Intensive Care Society State of the Art (SOA) 2023 Congress Abstracts

5503

Trends in emergency airway management outside the operating room at a UK major trauma centre; a five-year iterative quality improvement project

Daniel Horner¹, Christopher Ambrose², Christopher Taylor², Lola Erinle²

¹ Northern Care Alliance NHS Foundation Trust

² Health Education North West

Introduction: Emergency airway management outside a controlled theatre environment is associated with a high rate of adverse events.^1-3 Several initiatives to improve safety (such as video laryngoscopy, checklists, simulation training etc. .) have been studied in isolation and are now recommended in national guidance.⁴ The incorporation of some of these initiatives into routine or ‘habitual’ care remains controversial.⁵ It is also unclear as to how these interventions have been embedded into airway management outside the operating room and whether they offer cumulative marginal gains in safety.

Objectives: We sought to evaluate all emergency airway interventions conducted outside a controlled theatre environment at a single major trauma and neurosciences centre in North West England over a 5 year period. Our main aims were to evaluate first pass success and complication rates over time in the context of iterative quality improvement measures and report parallel changes in practice over the same period. Our secondary aim was to evaluate airway management practice, technique and outcomes during the pandemic with routine practice outside of pandemic periods.

Methods: A prospective 5-year service evaluation delivered between 2017 and 2022. We designed a rolling quality improvement program to mitigate procedural airway risk through iterative and collaborative development of embedded digital reporting metrics, multidisciplinary education events, and planned service developments. PDSA cycles included revised documentary guidance (including flowcharts and checklists), high fidelity simulation training, equipment/trolley redesign and introduction of prefilled medications (including induction agents, neuromuscular blockers and vasopressors) to key clinical areas. Data on individual intubation episodes was sourced through business analytics (via a predesigned ‘endotracheal intubation’ form used within EPR) with cross referencing of anaesthetic ‘out of theatre’ notes, cardiac arrest data, major trauma and intensive care admissions. The project was registered with local R&I prospectively as a service evaluation, in accordance with the HRA decision tool.

Results: We obtained valid data on 2034 endotracheal intubation episodes, after cleaning and removal of duplicates. The rate of intubation episodes occurring in a critical care (CCU) and Emergency Department (ED) environment were roughly equal, with 912 (45%) and 964 (47%) respectively. The remainder of emergency episodes were documented as performed in a theatre recovery or ward environment.

Overall first success rate was 93.02% during the study period. Overall periprocedural complication rate was 13.57% during the study period, with critical hypoxaemia and cardiovascular instability as main contributors, at 7.40% and 4.50% respectively. Cardiac arrest and oesophageal intubation occurred at a rate of 0.62% and 0.37% respectively.

Use of Video laryngoscopy increased during the 5 year period compared to direct laryngoscopy, occurring in dominant use of VL overall (63.89%) during the study period. Documentation of consultant presence increased in parallel, noted during 62.54% of episodes. We are currently analysing temporal data (by quarter) on use of primary induction agents, use of cricoid pressure other procedural variables and separate COVID19 analysis as described above.

Conclusions: In this service evaluation of a 5 year iterative and multidisciplinary quality improvement program, we report high overall first pass success and low overall complication rates compared to recent literature. In addition we describe trends in practice over time and will present further data on variation in practice during the pandemic.

References

1. Russotto V, Myatra SN, Laffey JG, et al. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA. 2021; 325(12):1164–1172. doi:10.1001/jama.2021.1727

2. Grillot N, Lebuffe G, Huet O, et al. Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial. JAMA. 2023;329(1):28–38. doi:10.1001/jama.2022.23550

3. Russell DW, Casey JD, Gibbs KW, et al. Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2022;328(3):270–279. doi:10.1001/jama.2022. 9792

4. Higgs A, McGrath BA, Goddard C et al. Guidelines for the management of tracheal intubation in critically ill adults. BJA 2018; 120 (2): 323-352

5. Lyons, C. and Harte, B.H. (2023), Universal videolaryngoscopy: take care when crossing the Rubicon. Anaesthesia. https://doi.org/10.1111/anae.15977

5587

Tracheostomy care: Impact of a reduction in sedation on overall length of stay

Cara Pardoe¹, Samuel Howitt², Miguel Garcia², Claire Keen²

¹ Manchester University Hospital NHS Trust

² Manchester University Hospital NHS Trust

Introduction: Over 12,000 tracheostomies are performed each year in the UK and on average 20% of critical care patients are managed with a tracheostomy.¹ Performing a tracheostomy on a critical care patient provides a stable airway, allows for clearance of pulmonary secretions, support for weaning from ventilation and decreases laryngeal injury that comes with endotracheal intubation.² A study³ found that a significant reduction in sedation post tracheostomy insertion reduces both critical care length of stay and therefore reduces overall hospital stay.

Objectives: The objective of this study is to assess the incidence, duration of tracheostomy, length of time from tracheostomy to hospital discharge, and total amount of propofol in mls twenty-four hours pre and twenty-four hours post tracheostomy insertion.

Methods: This study is an observational prospective study. It was performed on a 30 bedded Cardio Thoracic Critical Care Unit, in a tertiary centre in the UK over a six-year timeline. We collected patients’ demographic records, critical care admission, tracheostomy insertion date and decannulation date. This allowed a calculation length of tracheostomy duration, critical care and hospital stay in days, including mortality at thirty days. Further data collection of mls/day of propofol.

Results: The results indicated that a thirty-day mortality at 10.3% from all patients who had a tracheostomy performed on the unit, with hospital mortality calculated at 17.9%. The median (IQR) duration of tracheostomy was 18.9 days (11.8-28.0), with a median (IQR) length of tracheostomy to hospital discharge of 34 days (22.1-54.2). There was a significant reduction in the use of Propofol post insertion; 75.3% reduction in the median pre-tracheostomy to post-tracheostomy daily mls of Propofol (210vs52mls).

Conclusions: In conclusion the significant reduction in Propofol use, contributes to a reduction in tracheostomy duration and overall hospital length of stay. This is further co-founded by a 89.7% thirty-day survival from hospital discharge. Further research is needed to ascertain the long-term morbidity of short-term tracheostomies.

References

1. Lewith H, Athanassoglou V. Update on management of tracheostomy. BJA Educ. 2019;19(11): 370–376.

2. El-Anwar M, Nofal A, Shawadfy M. Tracheostomy in the Intensive Care Unit: a University Hospital in a Developing Country Study. Int Arch Otorhinolaryngol. 2017;21(1):33-37.

3. Kapp C, Latifi, A, Kopman, D. Sedation and Analgesia in Patients Undergoing Tracheostomy in COVID-19, a Multi-Center Registry. Journal of Intensive Care Medicine. 2022;37(2) 240–247.

5045

A Nurse-Led Project Using Driving Pressure to Reduce Ergotrauma and Optimise Ventilation in Critcal Care Patients

Sam Lee Tarver, Jade Cole

NHS Wales

Introduction: Over the last two decades there has been a drive to raise health standards by empowering nursing professionals to expand their skills. Advanced clinical, leadership and research tasks are now common for nurses, and the Quality Improvement (QI) project discussed here builds upon many of these advancements.¹

Simultaneously, Intensive Care Unit (ICU) Patients with Acute Respiratory Distress Syndrome (ARDS) have been identified as an important area of research. This cohort has increased mortality and morbidity compared to the general ICU patient, and correct measurement and optimisation of Driving Pressure (ΔP) has been suggested as a means of improving these outcomes.^2,3

Objectives: Primary Objective - Improve patient safety through the routine measurement, assessment, and utilisation of ΔP.

Secondary Objective – Empower nurses to create and deliver a QI programme that can be validated and used as a template for future Quality and Safety projects.

Methods: The interventions discussed took place in the 37 bed General ICU of a tertiary hospital and involved all levels of nursing and medical staff.

A Plan, Do, Study, Act (PDSA) template was used to formulise the QI processes, with repeated PDSA cycles used to feedback and improve the project.⁴ SMART Goals and ideas around Sustainable Change were also included.⁵ These were; Promotion of the ΔP project with posters and social media, identification of ΔP Champions who are advocates for the project, and the presentation of ΔP theory and practice to groups of 30-40 nurses.

To validate the project a detailed audit trail had to be initiated. Elements of this were; a large survey of ΔP compliance across the nursing staff before any teaching had occurred, individual written feedback, and surveys pre/post teaching.

Results: Please note that this project is still running and any results will be provisional and correct at the time of publication.

Figure 1.

ΔP knowledge before/after training.

Figure 2.

Mechanical Power knowledge before/after training.

Before the teaching 29% of respondents said they knew how to measure ΔP, and after the teaching this number rose to 100%. Pre-training 73% of nurses said they could not identify the basic principles of Mechanical Power. Post-training only 3% could still not describe this theory, with 8% remaining unsure.

Qualitative feedback has been obtained from nurses who have been through the training. Prominent themes that emerged from this were; Nursed found the ‘blended’ nature of the learning package was effective, nurses thought the delivery of the teaching was very effective, and found the use of small group drop-ins very helpful.

Conclusion: This initial dataset suggests the programme has made good progress and has the potential to accomplish its aims. The nurse-led aspect has been received with enthusiasm and could be used as a template for further nurse-led initiatives if validated. Nurses reported a large increase in their knowledge around ΔP and it is hoped this continues as the project expands.

References

1. Adam S. Critical care nursing. Oxford University Press; 2017.

2. Amato MBP, Meade MO, Slutsky AS, Brochard L, Costa ELV, Schoenfeld DA, et al. Driving pressure and survival in the acute respiratory distress syndrome. New England Journal of Medicine. 2015; 372(8):747–55.

3. Gattinon L, Carlesso E. Acute respiratory failure and acute respiratory distress syndrome. Oxford Medicine Online. 2018.

4. Webb AR. Handbook of Intensive Care Organization and Management. Covent Garden, London: Imperial College Press; 2016.

5. 1000 Lives Improvement 2014. The Quality Improvement Guide: The Improving Quality Together Edition. Cardiff: 1000 Lives Improvement.

5356

A process-improvement project for the preparation of patients requiring transfer from the Intensive Care Unit to Operating Theatres

Bethany Gwyther¹, Vimal Grover²

¹ North West London Foundation Trust

² Royal Marsden NHS Foundation Trust

Introduction: Patients are frequently transferred from the intensive care unit (ICU) to operating theatres for surgery; a variety of procedures may be undertaken on a temporal spectrum from semi-elective to an emergent basis. Optimal preparation is vital to facilitate both timely management and minimise associated risks.

Requirements for successful planning and execution include: effective communication between teams, obtaining consent, review of anticoagulation and bleeding risk, management of infusions, and infection prevention and control assessment. Furthermore, it is desirable to accurately manage enteral feeding. Critically ill patients are at risk of underachieving target nutritional requirements, and this can be exacerbated by inappropriate prolonged fasting.¹ To combat this, the trust has developed guidance for perioperative cessation of enteral nutrition.²

Our project aims to improve multiprofessional preparation of patients for surgery, through the development of a novel checklist.

Objectives: The aim of this project was to improve multiprofessional preparation of patients for transfer to theatre from ICU.

Primary Objective: Improve communication between multidisciplinary and multiprofessional teams.

Secondary Objectives: Improve coordination of care with regards to management of anticoagulation and bleeding risk, consent, enteral feed management and infection prevention and control.

Methods:

1. Multiprofessional ICU staff were surveyed regarding their experiences of patient preparation for surgery.

2. Results were used to inform development of a checklist.

3. This checklist was piloted within ICU.

4. 2 further PDSA cycles were completed for optimisation.

Results:

Cycle 1: 20 nursing and medical staff of differing seniority levels were surveyed. There was variability in the confidence of preparing a patient for theatre, but all felt a checklist would be beneficial. An initial checklist was developed and presented locally. It included a QR code to signpost the local enteral fasting guidelines² and features to improve communication between all team members.

Cycle 2: All 19 respondents to the second survey felt the checklist to be beneficial in preparing a patient for theatre; 16 felt that it would improve multiprofessional communication. However, there was a desire to improve the form to streamline responsibilities for the medical and nursing staff. A new version of the checklist was developed to streamline processes between the medical and nursing teams as well as incorporating an airway plan for emergent management during transfer.

Cycle 3: 12 staff were surveyed, and all again agreed that this would be beneficial in preparing a patient for theatre. They recommended some additional components be added, and a final version of the checklist, for incorporation into the new digital health record, was produced.

Conclusions: We have successfully piloted a checklist designed to improve the preparation and transfer of patients from ICU to theatres; 100% of surveyed staff finding the checklist beneficial in patient preparation. Our primary outcome related to improved communication; 84% of staff surveyed felt that the checklist would improve communication between teams. This demonstrates potential for supporting multiprofessional communication.

