumar
80. Iatrogenic blood loss in intensive care units — a pervasive problem S Karmali, M Raza, D Walker
81. Prophylactic plasma and platelet transfusions before interventional radiological procedures: an audit and national survey (abstract not available) SP Hibbs, S McKechnie, MW Little, R Uberoi, M Desborough
82. An audit of acute respiratory distress syndrome across the Greater Manchester Critical Care Network S Knight, R Frank, T Thomas
83. Ventilator-associated pneumonia rates as a quality indicator — can current scoring systems be used? S Shuttleworth, N Wee, H Reschreiter
84. A standardised form for interhospital patient transfer TEP Blanks, M Daunt, A Feerick, A Wolverson
85. Fast is fine, but accuracy is everything; a technical evaluation of the Gem Premier 4000 blood gas analyser T Pratt, J Davies, J Cranshaw
86. Case presentation — peripartum cardiomyopathy requiring ECMO TG Martindale, M Jonas
87. Echocardiography in a general intensive care unit — a service evaluation T Greenway, J Glen, S Bruemmer-Smith
88. Utilisation of intensive care unit services in the management of parturients with grown-up congenital heart disease TAC Snow, D Walker, F Walker
89. Grown-up congenital heart disease intensive care admissions; an eight-year experience TAC Snow, D Walker, F Walker
90. Weight and height inaccuracies in intensive care TC Thomas, S McKechnie
91. Implementing red cell transfusion guidelines in critically ill patients VJ Page, SM Chan, A Casarin, H Payne, S Bradley
92. Comparison of the National Early Warning Score with a local Early Warning Score, in acute burns patients, in a UK regional burns unit V Marsh, JM Handy, A Blay
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93. Dexmedetomidine in ICU: right drug for the right patient? V Peacock, A Padmakumar, L Langton
94. Early antibiotics in post cardiac arrest patients V Paul, K Shuker, A Morgan, A Temple
95. Inadvertent hyperthermia in traumatic brain injury L Van Turenhout, V Sathianathan, C Gomez
96. Management of patients with traumatic brain injury and an abbreviated injury score of 3 or greater at a district general hospital; January to December 2012 W Allan, I Blaskovics, H Madder, C Sweasey, F Jeddi, J Sheehan, A McAndrew, R De Caux, L Keating
97. The association between mortality and intensive care unit length of stay for surgical admissions (abstract not available) M Hameed, M Maruthappu, DC Marshall, J Salciccioli, J Shalhoub
98. iCoughUKTM — reducing postoperative pulmonary complications M Moatari, H Owen, J Lewis, D Atkinson, J Boorman, D Cummings, D Conway, P Rosenkranz, K McCabe, J Moore
99. Nurse satisfaction with a continuous cuff pressure control device N Smith, V Martinson, L Sleight, R Bennett
100.Citrate anticoagulation in continuous renal replacement therapy — a service evaluation A Mizen, C Swanevelder, H Gilbrook, R Fenton, S Hart, C Burbridge, K Charlton, M Hall, C Bolwell
101. Is the FIM+FAM a useful outcome measure in long-term intensive care follow-up? G Pound, C Purkiss, S Cooke
102.Night discharges from intensive care unit: Trends and impact on readmission and mortality rate (abstract not available) M Michael
103.Critical analysis of cardiac arrests: going beyond outcomes L Barker, J Kinnear, G Donohue, D Higgins
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1.