References

1. Matejovic M, Huet O, Dams K, et al. Medical nutrition therapy and clinical outcomes in critically ill adults: a European multinational, prospective observational cohort study (EuroPN). Crit Care [Internet]. 2022;26(1):143. Available from: http://dx.doi.org/10.1186/s13054-022-03997-z

2. Microguide viewer - web viewer [Internet]. Microguide.global. [cited 2023 Feb 8]. Available from: https://viewer.microguide.global/guide/1000000375#content,b39cca6f-6472-4e34-be24-dc2cce5b6af4

Figure 1.

5569

A service development project to improve recruitment through engagement for the Critical Care Specialist Group (CCSG)

Emma Gaskin

Critical Care Specialist Group, British Dietetic Association

Introduction: The Critical Care Specialist Group (CCSG) is a prestigious dietetic group of the British Dietetic Association (BDA). It has been running for 11 years and has over 500 members. In November 2021, the CCSG committee had issues with recruiting into vacant posts; five members had left, and an additional four posts were vacant due to sickness and maternity leave. Potential reasons include burnout after the covid-19 pandemic, where a recent paper indicated a third of intensive care staff were at high-risk of burnout and post-traumatic stress at work¹. In addition, the lack of public facing roles such as social media and website officers could have had an impact on engaging members to apply for posts and participate in CCSG projects, which were also struggling to engage members.

Aim: Increase engagement to recruit into vacant posts of the CCSG by the 2022 AGM.

Methodology: An initial recruitment drive in spring 2022 to six key vacancies (including newly created posts and dual posts), which were promoted to all members. To recruit a larger geographical spread of volunteers and improve accessibility, committee meetings were made virtual. A goal-setting committee meeting was arranged to ensure improvements in communication channels and engagement with members was set. Articles were written and promoted in dietetic magazines, website and on social media, all to increase engagement. The newsletter was updated and modernised. An additional recruitment drive was completed in autumn 2022 heavily involving the new website officer and social media team.

Primary outcome = recruitment into vacancies

Secondary outcomes = website engagement, social media engagement & newsletter engagement

Results:

Primary outcome: In Spring 2022, recruitment was successful into six vacancies. An additional recruitment drive in Autumn 2022 was successful for an additional five vacancies with only one member leaving the committee in 2022, showing a decreased turnover. As of November 2022; the committee was fully recruited, a team of 18.

Secondary outcome:

• Increase in social media engagement from March-Nov 2023: Instagram: new account (642 followers); Twitter: 9% increase (4225 followers); Facebook: 6% increase (486 followers)

• Increase in website engagement from March-Nov 2022: An increase in average monthly views per quartile from 976 - 1185 (21%)

• Newsletter: Begun logging of opening of digital newsletter, >50% of members now opening compared to the 15% target for BDA specialist groups

Other impacts:

• Significant increase of CCSG Annual Award entries: 2021: no winner; 2022: 11 submissions & 6 shortlisted

• Significant increase in attendees (42%; 134 in 2021 & 190 in 2022) and registrations (18%; 167 in 2021 & 197 in 2022) to the CCSG Annual Study Day. An increase in post-study day feedback completion (2021: 37% & 2022: 52%)

• The CCSG was shortlisted for two BDA awards, Social Media Influencer of the Year Award and Student Champion Award

Conclusion: Primary and secondary outcomes demonstrate that the project met its aim. While it is impossible to demonstrate true causality, outcome measures strongly correlate with recruitment and engagement efforts by the committee. The positive impact of this is that vacancies are filled, and the committee has expanded, meaning workload is shared, reducing the risk of burnout to aid sustainability. The challenges that lay ahead will be maintain momentum; these roles are volunteer and based on the enthusiasm and time pressures of the individuals and workforce burnout continues to be a pressing issue for ICU staff.

Reference

1. Vincent L, Brindley PG, Highfield J, Innes R, Greig P, and Suntharalingam G. Burnout Syndrome in UK Intensive, Care Unit staff: Data from all three Burnout Syndrome domains and across professional groups, genders and ages. Journal of the Intensive Care Society 2019; 20(4) 363–369.

5509

A service review of time to tracheostomy insertion and impact on patient centred outcomes on Critical Care, Mater Misericordiae Hospital, Dublin

Áine Murphy¹, Renju Cherian², Aisling McMahon², Basheer El Gammal², Sarah Duggan²

¹ Mater Misericordiae Hospital (MMUH)

² MMUH

Introduction: Patient’s requiring intra-oral ventilation on Critical Care (CC) are unable to communicate verbally which has negative implications on their mood, well-being, quality of life and ability to participate in their care. The aim of this project was to compare time of tracheostomy insertion and patient-focused tracheostomy outcomes across two years; specifically Nov 2020-Oct 2021 versus Nov 2021 - Oct 2021. This period was selected following an uplift of Speech & Language Therapy (SLT) and wider Health Care Professional staffing on Critical Care (CC) in a primarily cardio-thoracic adult CC unit.

Objectives: The objective is to compare median days to tracheostomy insertion in comparison to prolonged intubation and in conjunction with this capture the specific impact of the tracheostomy on patient centred outcomes; verbal communication, oral intake, potential for mobility and rehabilitation.

Materials & Method: Intensive Care Medicine (ICM) carried out a review of available local tracheostomy data which is captured at the time of tracheostomy insertion from a local Advanced Nurse Practitioner database (inclusive of patient demographics, diagnosis, mechanical ventilation requirements, days to tracheostomy from endo-tracheal tube, days under sedation, days to trache decannulation). SLT carried out retrospective data collection locally using Critical Care electronic health records and SLT databases (specifically if patients with a tracheostomy were referred to SLT, days to SLT contact if referred, days to verbal communication restored, days to oral intake, if a fibre-optic evaluation of swallowing assessment was provided). CC and SLT data was combined in a new centralized excel spread-sheet in line with Organisation governance/clinical audit form processes.

Results: Data was collected on 192 patients with a tracheostomy in total. A comparison was made between the years 2020 and the year 2021 to capture the median time from intubation to tracheostomy (X); median time to SLT initial intervention, median time to verbal communication, median time to oral intake, median time to physical mobility, median time to decannulation and also to capture if patients with a tracheostomy in situ were seen by SLT to support their CC rehabilitation; availability of FEES assessment to support tracheostomy wean, secretion management and swallow rehabilitation and median duration of sedation.

Conclusion: In the year 2021 in comparison to 2020; X number of patients had a tracheostomy inserted to support ongoing ventilation requirements. Of these patients the review indicated an average of X number of days in terms of earlier restoration of verbal communication, restoration of oral intake as well as a median of X days to sedation reduction and X days to commencing mobilising.

Reference

1. The communication experience of tracheostomy patients with nurses in the intensive care unit: A phenomenological study Angela Tolotti a, Annamaria Bagnasco a,⇑, Gianluca Catania a, Giuseppe Aleo a, Nicola Pagnucci b, Lucia Cadorin c, Milko Zanini a, Gennaro Rocco d, Alessandro Stievano e, Franco A. Carnevale f, Loredana Sasso a.

2. A Systematic Review of Patient and Caregiver Experiences with a Tracheostomy Ivana Nakarada-Kordic, Niamh Patterson, Jill WrapsonStephen D. ReayThe Patient - Patient-Centered Outcomes Research volume 11, pages175–191 (2018).

3. The use of tracheostomy speaking valves in mechanically ventilated results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients Sutt, A-L, Cornwall, P., Mullany, D., Kinneally, T., Fraser, J. Journal of Critical Care 30 (2015).

4. Earlier tracheostomy is associated with an earlier return to walking, talking and eating. Sutt, A-L., Tronstad, O., Barnett, A., Kitchenman, S., Fraser, J. Australian Critical Care Journal, 33; 3 (2020).

5015

Use of the Arctic Sun targeted temperature management system to achieve rewarming during a 6.5 hour hypothermic cardiorespiratory arrest

Anive Grewal, Richard Thomas

Royal Hampshire County Hospital

We report a case of successful cardiopulmonary resuscitationlasting 6.5 hours, following cardiac arrest secondary to severe hypothermia, with rewarming using an Arctic Sun 5000 device.

The Arctic Sun is a targeted temperature management device which is conventionally used to cool patients post-cardiac arrest.

A 74 year old man was found collapsed at home and wasbrought into the Emergency Department (ED) with a tympanic temperature of 24°C. He arrested in ED and CPR was commenced. The admitting district general hospital has limited access to extra-corporeal life support. After a poorresponse to traditional non-invasive rewarming methods was observed, we used the Arctic Sun 5000 device to re-warm the patient. A return of spontaneous circulation was achieved afteroesophageal temperature had exceeded 30°C, following 6.5 hours of CPR. The patient was transferred to the intensive care unit, and after 49 days in hospital, made a full recovery and returned home.

We have demonstrated that the Arctic Sun 5000 device can be used during prolonged CPR and was able to re-warm successfully an elderly, obese patient in hypothermic arrest.

5532

Out of hospital cardiac arrest - ICU management and predictors of outcomes

Delphi Henderson¹, Florence Neyroud², Ahilanandan Dushianthan²

¹ Southampton University

² Southampton General Hospital

Introduction: Out-of-Hospital Cardiac Arrest (OHCA) imposes significant health and financial burdens worldwide and is associated with high mortality.¹ A poor neurological outcome, caused by hypoxic-ischaemic brain injury, is the primary determinant for withdrawal of life-sustaining treatment.² Although studies have identified several patient-related and cardiac arrest-specific predictive factors of poor outcomes, there is still much debate regarding which are the most influential. Moreover, guidelines recommend Intensive Care Unit (ICU)-specific targets for common variables such as oxygenation, carbon dioxide, glucose, temperature, blood pressure and strict seizure control management as secondary neuroprotective measures, which warrant further evaluation.

Objectives: This study aims to assess the outcome of OHCA patients admitted to the ICU and evaluate the predictors of poor outcomes in more detail.

Methods: This is a retrospective study of all consecutive adult (>18 years old) OHCA patients admitted to the ICU between August 2019 and September 2022. This study is part of a larger study (CRIT-CO) evaluating patient outcomes in ICU (IRAS:232922). We collected details of cardiac arrest characteristics, patient demographics, oxygenation, ventilation, and cardiovascular variables during the first week of ICU admission. We also calculated the MIRACLE₂ score, which is a point-based score consisting of 7 independent predictors. The primary outcome was 30-day hospital survival.

Results: There were 123 patients admitted to the ICU following an OHCA. The median age was 63 (Inter quartile Range (IQR) 51-73). The 30-day hospital survival was 35.8% (N=44). Although the survivors were younger (median age 57 vs 65) this was not statistically significant. The were no differences in gender or comorbidities between survivors and non-survivors. The down time was shorter for survivors, 15 (IQR 10-22) minutes vs 30 (IQR 22-48) minutes for non-survivors (p<0.0001). Survivors had proportionately more initial shockable rhythms (VT/VF), 71% vs 42% (p=0.002). Reactive pupils upon admission were more common in survivors than non-survivors (93% vs 53%, p<0.0001). Myoclonus was less prominent in survivors (7% vs 27%, p=0.008). Survivors had a normal initial pH recorded immediately upon admission (7.35 vs 7.23, p<0.0001).

Prolonged downtime of >31 minutes (OR 17.3, 95% CI 1.6-188.7, p=0.019), presence of myoclonus (OR 5.0, 95% CI 1.2-21.0, p=0.018), initial pH of <7.2 (OR 28.0, 95% CI 3.5-227.2, p=0.0018) and non-reactive pupils on admission (OR 26.5, 95% CI 3.3-213.6, p=0.002) were independent predictors of 30-day hospital mortality. All patients with an initial admission pH of <7.1 died and all patients with a pH of >7.4 survived. There were no differences in the mean daily PaO₂, PaCO₂, core temperature, pH, systolic blood pressure and diastolic blood pressure up to 7 days between survivors and non-survivors. The median ICU and hospital days for survivors were 5 (IQR 2-9) and 14.5 (IQR 10-20) days respectively. MIRACLE₂ score was highly predictive of mortality (AUC 0.932, p<0.001).

Conclusions: Mortality from OHCA remains high. In this retrospective observational study, cardiac arrest characteristics of initial rhythm and downtime duration with admission variables of initial pH, presence of myoclonus and absence of pupillary reflexes were better predictors of mortality than ICU secondary neuroprotective markers or patient demographics.

References

1. Gräsner J-T, Herlitz J, Tjelmeland IBM, et al. European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe. Resuscitation 2021; 161: 61-79.

2. Sandroni C, D’Arrigo S, Nolan JP. Prognostication after cardiac arrest. Critical Care 2018; 22(1): 150.

5559

Extracorporeal cardiopulmonary resuscitation – a 1-year retrospective case series in a UK cardiac centre

Philip Leadbeater, Nicholas Haslam, Martina Buerge, Simon Finney, Ben Singer, Sachin Shah

Barts Health NHS Trust

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) is a potentially life-saving intervention in refractory cardiac arrest as recognised by both the European Resuscitation Council and Extracorporeal Life Support Organisation (ELSO).^1,2 Despite this, access to this intervention is limited to specialist cardiac centres with few pathways to expedite access in out-of-hospital cardiac arrest (OOHCA).

This narrative case series describes our institution’s experience of ECPR – delivered as veno-arterial extracorporeal membrane oxygenation (VA-ECMO) – over a 12 month period.

Objectives: To describe ECPR activity and outcomes in adult patients at a single UK tertiary cardiac centre over a 1-year period.

Methods: Adult patients (age >16 years) in whom ECPR was attempted were identified retrospectively between 1^stJanuary 2022 and 31^st December 2022. ECPR was defined as per the 2021 ELSO guidelines (2). Patients initiated on VA-ECMO post-cardiotomy were excluded, even if technically meeting the ELSO criteria on the basis of intra-operative resuscitation. Patient characteristics, features of the cardiac arrest, timings and outcomes including Cerebral Performance Category (CPC) were obtained from electronic patient records.

Results: 13 consecutive cases (2 female and 11 male) were identified during the study period. Age ranged from 17 to 69 with a median age of 52 years. This cohort had a varied aetiology and location of cardiac arrest as detailed in Table 1, with VA-ECMO flow achieved in 12/13 cases. The median time from decision to cannulation was 21 minutes and from cardiac arrest to VA-ECMO flow 40 minutes (IQR 38-55mins). Mortality in patients with OOHCA was 84.7% (6/7 cases). The only survivor, albeit with a poor neurological outcome (CPC 3), was one of two patients within the cohort to receive pre-hospital ECPR. Three of six patients receiving ECPR for in-hospital cardiac arrest (IHCA) survived with good neurological outcome (CPC 1 or 2). Overall, episode mortality was 69% (9/13 cases) and survival with good neurological outcome 23% (3/13 cases). All patients were expected to die without the use of ECPR.

Conclusion: Our experience with ECPR demonstrates comparable episode mortality and neurological outcome to larger cohorts and randomised control trials.³ Patient selection remains a considerable challenge as available information is often limited. Whilst objective evidence of high quality conventional CPR may influence decision making, it does not in itself predict a good outcome. With the exception of hypothermia,⁴ validated decision making aids for ECPR are not widely available, although the recently published RESCUE-IHCA tool may have some utility for IHCA.⁵

Despite these challenges, our opinion is that ECPR is an important link in the chain of cardiac arrest survival and the continued evolution of both pre- and in-hospital resuscitation services should strive to reflect this.

References

1. Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021 Apr;161: 152–219.

2. Richardson A (Sacha) C, Tonna JE, Nanjayya V, Nixon P, Abrams DC, Raman L, et al. Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization. ASAIO J. 2021 Mar;67(3):221–8.

3. Abrams D, MacLaren G, Lorusso R, Price S, Yannopoulos D, Vercaemst L, et al. Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications. Intensive Care Med. 2022 Jan; 48(1):1–15.

4. Pasquier M, Rousson V, Darocha T, Bouzat P, Kosiński S, Sawamoto K, et al. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: An external validation of the HOPE score. Resuscitation. 2019 Jun;139: 321–8.

5. Tonna JE, Selzman CH, Girotra S, Presson AP, Thiagarajan RR, Becker LB, et al. Resuscitation Using ECPR During In-Hospital Cardiac Arrest (RESCUE-IHCA) Mortality Prediction Score and External Validation. JACC Cardiovasc Interv. 2022 Feb;15(3): 237–47.

5599

Somatosensory evoked potential analysis: utilising additional components to improve the prognostication of short term neurological outcome after cardiac arrest

Nicholas Gourd¹, Nikitas Nikitas¹, Colin Bigham¹, Nicola Broomfield¹, Lucy Nye¹, Liana Stapleton¹, Emma Stead¹, Andrew Smith¹, Amy Baker², Jade Chynoweth², Joanne Hosking², Nigel Hudson²

¹ University Hospitals Plymouth NHS Trust

² University Of Plymouth

Introduction: Unfavourable neurological outcome after out of hospital cardiac arrest (OHCA) is due to hypoxic-ischaemic brain injury (HIBI).¹ Confirmation of this outcome determines clinical decision-making. Currently a multi-modality approach is used to predict/confirm this outcome. A main element of this approach is the somatosensory evoked potential (SSEP). SSEP use to predict the neurological outcome relies on a qualitative interpretation of the recording where presence/absence of the N20 (component of the 20-30 milliseconds (msec) complex) is determined by inspection. Whilst N20’s absence is strongly linked to unfavourable neurological outcome [high negative predictive value (NPV)], its presence is less predictive of the favourable outcome [low positive predictive value (PPV)].² Methodological aspects of qualitative interpretation, like inter-observer variation,³ also limit the PPV of N20.

Objectives: To test the effectiveness of the addition of the quantitative interpretation of the P25/30 SSEP (the second component of the 20-30msec complex) to the currently quantitatively analysed N20 in the prognosis of the short-term neurological outcome post OHCA. P25/30 was tested when interpreted alone against N20 as well as when interpreted in combination with N20 as the Peak to Trough (PTT) amplitude of the 20-30msec complex.

Methods: Single-centre prospective, observational study in adult comatose survivors of OHCA.

Enrolled participants were normothermic and had a SSEP recording at 24-36 hours post ROSC. Anonymised recordings were interpreted by two blinded to each other and the outcome interpreters. The presence or absence of P25/30 was defined by its amplitude against two different tested thresholds of 0.5 and 0.2 microvolts (μV). The association of the measured amplitude of the PTT with the short–term neurological outcome was tested for different thresholds of its size.

Short-term neurological outcome was favourable or unfavourable, based on the cerebral performance category score (CPC) at hospital discharge.

Results: Eighty-nine participants were analysed. 43.8% had a favourable (CPC score 1-2) and 56.2% an unfavourable (CPC score 3-5) outcome. Calculated sensitivity, specificity, NPV and PPV of the quantitative interpretation of the P25/30 and the PTT for the favourable outcome were compared to those of the qualitative interpretation of the N20.

The presence of P25/30 was associated with increase of the PPV [from 62.9% to 81.8% (for 0.5μV threshold) and to 73.58% (for the 0.2μV)] for the favourable neurological outcome. The size of PTT higher than 0.6μV was associated with higher PPV (80%). Presence of the P25/30 using the 0.2μV threshold and PTT size retained the same 100% NPV, equal to the NPV of the N20. Short-term neurological outcome was accurately predicted by the addition of the quantitative analysis of P25/30 and PTT to the bedside N20 interpretation. 100% inter-interpreter agreement noted in the analysis of PTT, which also was associated with no need for dichotomised (presence or absence) interpretation.

Conclusions: Inclusion of the quantitative interpretation of the P25/30 SSEP and the PTT of the 20-30millisecond complex, to the clinically used N20 can potentially improve the prognostic accuracy of SSEP for the short-term neurological outcome in comatose survivors of OHCA.

Sponsor

University Hospitals Plymouth NHS Trust (UHPNT) [RD&I reference: 18/P/088]

Funding

University Hospitals Plymouth NHS Trust Charitable Funds

References

1. Witten L, Gardner R, Holmberg MJ, Wiberg S, Moskowitz A, Mehta S, Grossestreuer AV, Yankama T, Donnino MW, Berg KM. Reasons for death in patients successfully resuscitated from out-of-hospital and in-hospital cardiac arrest. Resuscitation. 2019; 136: 93-99.

2. Sandroni C, Cavallaro F, Callaway CW, Sanna T, D’Arrigo S, Kuiper M, Della Marca G, Nolan JP. Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 1: patients not treated with therapeutic hypothermia. Resuscitation. 2013; 84(10):1310-23.

3. Zandbergen EG, Koelman JH, de Haan RJ, Hijdra A; PROPAC-Study Group. SSEPs and prognosis in postanoxic coma: only short or also long latency responses? Neurology. 2006;67(4):583-6.

5322

Thoracic Artery pseudoaneurysm causing a haemothorax

Michelle Hatch¹, Venkat Sundaram¹, Gurpreet Kaur²

¹ BCUHB

² Betsi Cadwalladr University Health Board

Introduction: Pseudoaneurysm formation is a known complication of Type 1 Neurofibromatosis (NF1). The evidence suggests that this complication is commoner in women and that thoracic arteries in the left chest cavity are particularly at risk.¹

Case Presentation: A 54 year old lady presented to ED with a history of increasing shortness of breath (SOB), tachycardia and Type 2 Respiratory Failure (T2RF). A Chest X-Ray (CXR) on admission showed a left-sided whiteout and infection markers were raised. The initial diagnosis was of a Community Acquired Pneumonia and she was admitted to intensive care for High-Flow Nasal Oxygen (NHFO) and intravenous antibiotics.

A CT pulmonary angiogram (CTPA) was negative for pulmonary embolus but showed left-sided consolidation, pleural effusion and moderate pericardial effusion.

She was reviewed by a respiratory consultant who felt the imaging showed mostly consolidation with a small effusion and that drainage was not warranted.

Her past medical history included previous thoracolumbar spinal fixation for scoliosis and iron-deficiency anaemia thought to be due to gastro-oesophageal polyps (found at endoscopy) which were under surveillance.

Despite clinical improvement, a normalizing of her infection markers and a stepdown from antibiotics, she remained dependent on NHFO and her haemoglobin had dropped from 116g/l to 76g/l over 6 days. She remained persistently tachycardic, but her blood pressure was stable throughout. A repeat CXR showed persistent whiteout on the left side.

At this point a chest ultrasound and pleural tap were performed. Frank blood was aspirated and an intercostal drain was inserted. This drained 1.8 litres of fresh blood. Her blood pressure became labile, dropping below 100mm Hg systolic, at times. She was given Tranexamic Acid, Vitamin K and 2 units of Packed Red Cells.

On further discussion with the patient a history of a Vertebral Artery Pseudoaneurysm requiring coiling had occurred 20 years previously.

Multidisciplinary Team (MDT) discussion with radiology and respiratory specialties led to a CT Thoracic Angiogram which reported ‘An 11mm blush of contrast is seen on the left side of the upper posterior mediastinum (consistent with) a pseudoaneurysm arising from a left thoracic artery off the left subclavian artery. This is communicating with the left pleural cavity.’

The pseudoaneurysm was coiled with good effect in a tertiary cardiothoracic centre.

Discussion: Pseudo-aneurysms are a rare complication of NF1. They occur more commonly in women (71%) generally in the 3^rd decade of life and, in the case of thoracic lesions, are more likely in the left chest cavity.¹

Prognosis of spontaneous, massive haemothorax in NF1 patients treated with coil embolization is superior to those treated with thoracotomy. However, this should be carried out in a centre with the appropriate expertise. In our case, the patient was high risk due to her previous spinal surgery.

CT angiogram is the imaging modality of choice. After treatment yearly follow-up imaging is advised.²

Conclusion: Vascular malformations in NF1 are rare, and a high index of suspicion (in addition to a thorough history) is necessary early on. An MDT approach can help ensure the correct imaging modality.

References

1. Oderich et al. Vascular abnormalities in patients with Neurofibromatosis syndrome Type 1: clinical spectrum, management, and results. J Vasc Surg. 2007 Sep; 46(3): 475-484.

2. Hongsakul et al. Spontaneous massive hemothorax in a patient with neurofibromatosis type 1 with successful arterial embolization. Korean J Radiol. 2013 Jan-Feb; 14(1): 86-90.

5420

The impact of Extra Corporeal Membrane Oxygenation (ECMO) on dysphagia development

Elizabeth Walkden, Molly Savva-Briggs, Sarah Wallace

Manchester NHS Foundation Trust

Background & Aims: The purpose of this study was to evaluate the characteristics of a cohort of patients receiving Extra Corporal Membrane Oxygenation (ECMO) and to identify any defining features of those who present to Speech & Language Therapy (SLT) with dysphagia and those who do not. Research relating to ECMO and dysphagia is very limited and largely limited to ECMO being commented on as a contributing factor in dysphagia development (Pirzada, Styles and Stewart, 2023) or dysphagia as a secondary outcome (Vanstrum et al., 2022). This is currently limited to single case studies, however the prevalence of dysphagia in critical care populations is well documented. The relationship between dysphagia and critical care interventions is well documented, with prolonged intubation, critical illness myopathy, poor respiratory function, ventilation and tracheostomy (Brodsky et al., 2018; Plowman et al., 2021; Schefold et al., 2017). In addition to this, factors have been identified in patients undergoing cardiothoracic surgery have been identified pre-operatively; lung disease, heart failure, GORD, cerebrovascular disease (Black et al., 2019; Grimm et al., 2015), intra-operatively; complex procedures, circulatory arrest, cardiopulmonary bypass (Black et al., 2019; Grimm et al., 2015), and post-operatively; longer periods mechanical ventilation, tracheostomy presence and increased duration (Black et al., 2019; Miles et al., 2018).