Survey of management of cardiac arrest survivors in UK intensive care units
AH Ford*, T Clark†, K Shelley*, EC Reynolds*, C Ross*, L Simmonds*, M Thomas‡, J Soar§, J Nolan~, J Benger‡+¶ *Severn Deanery, Bristol, UK. †Peninsula Deanery, Plymouth, UK. ‡University Hospitals Bristol, UK. §Southmead Hospital, Bristol, UK. ~Royal United Hospital, Bath, UK. +University of the West of England, UK. ¶Urgent Care for NHS England, UK Survivors of cardiac arrest are commonly admitted to intensive care. We undertook a standardised telephone survey of intensive care units (ICUs) in the UK to assess the interventions they offer to these patients. All 235 UK ICUs were contacted with 208 responses (89%). All these units admitted comatose survivors of in- or out-of-hospital cardiac arrest. Most units (82.7%), follow a protocol for the management of these patients. Access to emergency cardiology services varied, with percutaneous coronary interventions (PCI) available 24 hours a day, seven days a week in only 26% of hospitals. A further 6.7% had PCI available during working hours Monday-Friday, whereas most hospitals (55.8%) transferred patients to other units. Just 1.4% of hospitals had another arrangement to access PCI and 5.3% of hospitals reported no access to PCI. Nearly all units use a ventilator care bundle (94.7%), control blood sugar (98.1% with 97.1% aiming for blood sugar 300 micromol/L is used. In steady state glomerular filtration rate (GFR) can be estimated (eGFR) using a formula, such as the Modification Diet in Renal Disease Study (MDRD) equation.1 In acute renal failure while serum creatinine is rising the eGFR will overestimate the GFR and during recovery underestimate the GFR. If the change in creatinine is taken into account a better estimate of GFR can be obtained. Various complicated formulae have been produced but in 2013 a relatively simple equation requiring only serum creatinine measurements was published.2 This equation has be used in a spread sheet to calculate and plot the KeGFR. The KeGFR could either be used as indicator in own right or could be used to predict the maximum creatinine. The equation uses two terms. This first estimates the creatinine production by multiplying the steady state creatinine plasma creatinine (SSPCr) by creatinine clearance (CrCl). This can be replaced by a plasma
creatinine and corresponding eGFR. Dividing by mean plasma creatinine (MeanPCr) leads to the eGFR. The second term adjusts for the change in plasma creatinine (DPCr) as a fraction of the maximum rise in plasma creatinine per day (MaxDPCr/day) if the pateint is anuric. The MaxDPCr/day can be used empirically as 130 micromol/L. (The equation uses hours between samples DTime(h) and so divides the MaxDPCr/day by 24). SSPCr * CrCl 24 * DPCr KeGFR = * 1– MeanPCr DTime(h) * Max DPCr/day
(
)
The graph data plotted retrospectively for a patient on ICU. The creatinine and eGFR are plotted when the samples were taken and the KeGFR at the midpoint between the two samples. At ‘A’ the creatinine had risen but not to a level that RTT would be consider. The KeGFR had fallen to 10 mL/min/1.73 m2, which corresponds to a steady state plasma creatinine of approximately 350 micromol/L. However it was only at point ‘B’ that RTT was started. Use of KeGFR may have allowed RRT to have been started at any time from ‘A’ onwards. References 1. Levey AS, Bosch JP, Lewis JB et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med 1999: 130:461-70. 2. Chern S. Retooling the creatinine clearance equation to estimate kinetic GFR when the plasma creatinine is changing acutely. JASN 2013;24:877-88.