Methods: In this retrospective audit, data was retrieved from the patient records of from 57 patients who received ECMO and survived their sedation wean. Records were reviewed from those admitted between April 2019-2021 and key characteristics extracted. All patients were treated at Wythenshawe Hospital Cardiothoracic Critical Care Unit. Descriptive data was collected regarding demographic, admission diagnosis, demographic, duration of ECMO, and post ECMO outcomes relating to dysphagia.

Results: COVID-19 was the most prevalent diagnosis accounting for 24/57 (42.1%), followed by Asthma for 10/57 (17.5%). 37 patients undergoing ECMO had clinically significant dysphagia (64.9%). Of which 32/37 remained at Wythenshawe Hospital for SLT intervention.

Those who presented with dysphagia and therefore referred to SLT had a significantly longer ECMO duration (p=0.012). They also had an overall longer length of stay (p=<0.001). In addition, duration on ECMO positively correlated to increased time Nil By Mouth (NBM) (p=0.006). Neither Age or sex were significantly different in those referred to SLT and therefore presenting with dysphagia, or not referred. Those who presented with dysphagia showed a significant relationship to increased days of ventilation (p=<0.001).

17/32 underwent a Fibreoptic Endoscopic Evaluation of Swallowing (FEES) (53.1%). 100% had significant laryngeal trauma; laryngeal oedema (70.6%) and impaired vocal fold movement/closure (47.1%) was most prevalent.

Conclusions: Dysphagia is common in the ECMO population and is more prevalent in those with complex presentations i.e longer ECMO duration. Dysphagia duration was longer for those with COVID-19 as opposed to other diagnoses. This study suggests prognosis for swallow recovery for patients with dysphagia post ECMO is promising and highlights the need for further research and early management/intervention of from SLT.

References

Black, R. J., et al. (2019). ‘Clinical predictors for oropharyngeal dysphagia and laryngeal dysfunction after lung and heart transplantation’, International Journal of Language & Communication Disorders, 54(6), pp. 894-901. doi: https://dx.doi.org/10.1111/1460-6984.12492.

Brodsky, M. B., et al. (2018). ‘Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review’, Critical care medicine, 46(12), pp. 2010-2017. doi: 10.1097/CCM.0000000000003368.

Grimm, J. C., et al. (2015). ‘A Novel Risk Score to Predict Dysphagia After Cardiac Surgery Procedures’, Annals of Thoracic Surgery, 100(2), pp. 568-74. doi: https://dx.doi.org/10.1016/j.athoracsur.2015.03.077.

Miles, A., et al. (2018). ‘Dysphagia and laryngeal pathology in post-surgical cardiothoracic patients’, Journal of Critical Care, 45(pp. 121-127. doi: https://dx.doi.org/10.1016/j.jcrc.2018.01.027.

Pirzada, A., Styles, K. and Stewart, R. (2023). ‘Massive left ventricular pseudoaneurysm presenting as dysphagia–a case report’, European Heart Journal-Case Reports.

Plowman, E. K., et al. (2021). ‘Dysphagia after cardiac surgery: Prevalence, risk factors, and associated outcomes’, The Journal of thoracic and cardiovascular surgery. doi: 10.1016/j.jtcvs.2021.02.087.

Schefold, J. C., et al. (2017). ‘Dysphagia in Mechanically Ventilated ICU Patients (DYnAMICS): A Prospective Observational Trial’, Critical care medicine, 45(12), pp. 2061-2069. doi: 10.1097/CCM.0000000000002765.

Vanstrum, E. B., et al. (2022). ‘Intractable Bleeding Following an Awake Bedside Injection Laryngoplasty in a Patient on KVAD ECMO’, Journal of Voice.

5560

A review of continuous versus intermittent monitoring of vital signs for preventing complications of patient deterioration

Solomon-Miles Donnelly¹, Brian Johnston², Ingeborg Welters²

¹ University of Liverpool

² Liverpool University Hospitals Foundation Trust; Liverpool Centre for Cardiovascular Sciences, University of Liverpool

Introduction: Early warning scores (EWS) based on key physiological parameters are used in clinical routine for standardised assessment of disease severity in acutely ill patients.¹ First described in the 1990s based on measurements of heart rate, respiratory rate, blood pressure, temperature, and level of consciousness, the principles of EWS are now internationally accepted for early identification of patient deterioration and escalation planning.² EWS rely on intermittent, non-invasive recording of vital signs.¹ In contrast, wearable, wireless devices that continuously record measurements have the potential to radically change how vital signs monitoring is conducted. The rationale for such devices comes from intermittent recording of physiology data representing a major limitation of EWS. The idea is that continuous monitoring may reliably identify episodes of patient deterioration between intermittent, manual measurements, thus providing opportunity to treat changes in the clinical condition earlier and prevent clinical complications. This is important as delayed response to deterioration and admission to the intensive care unit (ICU) is associated with increased patient mortality.³ Current literature is conflicting as to whether such devices provide meaningful clinical benefit in diagnosing patient deterioration.

Objectives: This review aimed to examine the current evidence for continuous, non-invasive monitoring in preventing complications of patient deterioration, and whether there are any specific indications for its use.

Methods: Studies were identified through four electronic databases (Medline, Embase, PubMed, and the Cochrane Library). Search terms were derived from inclusion and exclusion criteria generated from the PICO statement, using hospitalised, ward-based adult patients for population, continuous, non-invasive monitoring of vital signs for intervention, intermittent, non-invasive monitoring of vital signs as comparator, and prevention of complications from patient deterioration as outcome. Studies were appraised using Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and BestBETs (best evidence topic) checklists.^4,5

Results: Of the 1461 records identified, 14 full-text articles (254701 patients) met the inclusion criteria, including five studies (29185 patients) identified from reference lists. Results were categorised into six outcomes describing complications from patient deterioration: rates of ICU transfers, escalation calls, clinical complications, mortality, unplanned emergency interventions, and length of hospital stay. There was a general trend towards improved outcomes with continuous, non-invasive monitoring, particularly with regards to ICU transfers and escalation calls. However, results were often nonsignificant and clinical heterogeneity in study methodology often impacted comparisons and prevented generalisable conclusions. There were large differences between the features of wearable devices, vital signs measured, patient populations, and frequency of monitoring in both continuous and intermittent monitoring arms. Large, well-controlled trials were lacking, and the widespread use of before-and-after cohort studies limits the ability to determine causality, as the temporal changes between pre- and post-intervention are major confounders.

Conclusions: There is currently insufficient evidence available to determine if continuous, non-invasive monitoring of vital signs is superior to standard, intermittent monitoring for preventing complications of patient deterioration. Large, randomised control trials using agreed core outcome sets and comparable definitions of ‘continuous’ and ‘intermittent’ monitoring are required to determine clinical benefits of continuous non-invasive wireless monitoring devices.

References

1. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London, UK, Dec 2017.

2. Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care 1997;8(2).

3. Cardoso LT, Grion CM, Matsuo T, Anami EH, Kauss IA, Seko L, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Crit Care 2011;15(1):R28.

4. Jeremy H, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Alessandro L, et al. The Oxford 2011 Levels of Evidence, http://www.cebm.net/index.aspx?o=5653 (2011, accessed 26 February 2023)

5. Mackway-Jones K. BETs CA Worksheets, https://bestbets.org/links/BET-CA-worksheets.php (2012, accessed 26 February 2023)

5591

How does age influence how vital signs change during infection? A systematic review and meta-analysis

Charlotte Harrison¹, Phoebe Tupper¹, Christopher Biggs¹, Bethany Seale¹, Stephen Gerry², Tatjana Petrinic³, Sarah Vollam¹, Oliver Redfern¹, Peter Watkinson⁴

¹ Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford

² Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford

³ Bodleian Health Care Libraries, University of Oxford

⁴ Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford. Oxford Critical Care, Oxford University Hospitals NHS Foundation Trust

Introduction: Infection affects older adults more frequently^1,2 and severely³ than younger adults. At admission to hospital, specific vital sign patterns may prompt consideration of a diagnosis of infection, triggering initiation of investigations and treatment.

It is unclear how age influences the presentation of infection in older adults. It has been suggested that older patients exhibit subtler changes in vital signs⁴ but results from existing studies appear contradictory. Incomplete understanding of the vital sign changes that accompany infection in older adults may contribute to delays in recognition and treatment, or overdiagnosis, leading to unnecessary investigations and inappropriate antibiotic use.⁵

Objectives: We systematically reviewed the literature, to describe the current knowledge base on how age influences change in vital signs during infection.

Methods: We searched MEDLINE Ovid, EMBASE Ovid and CINAHL EBSCO from inception to 6th September 2021 using a broad search strategy developed by clinicians working alongside a qualified librarian. All English-language original research articles describing admission vital signs, stratified by patient age, in patients admitted to hospital with a diagnosis of bacterial infection were included. Studies in immunosuppressed participants or those studying a specific co-morbidity were excluded. The quality of evidence was assessed using an adapted version of the QUADAS-2 tool. Paper screening, selection, data extraction, and grading of evidence quality were performed by two independent investigators, with a third for remediation if required. Where meta-analysis was feasible, effect measures were combined using a random effects meta-analysis. This study is registered on PROSPERO, number CRD42021298756.

Results: Our search identified 8510 unique studies. 228 studies were deemed eligible after title and abstract screening. After full text review, we identified 87 studies meeting the inclusion criteria. These studies included 78,824 participants (ranging from 10 to 20,192 per study). Most studies were retrospective with 30 being prospective and one being ambispective. 49 studies looked at one age group and 38 included two or more age groups. Studies were heterogenous with a range of age groupings and infections studied. Bacteraemia was the most common infection studied (18 studies), followed by pneumonia (14 studies). The most studied vital sign was temperature (79 studies), followed by heart rate (48 studies), systolic blood pressure (38 studies) and respiratory rate (33 studies). Most studies were deemed to have a high risk of bias. Full results of meta-analysis to follow.

Conclusion: Prompt and appropriate recognition of infection in older adults is a priority given the aging population⁶ and risks of over and under-use of antibiotics.⁷ Understanding how infection manifests in the vital signs of these patients is key to achieving this aim.

References

1. Bellmann-Weiler R, Weiss G. Pitfalls in the diagnosis and therapy of infections in elderly patients–a mini-review. Gerontology. 2009;55(3):241-9.

2. Gbinigie OA, Ordóñez-Mena JM, Fanshawe TR, Plüddemann A, Heneghan C. Diagnostic value of symptoms and signs for identifying urinary tract infection in older adult outpatients: Systematic review and meta-analysis. J Infect. 2018;77(5):379-90.

3. Yoshikawa TT, Norman DC. Geriatric Infectious Diseases: Current Concepts on Diagnosis and Management. J Am Geriatr Soc. 2017;65(3):631-41.

4. Yahav D, Schlesinger A, Daitch V, Akayzen Y, Farbman L, Abu-Ghanem Y, et al. Presentation of infection in older patients–a prospective study. Ann Med. 2015; 47(4):354-8.

5. Caterino JM, Stevenson KB. Disagreement Between Emergency Physician and Inpatient Physician Diagnosis of Infection in Older Adults Admitted From the Emergency Department. Academic Emergency Medicine. 2012;19(8):908-15.

6. Office for National Statistics. Overview of the UK population: January 2021 [Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/january2021).

7. National Institute for Health and Care Excellence. NG51. Sepsis: recognition, diagnosis and early management. [Available from: https://www.nice.org.uk/guidance/ng51.]

5035

The importance of twice daily ward rounds in the Intensive Care Unit: a Quality Improvement Project

Mariya Rajesh¹, Ahmed Nazari², Sharon Rajesh², Elizabeth Aloof², Duangkaew Jittasaiyapan³

¹ Northampton General Hospital

² Northampton General hospital

³ Northampton general hospital

Introduction: Effective communication between staff in the forms of handovers and ward rounds have been a general practise throughout hospitals and often occurs during the changeover of staff at the beginning and end of shifts. The guidelines for the Provision of Intensive Care Services state that consultant lead ward rounds must occur twice a day with daily input from nursing staff, it was found that at Northampton General Hospital (NGH) Intensive Care Unit there is one handover and consultant lead ward round in the morning, an informal handover between day and evening staff and a formal handover in the evening which did not meet guidelines. A preliminary survey found that 41.7% of staff found the informal evening handover inadequate and 50% of doctors spend time at the beginning of their evening shift looking through patient notes.