15. An audit of ICS core standards in a neurosciences intensive care unit D Wood, B Millette, S Raby John Radcliffe Hospital, Oxford, UK The Intensive Care Society published its “Core standards for intensive care units”1 in November 2013 that apply to all units caring for level two or three patients in the UK. These 57 standards cover a range of domains including staffing, operational, equipment and data collection. Their aim is to provide evidence-based recommendations to serve as a framework for the improvement of patient care and outcome. In January 2014 we audited our hospital’s neurosciences intensive care unit to determine whether we meet these standards. We assessed all 57 of these standards. Some required interviewing relevant members of the multi-disciplinary team to ascertain staffing levels and care was provided. Clinical criteria required a “snapshot” audit of notes and a retrospective review of discharges in order to gain appropriate data. The results for each standard were categorised into full compliance, partial compliance and non-compliance. Of the 57 standards, the neuroscience unit was fully compliant with 33 standards, partially with 15 standards and non-compliant with nine standards. All of the areas for improvement were to be found in the staffing and operational domains. These could be broadly divided into resource issues and documentation issues. Resource allocation concerns included out of hours resident doctor: patient ratio; occasional difficulties with levels of nursing staff; pharmacy support, and lack of access to a follow-up
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clinic. Documentation concerns included recording presence of all MDT professionals at the ward round, regular documentation of the evening round, decisions regarding admission and discharge being clearly documented and clear documentation of a treatment plan as discussed with a consultant. Documentation of decision to admit was often lacking, but this reflects the units role as a tertiary referral centre with patients accepted by a neurosurgeon from surrounding hospitals, requiring transfer and often immediate neurosurgical intervention prior to admission. We presented this data at a local clinical governance meeting to raise awareness of the areas for improvement and to generate a discussion regarding the core standards. Our institutional experience of applying these standards has been generally positive and we have adopted a pragmatic approach to easily correctable documentation issues before tackling the more difficult staffing concerns. Unfortunately re-audit of the clinical domains in July 2014 showed little progress, especially regarding documentation of ward-rounds and multi-disciplinary input. Further discussions on how to move forward are on-going, including templatelabels or moving to an electronic record. Declaration No conflicts of interest declared. Reference 1. Intensive Care Society. Core standards for ICU 2014. http://www.ics.ac.uk/icshomepage/guidelines-standards Accessed 6/8/14.
reviewing the patient at a later time. This project demonstrates that significant changes can be made with determination, cooperation and patience, no matter how small or trivial the idea may appear to be. References 1. NHS England. The NHS belongs to the people: A call to action. 2013. 2. Monitor. Closing the NHS funding gap: how to get better value health care for patients October 2013.
17. Rethinking and redesigning ICU escalation pathways for critically unwell patients D Katarey, A Curtis Kingston Hospital, Kingston Hospital Trust, London, UK The National Early Warning Score (NEWS) is an internationally validated “track and trigger” tool used to identify unwell patients requiring clinical escalation,1 including to an intensive care unit (ICU). At current, not all hospitals use NEWS as the National Institute of Clinical Excellence recommends that routine observations with locally defined thresholds for escalation is acceptable.2 We compared the local escalation pathway at Kingston Hospital Trust (Table 1) with the NEWS pathway to determine which confers optimal patient care. Escalate to FY1/FY2/SHO and/or Outreach if any two or more of the following are present:
16. Austerity in the NHS: small changes can make a difference
Patient unresponsive or only responsive to pain
D Fawkes, K Kiff Broomfield Hospital, Chelmsford, UK
O2 saturations ≤90%