Objectives: The main objective was to implement a round during the afternoon whereby the junior doctors, consultants and nursing staff would handover patients to the evening staff at each bedside. This would enable staff to ensure completion of jobs from the day, identify outstanding problems, act on results from the day shift and create a clear management plan for the evening where there are less staff available. The afternoon round was introduced for efficient communication between day and evening staff as well as medical and nursing staff in order to maintain patient safety and ensure continuation of care.

Methods: NGH ICU is split into two halves: East and West. The first cycle of this project involved both consultants working at both halves, the new late shift doctors, the nurse in change and the day shift doctors walking through each bedspace at 5pm, identifying key problems, ensuring jobs are complete and adjusting the management plan accordingly with input from both the medical and nursing team. The staff completed a survey at the end of each round.

The second cycle was adjusted according to previous survey results, only the evening consultant was required to attend, the round time was made fluid, between 4-6 pm and a new jobs book was created in order to track the progress of jobs in the day and creation of new tasks during the round.

Results: The main outcome measures were the level of confidence of staff managing patients at NGH ICU, the percentage of daily jobs completed and for the evening round to become daily practise.

Survey results found that after the round 100% were more confident in managing the patients at NGH ICU, 60% expressed that the afternoon round provided clarity regarding management plans and main problems and 100% of staff agreed that the round improved communication. During the first cycle 88% of jobs were completed, outstanding issues were identified, and jobs were created during the handover which otherwise would have been left for the next morning ward round, during the second cycle 91% of jobs were found to be completed.

Summary: Twice daily ward rounds which include nursing and medical staff improve communication and confidence between staff and ensures the continuation of high-quality care throughout the day and night.

Reference

1. Guidelines for the provision of Intensive Care Services [Internet]. Guidelines for the Provision of Intensive Care Services | The Faculty of Intensive Care Medicine. [cited 2023Jan5]. Available from: https://www.ficm.ac.uk/standardssafetyguidelinesstandards/guidelines-for-the-provision-of-intensive-care-services

5219

The use of eye tracking technology to facilitate communication and improve wellbeing in intensive care: a case study

Daisy Richens, Sarah Harris

University Hospitals Bristol and Weston NHS Foundation Trust

Introduction and Objective: Communication difficulties are a well-documented and significant problem for invasively ventilated patients in the ICU.^1,2 The Guidelines for the Provision of Intensive Care Services state that patients should have access to a communication aid according to individual need to facilitate interaction and rehabilitation.³ Eye tracking (ET) technology, which uses infrared cameras and associated equipment to convert eye movements to cursor movements on a screen (Figure 1), can be used to support the communication of voiceless patients who are unable to access traditional forms of alternative and augmentative communication (AAC).⁴ This case examines the use of ET technology to support such a patient’s communication and improve his wellbeing.

Figure 1.

Diagram of the eye tracking set-up.

Method: We describe the case of a 34-year-old man with a medical history of obesity (BMI=70.2). He was admitted to the ICU following mitral valve repair with subsequent inoperable dehiscence of the valve, multi-organ failure and severe pressure ulcers. Post-operatively he underwent surgical tracheostomy and presented with profound ICU-acquired weakness but no cognitive deficits when off sedation.

Respiratory weaning and physical rehabilitation were significantly limited by his weight. Ventilatory requirements necessitated the near-constant inflation of his tracheostomy cuff, resulting in an inability to produce voice. He was unable to move his limbs and therefore could not access traditional forms of AAC. Support was sought from a charity helping people with disabilities to access technology, which provided an ET device and a tablet with accessibility, social messaging/media, and entertainment apps installed.

Results: Over a period of three months the patient had access to the aforementioned equipment. Its use initially enhanced his communication such that his ICU Functional Communication Scale⁵ score increased from 1 (mostly ineffective attempts to communicate) to 2 (mostly effective attempts to communicate). Contrary to expectations he did not use this set-up for face-to-face communication for very long, as increasingly comprehensible mouthing came to meet most of his communicative needs. He did however use it each day to send text messages to family and friends, to stream music, television programmes and films, and to play games. His ability to independently engage in social interaction and leisure activities had a positive impact on feelings of anxiety, isolation and boredom associated with his ICU admission, as evidenced by changes on his Mental State Examination when seen by Liaison Psychiatry and qualitative feedback from him and his family.

After five months in the ICU with little clinical change, the patient’s pressure ulcers continued to worsen. He found treatment increasingly burdensome and a decision was made to commence palliative care, after which he shortly died.

Conclusions: ET technology, in addition to supporting the communication of critically ill voiceless patients unable to access traditional forms of AAC, may also enable such patients to engage in greater social interaction and some leisure activities. Its use is therefore likely to alleviate stressors related to communication and mental health in the ICU, although it is only appropriate for use with a limited range of patients due to cognitive requirements.

References

1. Karlsen M-MW, Ølnes MA, Heyn LG. Communication with patients in intensive care units: a scoping review. Nursing in Critical Care. 2018 Aug 1;24(3): 115–131.

2. Krampe H, Denke C, Gülden J, Mauersberger V-M, Ehlen L, Schönthaler E, et al. Perceived severity of stressors in the Intensive Care Unit: A systematic review and semi-quantitative analysis of the literature on the perspectives of patients, health care providers and relatives. Journal of Clinical Medicine. 2021 Aug 31;10(17):3928.

3. Faculty of Intensive Care Medicine. Guidelines for the provision of intensive care services Version 2.1 [Internet]. 2022 [cited 2023 Jan 4]. Available from: https://ficm.ac.uk/sites/ficm/files/documents/2022-07/GPICS%20V2.1%20%282%29.pdf

4. Ull C, Weckwerth C, Schildhauer TA, Hamsen U, Gaschler R, Waydhas C, et al. First experiences of communication with mechanically ventilated patients in the intensive care unit using eye-tracking technology. Disability and Rehabilitation: Assistive Technology. 2020 Sep 19;18(1):44–49.

5. McGrath BA, Wallace S, Wilson M, Nicholson L, Felton T, Bowyer C, et al. Safety and feasibility of above cuff vocalisation for ventilator-dependant patients with tracheostomies. Journal of the Intensive Care Society. 2018 Mar 28;20(1):59–65.

5335

Effectiveness, experience and usability of low-technology augmentative and alternative communication in intensive care unit: a mixed-methods systematic review

Hissah Alodan¹, Anna-Liisa Sutt², Rebekah Hill¹, Joud Alsadhan³, Jane Cross¹

¹ University of East Anglia

² University of Queensland

³ King Saud University

Background: Patients in the intensive care unit (ICU) are commonly attached to mechanical ventilation, either through endotracheal intubation or tracheostomy, which leaves them nonverbal and often struggling to communicate with others. Although modern-day ICU sedation tends to be lighter than it was in the past, many patients report that their messages to others are either misinterpreted or not understood. Low-technology augmentative and alternative communication (AAC) strategies are simple and effective ways to enhance communication between patients and their communication partners (e.g. clinical staff, family). Previous literature has addressed low-technology AAC within the ICU, but the findings have not yet been synthesised.

Objective: To systematically review current evidence regarding the effectiveness, experience of use, and usability of low-technology AAC with nonverbal patients and their communication partners in the ICU.

Methods: Quantitative, qualitative, and mixed-methods studies were included in this review. Studies were included if the participants were adults (aged 18 or older) admitted to ICU, who were nonverbal due to mechanical ventilation and their communication partners. Studies using low-technology AAC (e.g. communication boards, pen and paper, communication cards, writing boards) were included. Following the Joanna Briggs collaboration (JBC) for mixed-methods systematic reviews, a convergent segregated approach was used for data synthesis. Searches were conducted using MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), PsycINFO (EBSCO), the Cochrane Library and Web of Science. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The JBC tools were used for experimental quantitative and qualitative studies, the Crowe Critical Appraisal Tool was used for observational quantitative studies, and the Mixed-Methods Appraisal Tool was used for mixed-methods studies.

Results: Thirty-one studies were included, of which 24 were quantitative, 4 were qualitative and 3 used mixed methods. The methodological quality of the included studies varied from low to moderate. The results from the quantitative and qualitative data showed that low-technology AAC increased patients’ satisfaction, facilitated the communication process and addressed their physical and psychological needs. Among the low-technology AAC strategies, a communication board with mixed content (e.g. pictures, words and letters) was the preferred method. However, low-technology AAC was generally used less frequently than unaided strategies (e.g. lip reading and eye blinking). Barriers to use were mostly related to patients’ medical statuses, a limited availability of tools and clinical staff poor attitudes. The communication board should be easy to use and adapted to match patients’ needs within the ICU and should be supplemented with a pen and blank paper. Patients who are undergoing operations should be shown the communication board beforehand to help them absorb the content and feel comfortable when using it post-operatively.

Conclusion: The existing evidence, although limited, suggests that as low-technology AAC strategies satisfy patients’ needs, if they are properly implemented and their challenges addressed, then better usability could be achieved. Further investigation is needed to establish a more thorough understanding of the fundamentals of designing and presenting a communication board that is simple to use yet sufficient for the patients’ needs in ICU.

5402

Exploration of Effective Nursing Handover in the Intensive Care Units: A Study Protocol of Adaptation and Validation of the Handover Evaluation Scale

Abrar Alamrani, Catriona J. Buick, Danielle Dunwoody, Elsabeth Jensen

York University

Introduction: There is a compelling need for nurses to provide effective handover communication, which is considered an essential requirement to ensure continuity of care, patient safety, and minimize the risk of adverse events (The Joint Commission, 2017). The increasing globalization of nursing and subsequent multicultural workplaces within healthcare settings may create the potential for cultural complexities that affect communication. A multicultural workplace is where workers come from diverse cultural and linguistic backgrounds to work in a foreign country. In this study, Saudi Arabia is a foreign country for many nurses who work their and not only culturally diverse from the patients they care for but also culturally different from each other. A report on patient safety culture involving data from 366 Saudi hospitals, indicated that 50% of nurses perceived handover as “problematic” in their hospitals and needing improvement (Saudi Patient Safety Centre, 2022). There is a need for attention to, and consideration of cultural and language differences in order to ensure effective handover practice within the multicultural workplace. To date, no study has considered the multicultural workplace as a variable when evaluating handover practice.

The handover evaluation scale (HES) examines nurses’ perceptions about the quality of information, interactions, and efficiency of handover (O’Connell et al. 2014). This tool has been validated in different settings and countries, such as Belgium, China, and Korea. This tool, however, measures only the handover process; it lacks more specific items related to handover content and factors that contribute to the quality of handover. Moreover, there is no valid and reliable HES for measuring the quality of nursing-shift handover in Saudi Arabia (i.e., a multicultural workplace). To study and measure the quality of handover in the ICU in a multicultural workplace, a dedicated tool with the capacity to capture the content, the process and the factors that influence the handover practice is necessary to identify communication challenges and opportunities for improvement.

Purpose and objectives: To adapt and assess validity and reliability of the HES for measuring effective handover and the factors that contribute to effective handover in the ICU.

1. To explore and gain an understanding of ICU nurses’ perceptions of quality of handover and factors associated with effective handover.

2. To utilize the findings of the exploration phase to modify the HES.

3. To identify items related to the factors associated with the effective handover from the ICU nurses’ perspectives.

4. To assess the reliability and validity of the HES to fit the multicultural ICU contexts.

Methods: We will employ an exploratory sequential mixed method design. The first phase will be a qualitative exploration of what effective shift handover means to ICU nurses and which factors contribute to effective shift handover. From this initial exploration, the qualitative data will be developed into items that modify the HES as an intermediate step; this will be followed by the modification and validation phase in which the tool will be validated.

Exploration phase

The data will be collected from 20 experts ICU nurses by using semi-structured interview. The data will be analyzed by using an interpretive description approach (Thorne, 2008).

Modification and validation phase

Boateng et al. (2018) approach will influence the instrument modification and validation procedures. The sample size will be determined based on the number of items; 10 respondents per item are required. The data will be analyzed in the SPSS.

Results: Findings have the potential to validate a tool to measure the quality of nursing shift handover and identify current challenges and factors affecting the quality of handover in the multicultural critical care context.

References

1. The Joint Commission. Sentinel event alert: Inadequate hand-off communication. Report, 2017.

2. Saudi Patient Safety National project for measuring and enhancing patient safety culture within hospitals. Report, August 2022.

3. O’Connell B, Ockerby C, Hawkins M. Construct validity and reliability of the Handover Evaluation Scale. Journal of Clinical Nursing. 2014;23(3-4): 560-70.

4. Thorne, S. Interpretive description. Left Coast 2008.

5. Boateng G. NT, Frongillo E., Melgar-Quiñonez H., and Young SL. Best practices for developing and validating scales for health, social, and behavioral research: A prime r. Frontiers in Public Health. 2018; 6(149):1-18.

5454

Artificial intelligence based recognition software for communication in ICU

Shravan Nanda, Imran Patel

Lancashire Teaching Hospital

Introduction: Approximately 13,000 critical care patients will undergo a tracheostomy annually in the UK.¹ This poses a challenge for communication in a critical setting. Simple tasks currently employed include writing, visual charts and eye gaze boards.² Currently, there is no communication tool in which all patients’ needs are met. Artificial intelligence based recognition software could play a role in fulfilling patients’ communication needs in hospital and a wider community setting.

Objectives: Evaluating artificial intelligence based deep learning software for phrase/speech in critically ill patients

Methods: A prospective study was undertaken in a tertiary hospital critical care unit in the north west of England. Using artificial intelligence based deep learning software app, patients attempted mouthing various supported phrases with recordings evaluated by deep learning processing methods. Potential speech/phrases were displayed by the speech/phrase recognition for the voice impaired (SRAVI) app based on this deep learning technology.

Results: A total of 586 videos were recorded across 70 users. Each video frame applied a 64 point facial identification for extraction of lip movements in each video frame. It was further then applied to the artificial intelligence based deep learning software to identify the top 3 phrases with high accuracy.

Conclusion: Artificial intelligence based deep learning software provides high accuracy detection of speech/phrases for communication in the voice impaired. This suggests that speech/phrase recognition technology combined with deep learning artificial intelligence can be a therapeutic option to bridge the gap in communication in critically ill patients.

Funders

Innovate UK

References

1. McGrath BA, Ramsaran R, Columb MO. Estimating the number of tracheostomies performed in critical care in England. Br J Anaesth. 2012; 109(4):662P.

2. Ten Hoorn S, Elbers PW, Girbes AR, Tuinman PR. Communicating with conscious and mechanically ventilated critically ill patients: a systematic review. Crit Care. 2016; 20(1):333.

5483

Improving staff identification and team-work on the intensive care unit

Camilla Lees, Raj Nichani

Royal Oldham Hospital

Introduction: Better team work improves staff morale and patient safety.¹ The NHS is facing a workforce crisis with high staff turnover and a greater reliance on agency staff to fill rotas.² It is not surprising that nurses and doctors are often working together in unfamiliar teams. Doctors working on our intensive care unit (ICU) have varied levels of experience and are frequently changing.

Objectives: We wanted to improve the nurses’ ability to identify which doctor to call in an emergency and to better understand the grade and level of experience of all the doctors working on the ICU.

Methods: Questionnaires were given out to twenty-one ICU nurses over a week-long period. Questions focused on knowledge of each doctor’s grade and level of experience, how confident they were at knowing who to call for help in an emergency and what skills they expected each doctor to have.

Results: Twenty-one nurses were surveyed. The majority were band 5 level (81%). Most nurses felt it was very important to know a doctor’s training grade and level of experience, however many were not very confident they knew each doctor’s grade. 38% of doctors’ rarely introduce themselves with name and role during the first patient review. 33% of nurses expected all doctors on ICU should know how to intubate a patient. 48% of nurses expected them to be able to manage an airway and 86% expected doctors to know how to change ventilator settings. 90% of nurses expected each doctor to know how to administer vasopressor drugs and manage a major haemorrhage (95%). When asked ‘who you are most likely to call in an airway emergency or cardiac arrest’ the majority knew the correct procedure and call 4444 which alerted all ICU doctors holding a bleep to the patient’s bedside.

Conclusion: The results from our survey demonstrate that many nurses are not confident they know the grade of each doctor and what circumstances they are capable of managing. Some doctors have had very little critical care training, others are very experienced but there is little to differentiate the two groups. We are working on improving the identification of doctors’ grade and competencies on our unit by highlighting this at multi-disciplinary team (MDT) teaching sessions, simulation and safety huddles. With these methods, we hope to help nurses identify doctors’ level of experience to improve team work and ultimately patient safety.

References

1. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004; 13: i85-i90.

2. House of Commons Report. 20 July 2022. Health and Social Care Committee Workforce: recruitment, training and retention in health and social care. Available from: https://committees.parliament.uk/publications/23246/documents/171671/default/

5567

“Doc Your Micro”: An Audit into Microbiology Documentation on the Intensive Care Unit of a District General Hospital

Hannah Bardsley, Jacyntha Khera, Ashok Sundar

Croydon University Hospital

Introduction:

• Intensive care medicine involves a multidisciplinary team in order to target patient management. Microbiology is one such specialty which has a significant impact on patient care, and thus daily microbiology input is a standard, as outlined in the Guidelines for the Provision of Intensive Care Services.¹

• Antimicrobial treatment is particularly pertinent among critically ill patients, with 70% of patients on the ICU receiving at least one antibiotic.² It is well documented that undertreated infection as well as prolonged courses of antibiotics can lead to adverse events.³

• Effective communication with clear and accurate documentation of discussions between microbiology and intensive care teams is vital to safe and individualised patient care as well as timely antimicrobial de-escalation.

Objectives:

1. To audit the standard of Microbiology ward round documentation on the ICU.

2. To produce a quality improvement tool to increase the standard and encourage the incidence of Microbiology documentation.

3. To re-audit the above to monitor documentation standards and assess improvements.

Methods:

• Retrospective audit conducted over a two week period between November 2022 and January 2023. Data on the frequency and appropriateness of microbiology input documentation was collected.

• A quality improvement project was devised comprising of an ICU Microbiology template created on the electronic patient records.

• A closed-loop audit was performed assessing documentation standards post-intervention over a two week period between January and February 2023.

• Promotion of the ICU Microbiology template included a lecture, email, and notifications over a messaging app to all ICU junior doctors.

• Adult patients over 16 years of age both on and off antibiotic treatment were included.

Results:

• A total of 161 bed-days on antibiotics pre-intervention were compared with a total of 178 bed-days on antibiotics post-intervention. 13% bed-days (n=15) of the pre-intervention and 7% bed-days (n=7) of the post-intervention had documented Microbiology input.

• All domains of documentation assessed showed improvement following implementation of the ICU Microbiology template.

• The ICU Microbiology template had an 83% compliance rate.

Conclusions:

• We have demonstrated poor documentation of Microbiology input on our ICU. The implementation of an ICU Microbiology template has enhanced the quality of documentation, with an improvement seen across all domains.

• The two week period audited pre- and post-intervention may limit the accuracy of results by providing a “snapshot” view.

• Better availability of procalcitonin results along with freely available guidance of in-house antibiotic prescriptions may have reduced the need for daily discussion with the Microbiology team.

• This audit has highlighted a need for increased frequency of Microbiology input in order to meet national standards.¹ The approach should be pragmatic and tailored to our ICU. It will be discussed with the Microbiology department and the need for regular, well-documented input emphasised.

• Compliance with the use of the ICU Microbiology template and effectiveness of the QI on antibiotic stewardship will be monitored on a bimonthly basis.

• The audit results will be presented at the critical care clinical governance meeting.

References

1. The Faculty of Intensive Care Medicine. Guidelines for the Provision of Intensive Care Services. Version 2.1. July 2022.

2. Vincent JL, Sakr Y, Singer M, Martin-Loeches I, Machado FR, Marshall JC, Finfer S, Pelosi P, Brazzi L, Aditianingsih D, Timsit JF, Du B, Wittebole X, Máca J, Kannan S, Gorordo-Delsol LA, De Waele JJ, Mehta Y, Bonten MJM, Khanna AK, Kollef M, Human M, Angus DC; EPIC III Investigators. Prevalence and Outcomes of Infection Among Patients in Intensive Care Units in 2017. JAMA. 2020 Apr 21;323(15):1478-1487. doi: 10.1001/jama.2020.2717. PMID: 32207816; PMCID: PMC7093816.

3. Kollef MH. Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients. Clin Infect Dis. 2000 Sep;31 Suppl 4:S131-8. doi: 10.1086/314079. PMID: 11017862.

5618

Intensive care and frailty: an unlikely friendship

Diana Kluczna, Rasmus Knudsen, Neil Allan, John Norris

Mid Yorkshire NHS Trust

Introduction: Frailty scores are widely used and correlate to physiological reserves in patients admitted to a hospital, an important consideration for intensive care unit (ICU) admission.^1,2 Frailty is known to be associated with worse outcomes, including younger patients admitted to ICU.³ The National Institute of Clinical Excellence (NICE) highlights the importance of using clinical frailty scores (CFS) to assist with decision making.⁴ Good documentation remains a pinnacle of communication within and between teams in NHS settings and forms a basis of continuation of care across different healthcare groups.⁵

Many decisions in ICU take frailty into account, but poor documentation of this may affect outcomes and timeliness of decision making.

Objectives: To improve communication within and outside of the intensive care team with regards to documentation of patient’s Clinical Frailty Score on admission to ICU.

Methods: We collected data on rates of functional assessment and CFS documentation on admission to a single general ICU department in an acute district general hospital in the UK. Anonymous surveys explored the ICU medical staff’s understanding and beliefs on functional assessment, frailty scores, and their importance with relation to decision making on ICU.

Visual reminders for documentation of CFS were introduced directly onto paper clerking proformas and data was collected following this intervention. The reminder included a QR code which linked to a quick reference CFS. Changes rates of documentation were compared.

Results: Data was collected for all patients on ICU in October and November 2022, prior to introduction of visual reminders and again in January and February 2023 following the change. The initial cohort included 94 patients. Preliminary data collection of the cohort following visual aid introduction included 71 patients.

In the initial group, none of the patients had CFS documented, and 42.6% of patients had functional assessment findings documented. In the visual remainder cohort, we observed 85% of patients having CFS and 54.9% functional assessment documented on clerking.

An anonymous survey was conducted prior to the introduction of visual reminders in the clerking proformas. We received 20 responses across different grades of the medical ICU team. Of note, all responders indicated that patient’s frailty is very important consideration for ICU admission. The majority of responders (80%) reported recording an impression of patient’s frailty, while 25% indicated that they document a frailty score on admission to ICU.

Conclusions: The use of frailty scores, like CFS, make communication more transparent and provides a reliable impression of frailty in ICU patients. Despite clinicians indicating high importance of documenting an impression of frailty, our baseline data showed that the rates of functional assessment documentation were low, and none of the patients had a frailty score documented prior to our intervention. Preliminary analysis following the introduction of a visual reminder for clinical frailty score resulted in significant improvement in rates of documentation, as well as improving documentation rates for functional assessment. Further data will be available.

We have demonstrated that augmenting admission proformas provides a simple method of increasing documentation rates for key parameters.

References

1. Wallis SJ, Wall J, Biram RWS, Romero-Ortuno R. Association of the clinical frailty scale with hospital outcomes. QJM. 2015;108(12):943–9.

2. Muscedere J, Waters B, Varambally A, Bagshaw SM, Boyd JG, Maslove D, et al. The impact of frailty on intensive care unit outcomes: A systematic review and meta-analysis. Intensive Care Medicine. 2017; 43(8):1105–22.

3. De Geer L, Fredrikson M, Chew MS. Frailty is a stronger predictor of death in younger intensive care patients than in older patients: A prospective observational study. Annals of Intensive Care. 2022;12(1).

4. National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management [Internet]. [London]: NICE; 2016 [cited 2023 Feb 24]. (Guideline [NG56]). Available from: https://www.nice.org.uk/guidance/ng56

5. Ratnapalan M, Cooper AB, Scales DC, Pinto R. Documentation of Best Interest by Intensivists: A retrospective study in an ontario critical care unit. BMC Medical Ethics. 2010;11(1).

4937

Frequency and outcomes of COVID-19 associated pneumothorax and pneumomediastinum on an intensive care unit

Giles Coverdale

Birmingham Heartlands Hospital

Introduction: Pneumothorax (PTX) and/or pneumomediastinum (PM) is an important complication of COVID-19 in critical care. A UK COVID-19 case series from 2020 showed a mortality rate of 63.1% or 53% for patients with PTX or isolated PM respectively.¹ A large UK observational study between January 2020 and February 2021 found a 6.1% rate of PTX in patients requiring invasive ventilation².

Treatment of severe COVID-19 has changed over time; steroids and non-invasive positive pressure ventilation (NIPPV) became standard in 2020², interleukin-6 inhibitors were recommended in 2021³. The requirement for invasive ventilation has reduced.