Requirements of NHS health care are increasing as patients live longer, with more complex health problems and advancement of treatment options.1 The Nuffield Trust and NHS England have made projections that the funding gap in the NHS could grow to £30 billion a year by 2021.2 It is my responsibility as a healthcare professional to ensure that utilisation of resources is both efficient and rationalised. Therefore, I embarked on a project to diminish spending on unnecessary blood tests. A pre-set bundle of blood test investigations are requested daily for general and burns intensive care unit (ICU) patients at Broomfield Hospital. This existing bundle was compared to a protocol approved by the ICU consultants that removed total carbon dioxide and glucose in both ICU’s with the additional elimination of C-reactive protein (CRP) from general ICU. The blood test costs provided by the pathology laboratory were; total carbon dioxide £1.09, glucose £1.04 and CRP £1.17. The number of tests and associated expenditure were then compared for the period April to July 2012. If the proposed investigation bundle had been used each month it would have avoided 1,073 unnecessary tests totalling a potential saving of £1,182.55. This projected to an annual saving of approximately £14,000. These results were encouraging for such a simple idea. The surplus investigations were consequently removed from the daily bundle in August 2012 and staff were inducted with the new system of ordering bloods. To assess the effects of the change implemented I compared the number of tests ordered before and after August 2012 with respect to the cost of each investigation and ICU bed occupancy. There was a reduction in cost of tests per bed occupancy of £3.34 in general ICU and £0.49 in burns ICU. Extrapolating figures using average monthly bed occupancies equated to a total saving of £870.14 a month and £10,441.68 per year. I also completed audits in the emergency assessment unit (EAU) and emergency department (ED) with the same intention. I created a protocol of recommended initial blood tests for various patient presenting complaints. A 24 hr audit in EAU revealed a possible £100.80 reduction in expenditure if my protocol had been used for blood test selection. A retrospective audit of 60 patients in the ED indicated a potential saving of £50,000 a year. There has been difficulty implementing the protocol as staff are reluctant to omit investigations for fear it may result in a mistake or criticism by those
Pulse 60 yr scheduled to undergo major colorectal surgery referred for CPEX testing between March 2012-March 2013. High risk patients defined as: anaerobic threshold (AT) 42 on CPEX testing. Low risk patients defined as: AT ≥11 and VeO2 ≤42 on CPEX testing. Morbidity was assessed with the postoperative morbidity survey.1 Benchmarks: Morbidity – 30%, LOS – 10 days, use of intraoperative Doppler monitoring – 100%, optimisation in ICU in high risk patients – 100%. A logistic regression analysis was performed to determine Odd ratios + 95 % confidence intervals for predictors of morbidity. Differences between categorical and continuous variables tested with chi square and T-testing respectively p=87:658;7>
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Acknowledgements No source of funding or conflict of interest exists.
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Clinical practice poster presentations
From 70 patients who were assessed on data collection days, 48 patients (69%) were sedated with propofol at some point during their admission. Of these 48 patients mean age was 61 (range 25-87) years and 42% were female. The median duration for continuous propofol infusion was 43 (range 1-430) hours. Twenty-one patients (44%) received propofol continuously for more than 48 hours and 10 patients (20.8%) had received infusion doses greater than 4 mg/kg/hr. Forty-three patients (90%) had two or more risk factors for PRIS (range 1-7). Monitoring for PRIS was poor with only two patients (4%) having CK measured and three patients (6%) having had serum triglycerides measured. All three of these patients had elevated serum triglycerides. The mean plasma level was 6.59 (range 3.988.95) mmol/L. Of these three patients, all received propofol for >48 hours with mean infusion duration of 283 (range 200-400) hours, two had doses >4 mg/kg/hr and each patient had five or more (range 5-7) risk factors for PRIS. Although commonly used in the intensive care setting, continuous propofol infusion may be hazardous particularly when used for long duration and at high doses. Avoiding PRIS requires meticulous screening for risk factors and appropriate monitoring for signs of PRIS, both of which are likely to vary between critical care units and require improvement at our institution. A new screening tool is suggested (Figure 1). Reference 1. Loh NH W, Nair P. Propofol infusion syndrome. Contin Educa Anaesthesia, Crit Care Pain 2013;13,200-02.
37. A sustained progressive reduction in the acquisition of MRSA colonisation across an 18-bedded level 3 mixed neurosurgical and general intensive care unit A Neumann, M Ghrew, E Parkin, E Boxall, S Chinari, J Naisbitt Salford Royal NHS Foundation Trust, UK A five-year quality improvement clinical practice intervention was set up in order to achieve a 70% reduction in the incidence of MRSA colonisation acquisition within the intensive care unit (ICU) at SRFT within one year and further reductions sustained year on year. In 2008 within our ICU, MRSA colonisation was considered an inevitable consequence of acute illness, high patient turnover, ecological pressures and a higher than national average incidence of MRSA on admission to ICU (6% ICNARC data). Local audit data demonstrated that up to 30% of patients who became MRSA colonised during their intensive care stay, subsequently developed a systemic infection requiring antibiotic treatment in which MRSA was the suspected pathogen within six months. MRSA infection compromises patient recovery and has significant risks of morbidity and mortality. It may result in a prolonged length of stay increased cost to the organisation per patient. A 70% reduction in incidence would see fewer than 12 patients per year acquiring MRSA. A multidisciplinary team was set up to lead the project (Critical Care Infection Prevention Group); including consultant clinicians, senior nursing staff, a microbiologist, a pharmacologist and a physiotherapist. The project was supported at an executive level within the Trust. We utilised the IHI model for improvement methodology1 and MAGIC shared decision making to embed changes in clinical practice. Multiple evidence-based Plan-Do-Study-Act cycles were used including: • Introduction of medical and nursing daily infection control champions to ensure exemplar practice at the bedside with infection prevention techniques • 100 monthly audits of hand hygiene and damp dusting • Protocolised weekly universal culture screening • Mandatory ANTT and hand hygiene training for all trust employees • The use of universal decolonisation treatment with ProntodermTM lotion and nasal gel. • Electronic nurse-led prescription of Prontoderm and application within
four hours of admission to ICU. • Antimicrobial dressings round indwelling medical devices and the exit points of drains • Chlorhexidine impregnated dressings for vascular access lines • Root cause analysis of each acquisition • Trust-wide antibiotic stewardship with subsequent reduction in quinolone use. The results were as follows: • 2008-09 40 MRSA colonisation acquisitions within ICU (49.2 per 1000 admissions) • 2009-10 29 MRSA colonisation acquisitions within ICU (32.7 per 1000 admissions) • 2010-11 10 MRSA colonisation acquisitions within ICU (10.4 per 1000 admissions) • 2011-12 7 MRSA colonisation acquisitions within ICU (6.9 per 1000 admissions) • 2012-13 5 MRSA colonisation acquisitions within ICU (4.8 per 1000 admissions) • 2013-14 4 MRSA colonisation acquisitions within ICU (3.6 per 1000 admissions). In conclusion, our multidisciplinary approach has shown a safe sustained reduction in the incidence of MRSA acquisition in a high risk population Reference 1. Langley GJ, Moen RD, Provost LP et al. The Improvement Guide. 2nd Edition: ISBN 9780-470-19241-2.
38. Zero Clostridium difficile acquisition in an 18-bedded level 3 mixed neurosurgical and general intensive care unit: a three-year quality improvement clinical practice intervention E Parkin, A Neumann, E Boxall, A Jeans, J Naisbitt Salford Royal NHS Foundation Trust, UK Clostridium difficile (CDT) infection is a significant cause of morbidity and mortality across the healthcare sector.1 Patients in intensive care are at high risk of CDT acquisition and infection. All Foundation Trusts have centrally set annual targets to reduce the incidence of CDT acquisition. Failure to achieve a lower than trajectory prevalence incurs a marked financial penalty per case above trajectory (up to £500,000 each). In 2012 we embarked on a quality improvement project to reduce the rate of CDT acquisition. The Critical Care Infection Prevention Group is a multidisciplinary team meeting monthly to decide on strategy. It comprises consultant clinicians, senior nursing staff including an infection control nurse, a microbiologist, a pharmacologist and a physiotherapist, this team is supported at an executive level within the Trust. We used the IHI model for improvement methodology2 and shared decision-making to change clinical practice and meet our goals. To better understand our risk factors in the aetiology of CDT acquisition, we first performed root cause analysis of the five intensive care acquisitions over the year 2011/12. All patients had been exposed to greater than two empirical broadspectrum antibiotics and all were on a high dose of proton pump inhibitor (PPI) for stress ulcer prophylaxis. We used multiple Plan-Do-Study-Act cycles of incremental change including: • Medical and nursing daily infection control champions to ensure exemplar practice at the bedside with infection prevention techniques • 100 monthly audits of hand hygiene and daily bed area damp dusting • Mandatory ANTT and hand hygiene training for all staff • Immediate side room isolation of all patients with diarrhoea • Protocolised investigation and a treatment pathway in suspected CDT infection