This study evaluates the rate and outcomes of PTX/PM in patients admitted to University Hospital Coventry and Warwickshire (UHCW) intensive care unit (ICU) with COVID-19 between 1/8/21 and 31/1/22.

Methods: A complete list of UHCW ICU patients with COVID-19 was generated from ICU coding records. Patient hospital records and radiology images were reviewed to confirm non-traumatic PTX or PM, the maximum respiratory support delivered and dates of ICU discharge or death.

Results: There were 125 patients admitted to UHCW ICU with COVID-19 over the 6-months. The overall ICU mortality rate with COVID-19 was 48/125 (38.4%). 56 of the 125 (45%) patients received invasive ventilation. There were 13 patients with PTX/PM (2 had PM without PTX). 12 out of 56 (21.4%) patients who were invasively ventilated had PTX/PM. The one patient not invasively ventilated had a traumatic haemopneumothorax and incidental COVID-19. Overall, the rate of non-traumatic PTX/PM in all patients with COVID-19 on ICU was 12 out of 125 (9.6%).

The mortality rate of invasively ventilated COVID-19 patients was 33 out of 56 (59%) compared to 13 out of 69 (19%) either managed with NIPPV or high flow oxygen.

All patients with a non-traumatic PTX/PM and COVID-19 on ICU were invasively ventilated: The ICU mortality rate of COVID-19 patients who developed PTX/PM was 8 out of 12 (67%). The mortality rate of intubated COVID-19 patients without PTX/PM was 25 out of 44 (57%). The relative risk was 1.17 (95% CI 0.73 – 1.89) for invasively ventilated patients COVID-19 patients who develop PTX/PM compared to COVID-19 patients without PTX/PM⁴.

Discussion: The incidence of non-traumatic PTX/PTM with COVID-19 patients in this study was higher than UK publications in 2021². In UHCW, not all patients requiring NIPPV with COVID-19 were managed on the ICU; many had NIPPV on medical wards. These patients were not included and may have reduced the observed PTX/PM rate. By August 2021 invasive ventilation was avoided where possible in favour of NIPPV. It may be that the higher-than-expected rate of PTX/PM in invasively ventilated patients reflected a cohort with particularly advanced COVID-19 lung disease.

Conclusion: In this study of COVID-19 patients on UHCW ICU between August 2021 and January 2022, the rate of non-traumatic PTX/PM was 9.6% overall. In those requiring invasive ventilation, the rate of PTX/PM was 21.4%. The mortality rate for patients with PTX/PM was 67%; all these patients were mechanically ventilated.

References

1. Martinelli AW, Ingle T, Newman J et al. COVID-19 and pneumothorax: a multicentre retrospective case series. Eur Respir J. 2020; 19: 2002697.

2. Marciniak SJ, Farrell J, Rostron A, et al. COVID-19 pneumothorax in the UK: a prospective observational study using the ISARIC WHO clinical characterisation protocol. Eur Respir J. 2021; 58: 2100929.

3. National institute for Health and Care excellence. COVID-19 rapid guideline: managing COVID-19 (NICE guideline 191). 2021; Available at https://www.nice.org.uk/guidance/ng191/resources/covid19-rapid-guideline-managing-covid19-pdf-51035553326 (Accessed 13 January 2023).

4. MedCalc Software Ltd. Relative risk calculator. Version 20.118; Available at https://www.medcalc.org/calc/relative_risk.php (Accessed 18 November 2022).

5306

Intensive care delirium: a pandemic perspective on incidence at Aberdeen royal infirmary

Chakshu Joshi¹, Andrew Laurie²

¹ University of Aberdeen

² NHS Grampian

Introduction: Delirium is a common neuropsychiatric syndrome that disproportionately affects hospitalised older adults. It is historically recorded in 30% of ICU patients¹ and associated with increased mortality and longer hospital stay. Infection is a common precipitant of delirium and older adults with COVID-19 were found to present with delirium in 22% of cases.³

Objectives: Primary aim was to assess and compare the incidence, day of onset, number, and duration of delirium episodes in the COVID-19-positive and negative populations from March 2020 to July 2021. Secondary aims

Material and Methods: This retrospective descriptive study utilised 500 electronic patient entries from Aberdeen Royal Infirmary. Percentages, mean, median, and mode were calculated, and statistical analysis included a two-tailed T-test or a chi-square of independence. P values of ≤0.05 were considered statistically significant.

Results: 29% of the patient cohort was COVID-19 positive. COVID-19-positive patients were admitted for mean length of 11.3 days while the COVID-19-negative population stayed for a mean 4.3 days (p <0.01). Delirium incidence in the COVID-19-positive and negative groups was 35.8% and 34.9%. Mean day of delirium onset in COVID-19-positive patients was on day 21.3 while COVID-19-negative patients were delirious on day 10.3 (p = 0.01). 85.9% of delirious episodes in the COVID-19 population occurred with tracheostomy or intubation (p <0.01). 57.3% of COVID-19-positive patients were delirious for one day or less (p = 0.04). 73% of COVID-19 positive patients were prescribed antipsychotics (quetiapine being most common) compared to 51.6% of COVID-19 negative patients receiving antipsychotics (p = 0.02). 37.9% of the COVID-19 population died during admission, compared to 14.9% of the COVID-19-negative population (p <0.01).

Conclusion: The pooled incidence of delirium of both populations was 35.6%, showing little change from pre-pandemic data.² However, COVID-19-positive patients were in ICU for longer, experienced delirium later in admission, appear to have shorter episodes of delirium, and received antipsychotics more frequently than the COVID-19-negative population. Those with COVID-19 infection had a higher mortality rate. Delirium in the COVID-19-positive group most frequently occurred in patients with artificial airway support.

References

1. Ely EW. Delirium as a Predictor of Mortality in Mechanically Ventilated Patients in the Intensive Care Unit. JAMA [Internet]. 2004 Apr 14 [cited 2022 Dec 13];291(14):1753. Available from: https://jamanetwork.com/journals/jama/fullarticle/198503

2. Salluh JI, Soares M, Teles JM, Ceraso D, Raimondi N, Nava VS, et al. Delirium Epidemiology in Critical Care (DECCA): an International Study. Critical Care [Internet]. 2010 [cited 2022 Dec 13];14(6):R210. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3220001/?report=reader

3. Gan JM, Kho J, Akhunbay-Fudge M, Choo HM, Wright M, Batt F, et al. Atypical presentation of COVID-19 in hospitalised older adults. Irish Journal of Medical Science [Internet]. 2020 Sep 21 [cited 2022 Dec 13];190(2):1–6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505490/

5408

HME filter changes in mechanically ventilated Patients for COVID pneumonitis

Mohamed Khalaf Mady Morsy¹, Lucy Faulkne², Osama Ramadan³, Christopher Bouch³

¹ University Hospitals of Leicester NHS Trust

² University Hospitals of Leicester NHS Trus, Leicester, United Kingdom

³ University Hospitals of Leicester NHS Trus, Leicester, United Kingdom

Introduction & Objective: Heat and moisture exchanging filters (HMEFs) in ventilatory circuits minimise moisture loss in expiration to prevent drying of respiratory mucous. The filter also provides microbiological filtration, preventing cross-contamination into the clinical environment. Wetting of the filters occurs with use, compromising filter function and ventilator efficiency; hence regular changes are required during mechanical ventilation. Despite their widespread use in ICU, there is a lack of consensus over the frequency of HMEF changing required in patients during mechanical ventilation.

Methodology: Data were collected from 50 patients ventilated due to COVID pneumonitis by reviewing both the intubated patients and the ICU nursing charts. Patients were treated in Leicester Royal Infirmary, University Hospitals of Leicester, UK. The local protocol is 12 hourly changes, with documentation of the date and time of each change on ICU charts, which served as the audit standard. We also collected data on unplanned filter changes including the reason for replacement and some physiological parameters, MAP, PaCO2, FiO2, immediately preceding and 15 minutes after each event.

Results: HMEF changes were correctly documented in 22%of patients. Unplanned filter changes occurred in 84% of patients, most cited due to a water level being seen within the filter 80.95% Where unplanned filter changes occurred, a significant improvement in the mean PaCO2 by 1.228Kpa. Although no significant changes noticed in Mean Blood Pressure(p=0.0635), systolic blood pressure showed significant drop by 8.87mmHg within 15 minutes after filter change; however no significant improvement in Fi02 was seen.

Conclusion: We provide real-world data to support the need for education amongst ICU staff. The high rate of unplanned filter changes and improvement in documented physiological parameters suggest that continous HME filter’s observation and proper documentation, including time and date, are important to decrease the rate of unplanned filter changes. Additionally, deterioration in a COVID patient’s ventilation may indicate blockage of the HMEF, and assessment of the HMEF should form part of evaluating the cause for the deterioration.

Acknowledgement

We like to thank the following colleagues for their kind contributions in data collection Ayman Hassan, Luke Attwood and Upasana Topiwala. A special thanks to Dr Simon Scott for his valuable comments. Thanks for all my colleagues in the ICU for their kind support.

5415

Health related quality of life (HRQOL), functional capacity and posttraumatic stress disorder (PTSD) in post-ICU survivors with COVID-19 pneumonia in Sri Lanka

Tharuka Sikuradipathi¹, Kamal Krishakeesen², Nayana Fernando³, Pabasara Karunadasa³, Shabnam Wallin³

¹ Kings College Hospital

² Luton and Dunstable Hospital

³ University Hospital Kothalawala Defence University Sri Lanka

Introduction: COVID-19 pneumonia has been associated with poor HRQOL in post-ICU survivors. However, there is scarcity of data in resource poor countries.

Objectives: This study was designed to analyse the HRQOL, functional status and the incidence of PTSD symptoms in post-ICU survivors in 90 days following ICU discharge and to explore the determining factors of HRQOL, functional status and PTSD.

Methods: The study was conducted in 2021 over nine months in a 14 bed adult ICU dedicated to manage critically ill COVID-19 patients. Total of 68 patients, infected with COVID-19 (RAT or PCR confirmed), and received more than 24 hours of ICU treatment were recruited and data were collected at two time points. (Before the critical illness-from a proxy or by recall and 90 days after the ICU discharge through a telephone conversation). SF-36 questionnaire, PTSD checklist (PCL) civilian version and post-COVID-19 functional status (PCFS) scale were used to collect the data.

Results: Majority of patients were male (69.1%) and in the age group of 31-50 years (51.5%). Mean SOFA score was 3.9 and 88.2% had a P/F ratio <200. 19.1%, 30.9% and 73.55 received invasive ventilation, non-invasive ventilation and high flow nasal oxygen respectively. Mean length of ventilation was 5 days and mean length of stay was 9 days.

Results indicated a striking change between pre-COVID physical summery score (PSC) and post-COVID PSC score (t=10.733, df=67, p=0.001). It revealed a similar change between pre-COVID mental summery score (MSC) and post-COVID MSC (t=7.957, df=67, p=0.001). 48.5% of the patients were fully independent. 48.4% had mild to moderate limitation and 2.9% had severe limitations in the functional status. Prevalence of PTSD symptoms was 22.1%.

There was no statistically significant association found between the independent variables (age, charlson comorbidity score, duration of mechanical ventilation and duration of ICU stay) and HRQOL, functional status or PTSD.

Conclusions: HRQOL was significantly reduced from the baseline at 90 days from the ICU discharge, in COVID-19 infected post-ICU survivors.

References

1. Sameera Senanayake, Nalika Gunawardana, Paba Palihawadana, et al. Validity and reliability of Sri Lankan version of the Kidney Disease quality of the life questionnaire (KDQO-SF TM). Health and quality of the life outcomes. Article No: 119 (2017).

2. Klok FA, Boon GJAM, barro S, et al. The post COVID-19 Functional Status Scale: a tool to measure functional status over time after COVID-19. Eur Respi J. 2020; 56: 2001494.

3. Fernando GA, Bloodied but unbowed: Resilience examined in a South Asian Community. American journal of Orthopsychiatry. 2012; Vol 82 (No 3): 367-375.

5463

Long-term outcome after severe & critical COVID-19: observational study

Ngoc Nguyen Thanh¹, Phuong Le Thanh¹, Hong Nguyen Thi Le², Huyen Le Thi Bich², Thanh Pham Ba², Toan Le Mau², Dung Nguyen Thanh², Tan Le Van¹, Louise Thwaites¹, Yen Lam Minh¹, Hai Ho Bich¹, Thy Doan Bui Xuan¹, Thao Nguyen Thi Phuong¹, Van Cao Thi Cam Van²

¹ Oxford University Clinical Research Unit

² Hospital Tropical Disease

Introduction: COVID-19 in high income settings, persistent long-term impairment as well as difficulty returning to work with 50% of ICU survivors suffer from new physical, mental, and/or cognitive problems at 1 year after ICU discharge.^1-4 In low- and middle-income countries (LMICs), including Vietnam, there are few data concerning long-term outcome from critical illness generally and especially COVID-19, despite many millions affected. These data are vital to fully understand the impact of the pandemic and assist future healthcare resource planning, particularly as follow-up facilities or rehabilitation services are usually lacking in these countries.