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Clinical practice poster presentations
• Regular surveillance non-directed bronchioalveolar lavage cultures enabling early targeted antibiotic therapy • Antibiotic stewardship based on local ecology data • Strict evidence-based PPI stewardship based on a change in unit policy in stress ulcer prophylaxis – PPIs are only prescribed prior to the establishment of full enteral feeding after 72 hours – Preadmission PPI continued only with a documented ulcerative or bleeding indication – Early PPI dose reduction – Electronic prescription of PPI with a mandatory policy reminder. The results were as follows: • 2011/12 – five CDT acquisitions (4.94 per 1000 admissions) • 2012/13 – one CDT acquisition (0.94 per 1000 admissions) • 2013/14 – zero CDT acquisition (0 per 1000 admissions) Our efforts have been mirrored Trust-wide and contributed to one of the lowest incidences of CDT acquisition in a UK teaching hospital (10.11 per 100,000 bed days). In conclusion, through a multidisclipinary quality improvement strategy, it is possible to achieve a zero incidence in the rate of CDT acquisition in a high-risk population. References 1. Walters PR, Zuckerbraun BS. Clostridium difficile infection: clinical challenges and management strategies. Crit Care Nurse 2014;34:24-33. 2. Langley GJ, Moen RD, Provost LP et al. The Improvement Guide. 2nd Edition: ISBN 9780-470-19241-2.
39. Increasing the likelihood of awakening from coma through auditory stimulation J Daltrozzo, CM Conway Georgia State University, Atlanta, Georgia, USA To date, the progress in coma assessment/research has mostly focused on increasing the quality of diagnosis and prognosis of these patients with improved behavioral and neurophysiological procedures. However, there have been only few attempts to increase the likelihood of awakening from coma through any kind of treatment. We propose to test a method based on recent research focusing on brain plasticity whose aim is to increase the chance of these patients to awaken from their coma. The brain’s ability to discriminate sounds, measured by two neurophysiological indices of event-related potentials, the Mismatch Negativity (MMN) and the P300 effect, predicts the likelihood of awakening from coma.1 These two indices are recorded during the presentation of an oddball paradigm, which includes “deviant” (or “rare”) sounds presented pseudo-randomly within a sequence of “standard” (or “frequent”) sounds. Discrimination of rare sounds within such sequences is a type of basic sequential processing (SP) – eliciting “online” brain computation of the probability of occurrence of the next upcoming deviant sound.2,3 Our previous research has shown that SP can be trained and improved through four days of repetitive stimulation (45mn sessions each day) in healthy adults.4 Therefore, we predict that providing similar repetitive auditory exposure of oddball paradigms to coma patients using sessions of a similar duration every day has the potential to improve their discrimination performance and hence to increase their likelihood to awaken from coma. Each newly included patient of one (or several) intensive care unit(s) would be randomly assigned to a treatment or a control group, matched for coma aetiology, as coma outcome is known to depend dramatically on the etiology of coma.1 The patients of the treatment group would receive a one to two-hours daily session of auditory oddball stimulation with various types of tone deviants in an attempt to stimulate and train the brain network underlying the ability to discriminate sounds. Tone deviants differing along a number of dimensions from the standard sound (frequency, duration, and intensity) will be used in order to promote nonspecific generalisation of such abilities. The brain’s plasticity to this training will be monitored through the recording of the MMN and the
P300. This neurophysiological monitoring would also serve as an indicator of awakening from coma.1,5 The control group would not be exposed to this auditory stimulation. Patient outcome would be measured using the Glasgow Outcome Score and compared between the treatment and control groups. We believe that testing this method can easily be set up in several intensive care units who already record the MMN and/or the P300 of coma patients on a regular basis. Thus, large treatment and control group sizes could be quickly achieved, allowing a comparison with high statistical power. The successful validation of this method would provide one of the first treatments to increase the likelihood of awakening from coma. References 1. Daltrozzo J, Wioland N, Mutschler V et al. Predicting coma and other low responsive patients outcome using event-related brain potentials: a meta-analysis. Clin Neurophysiol 2007;118:606-14. 2. Daltrozzo J, Conway C. Neurocognitive mechanisms of statistical-sequential learning: What do event-related potentials tell us? Front Hum Neurosci 2014;8:437. 3. Stadler W, Klimesch W, Pouthas V et al. Differential effects of the stimulus sequence on CNV and P300. Brain Res 2006;1123:157-67. 4. Daltrozzo J, Conway CM, Smith GNL. Rehabilitating language disorders by improving sequential processing: A review. J MacroTrends Health Med 2013;1:41-57. 5. Tzovara A, Rossetti AO, Spierer L et al. Progression of auditory discrimination based on neural decoding predicts awakening from coma. Brain 2013;136:81-89.
40. Do no harm? The perils of infection control J Breeze, E Smithson, L Poole Royal Liverpool University Hospital, Liverpool, UK Transmission and acquisition of antimicrobial resistant organisms in intensive care units (ICUs) is rightly recognised as a costly and avoidable cause of increased morbidity, mortality and length of stay.1 Our unit has recently embarked on an enhanced screening programme for resistant organisms on all patients upon admission and weekly thereafter. We report a potentially catastrophic incident related to the new screening protocol. All line and tracheostomy sites are screened using a new design of swab that is scored at the mid-point of its shaft in order to allow the tip to be broken off and deposited in its transport medium without acquiring contaminants from the nurse or patient environment. During the swabbing of one patient’s tracheostomy site he became agitated and managed to push the swab into the lumen of his tracheostomy. Due to the design of the swab, the shaft snapped and became lodged in the lumen of the tracheostomy causing an obstruction. As a consequence of the short length of the detached tip it could not be retrieved and an emergency tracheostomy change had to be performed.
Figure 1.
The State of the Art 2014 Meeting
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Clinical practice poster presentations
In light of recent evidence2 suggesting screening and isolation of patients plays a limited role in limiting spread of organisms compared to simple measures such as hand hygiene and patient washing we question the wisdom of implementing potentially harmful interventions for limited benefit. References 1. Vincent J-L, Rello J, Marshall J et al. International study of the prevalence and outcomes of infection in intensice care units. JAMA 2009;302:2323-29. 2. Derde LPG, Cooper BS, Goossens H et al Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study & cluster randomised trial. Lancet Infectious Diseases 2014;14:31-39.
41. Not all cirrhotics are equal: acute-on-chronic liver failure in the ICU J Millar, J McPeake, R Fulton, J Kinsella Glasgow Royal Infirmary, Glasgow, UK Patients admitted to the intensive care unit (ICU) with cirrhosis have been shown to have a poor rate of survival.1 Traditionally, it has been difficult to differentiate these patients with regard to the severity of their current illness and its relation to their underlying liver disease. The development of a definition of acute-on-chronic liver failure (AoCLF), based on a modified Sequential Organ Failure Assessment score (CLIF-SOFA), may aid this.2 We performed a retrospective analysis of patients admitted to the ICU of Glasgow Royal Infirmary between 01/06/2012 and 31/05/2013 (a cohort of patients whose outcomes have previously been published3). Patients were scored according to the CLIF-SOFA and divided into groups; those without AoCLF and those with grade I, II and III AoCLF. Comparisons were made using the Mann-Whitney test or ANOVA and the Chi-squared test or Fisher’s exact test, as appropriate. During the period studied, 58 patients with cirrhosis were admitted to the ICU. Thirty-eight (65.5%) were male and the median (IQR) age was 50 (40-59) years. The majority (79.3%), had an alcoholic aetiology, while the median Model for End Stage Liver Disease (MELD) score was 17 (9-22). The ICU and in-hospital mortality rates were 31% and 46.6% respectively. Forty-one (70.7%) patients satisfied the diagnostic criteria for AoCLF. There was no significant difference in age, gender or aetiology between those with or without AoCLF. Patients with AoCLF tended to have higher MELD scores (21 [15-26] vs 9 [5-13]; p