Objective: To describe 1-year outcomes of ICU survivors of COVID-19 admitted to a tertiary referral hospital, Hospital for Tropical Diseases (HTD) Ho Chi Minh City, Vietnam.

Methods: Adult patients who had received mechanical ventilation for COVID-19 at HTD and were discharged alive, between July 2021 and December 2021 were eligible for enrolment in the study. 36-item RAND Short-Term Health Survey (SF-36), EuroQol’s five-dimensional 5-level utility score (EQ-5D-5L), Rankin Score, and return-to-work status were measured 12 months after hospital discharge by telephone interview administered by specially trained staff. Outcome data were matched with hospital data collected prospectively. Data are presented as descriptive data with median (interquartile range IQR) or number (%). EQ-5D-5L and SF-36 are given as domain summary scores. The study was approved by HTD and OxTREC ethics committees.

Results: 139 patients were eligible for enrollment, of whom 68 were enrolled. 10 patients had died after discharge and 35 could not be contacted. (Figure 1). Clinical and demographic data from the hospitalization period are given in Table 1. 49/68 patients (72%) had comorbidities present on admission. The most common were hypertension 27/49 (55.1%), joint diseases 12/49 (24.5%) and diabetes 11/49 (22.4%).

Figure 1.

Study flowchart.

At 12 months, 58/68 patients (85%) still had persistent symptoms although most who were eligible had returned to work (Table 2). The most common complaint was joint pain (18 patients (31%)), followed by weakness/fatigue (18 patients ((31%)), cough (15 patients (25.9%)), shortness of breath (14 patients (24%)). Overall recovery was good across physical and mental domains for both SF-36 scores (Figure 2) and EQ-5D-5L (data not shown).

Figure 2.

SF36 of participants 12 months after hospital discharge.

EQ5D-5L scores according to subgroups of vaccination status and comorbidity are shown in Figure 3 indicating that pre-existing comorbidity may be associated with impairment particularly for mobility, self-care and pain domains. (Figure 3).

Figure 3.

EQ-5D-5L score 12 months after hospital discharge according to vaccination status (above) or comorbidity status (below) Right hand panel gives Health score according to vaccination status comorbidity.

Note:

– NO-VACCIN: no previous vaccination

– VACCIN: previous vaccination

– NO-COMOR: no comorbidity

– COMORBIDITIES: pre- exisiting comorbidity

Conclusion: 1-year Quality of Life scores and return-to-work status were higher than reported in high income settings. Reasons are likely to be multifactorial but may include financial necessity of returning to work and additional support by living in extended families. Nevertheless, we note that SF-36 scores were lower than previously reported for a non-COVID cohort of Vietnamese ICU patients with similar lengths of stay.⁵ Whilst 10 patients had died after discharge, our study is limited in that we were unable to account for the status of an additional 35 patients who may have suffered adverse outcomes.

References

1. Amy MorganMBBS MRes FRCA FFICM is an Anaesthesia and Intensive Care Consultant at Northumbria Specialist Emergency Care Hospital, UK. Conflicts of interest: none declared. (2020). Long-term outcomes from critical care. Elsevier Public Health Emergency Collection, doi: 10.1016/j.mpsur.2020.11.005.

2. Hidde Heesakkers, MD; Johannes G. van der Hoeven, MD, PhD; Stijn Corsten, MD; Inge Janssen, MD; et al. (2022). Clinical Outcomes Among Patients With 1-Year Survival. JAMA, ;327(6):559-565. doi:10.1001/jama.2022.0040.

3. Joanne McPeake,^1,2 Martin Shaw,^1,2 Pamela MacTavish,¹, et al. (2021). Long-term outcomes following severe COVID-19 infection: a propensity matched cohort study. BMJ Open Resp Res, ;8:e001080. doi:10.1136/bmjresp-2021-001080.

4. Regis Goulart Rosa,^1,2,3* Alexandre Biasi Cavalcanti,^2,4 Luciano César Pontes Azevedo,^2,5 et al. (2023). Association between acute disease severity and one-year quality of life among post-hospitalisation COVID-19 patients:Coalition VII prospective cohort study. © 2023 Springer-Verlag GmbH Germany, part of Springer Nature, https://doi.org/10.1007/s00134-022-06953-1.

5. Truong N. Trung, Nguyen V. T. Duoc,et al. (publication 24 July 2019). Functional outcome and muscle wasting in adults with tetanus. Transactions of the Royal Society of Tropical Medicine and Hygiene, doi:10.1093/trstmh/trz055.

5475

Tapia syndrome following COVID-19; the potential value of early rehabilitation and medialisation a case series

Ruth Capewell, Molly Wood, Camilla Dawson

UHB QEHB

Introduction: Patients with Covid-19 may require intubation, mechanical ventilation and proning. Tapia syndrome is caused by simultaneous injury of the recurrent laryngeal branch of the vagus and hypoglossal nerves; occurring following orotracheal intubation.¹

Objectives:

• To describe the diagnosis and management of two patients with Tapia syndrome following Intensive Treatment Unit (ITU) admission for COVID-19 pneumonitis.

• Discuss the benefit of early assessment, diagnosis and targeted rehabilitation including medialisation, on voice, swallow and tracheostomy outcomes.

Methods: We describe the diagnosis and management of two patients with Tapia syndrome following ITU admission for COVID-19 pneumonitis. Both were males and admitted in January 2021 in the UK. They were proned, intubated and required tracheostomy for weaning from mechanical ventilation. Both presented with dysarthria, dysphonia and dysphagia at initial Speech and Language Therapy (SLT) assessment. Nasendoscopy verified Tapia syndrome with concurrent ipsilateral vocal cord and hypoglossal palsies.

Case A: 68 year old with T2DM, HTN, previous colorectal cancer, emphysema, anxiety, and depression, presented to hospital 5 days after testing positive for COVID-19.

Initial fibreoptic endoscopic evaluation of swallow (FEES) confirmed laryngeal sensation compromise and inconsistent cough response to aspiration. Swallow rehabilitation included effortful swallow, voice exercises and one-way valve use.

Vocal cord medialisation was completed using Restylane filler on day 76 with positive effect, due to incomplete airway protection and persisting aspiration of saliva.

Case B: 70 year old with no medical history presented to hospital 6 days after testing positive for COVID-19.

Severe aspiration was confirmed on FEES and they remained nil by mouth with swallow rehabilitation, including tongue base exercises, cuff deflation and one-way valve use. Tracheostomy was downsized and fenestrated to optimise laryngeal airflow and support secretion clearance.

At day 66 improvements in tongue tone and movement were noted, also improving apposition of the vocal cords, less bowing of the right vocal cord and increased movement of the right arytenoid.

Results:

	Time intubated (Days)	Proned	Time with tracheostomy (Days)	Length of admission (Days)	Laryngeal diagnosis	Intervention	No of FEES/FNE
Case A	12	Yes	85	127	Left vocal cord palsy	Medialisation, voice & swallow rehabilitation	4
Case B	10	Yes	57	80	Right vocal cord palsy	Voice & swallow rehabilitation	4

Case A responded well to medialisation and rehabilitation resulting in decannulation on day 97. He was discharged on day 127, tolerating normal diet and fluids, with improved voice and speech.

Following decannulation on day 67, Case B continued to receive voice and swallow rehabilitation and benefited from using a left head tilt postural techniques to compensate for oral stage difficulties. Case B was discharged home on day 80 tolerating normal diet and fluids with mild dysphonia.

Conclusions: Timely SLT referral is fundamental to assess cranial nerves, voice and swallow for this patient group in ITU to enable early management and rehabilitation.

Collaborative management with ENT and the early use of nasendscopy is key in patients with concurrent vocal cord and hypoglossal nerve palsies, to differentially diagnose Tapia syndrome, whilst ensuring that organic causes are ruled out.

Medialisation following no spontaneous recovery within 4 weeks of injury can be effective to support swallow and voice rehabilitation. We do not suggest medialisations are considered for all patients with vocal cord palsies following COVID-19, only for those with persistent palsies and silent aspiration of secretions.

Reference

1. Cinar S, Seven H, Cinar U, Turgut S. Isolated bilateral paralysis of the hypoglossal and recurrent laryngeal nerves (Bilateral Tapia’s syndrome) after transoral intubation for general anesthesia. Acta anaesthesiologica scandinavica. 2005;49(1):98-9.

5575

Prediction models for hospital mortality in COVID-19 patients

Duc Du¹, Dung Nguyen², Thao Nguyen¹, Louise Thwaites¹, Ronald Geskus¹, Thanh Tran¹, Yen Lam¹, Phong Nguyen², Quang Vo², Hau Nguyen², Chau Nguyen³, Tan Le¹

¹ Oxford University Clinical Research Unit

² Ho Chi Minh City Hospital for Tropical Diseases

³ Ho Chi Minh City Department of Health

Introduction: Early indentification of patients at risk of poor outcome from coronavirus disease-2019 (COVID-19) can facilitate effective triage and optimize the use of medical resources in low-middle income countries (LMICs), but there are limited data from these settings.¹ Models developed in high-income countries often show poor generalizability² but in many LMICs electronic health record (EHR) data is increasingly available and may enable the development of appropriate models.

Objectives: Using EHR data, we aimed to develop and validate prognostic models for mortality in hopitalised patients with confirmed SARS-CoV-2 infection using routine EHR data, considering risk of bias, model overfitting (e.g. calibration), and missing data, and to balance accuracy and simplicity to assist physicians in diagnosis and treatment of COVID-19 patients.

Methods: We included all confirmed COVID-19 patients hospitalised at a tertiary hospital for tropical diseases in Vietnam from March 2020 to December 2022. The highest number of hospitalized patients was associated with the Delta variant (B.1.167.2) in April 2021, and the Omicron variant (BA.1) in January 2022. Demographic, clinical, and routine laboratory characteristics ascertained at hospital admission available from EHR data were modelled and selected based on multivariable logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) and two backward stepwise selection methods. The performance of the derived prognostic models were validated internally by 10-fold cross-validation and evaluated by area under the receiver operating characteristic (ROC) curve (AUC). All models were performed for both completed cases and multiply imputed data using multivariable by chained equations (MICE). The final prognostic model were displayed using nomograms and a Web-based app (https://duhongduc.shinyapps.io/covid-19-mortality/).

Results: Of the 4,211 patients (median (1^st, 3^rd quartiles) age 54 (38, 66); 45% males) with confirmed COVID-19 included, 632 of 4,211 (14.7%) died during hospitalisation. From 25 common predictors for increased mortality, 16 variables were selected by Akaike’s information criterion (AIC)-based backward selection method for simplicity with great discrimination, and were included in the final prognostic model: older age (OR: 1.041; 95% CIs: 1.034-1.048), male sex (OR: 0.696; 95% CIs: 0.559-0.865), having comorbidities (OR: 1.664; 95% CIs: 1.336-2.073), respiratory rate (OR: 1.102; 95% CIs: 1.080-1.125), temperature (OR: 1.223; 95% CIs: 1.030-1.452), SPO₂ (OR: 0.975; 95% CIs: 0.959-0.990), white blood cells count (OR: 1.053; 95% CIs: 1.030-1.076), lymphocyte count (OR: 0.674; 95% CIs: 0.543-0.839), hematocrit (OR: 0.966; 95% CIs: 0.958-0.973), platlets (OR: 0.997; 95% CIs: 0.996-0.998), D-dmer (OR: 1.046; 95% CIs: 1.017-1.076), blood glucoses (OR: 1.024; 95% CIs: 1.003-1.045), creatine (OR: 1.003; 95% CIs: 1.001-1.004), sodium (OR: 0.988; 95% CIs: 0.970-1.006), AST (OR: 1.0010; 95% CIs: 1.0003-1.0015), and C-reactive protein (OR: 1.003; 95% CIs: 1.001-1.004). The AUC for the final models were 87.6% (95% CIs 82.7%-92.4%) and the mean AUC in the internal cross-validation cohort was 85.9% (CIs 82.6%-89.3%), demonstrating similar discrimination than the LASSO (AUC, 87.5% and 85.5%) or the conditional maximum likelihood estimates-based backward selection (AUC, 86.7% and 85.4%).

Conclusions: The developed models showed good performance. Internal cross-validation with consideration of missing data increased the reliability of the model to use in common practice in a hospital setting with similar resources.

References

1. Dessie ZG, Zewotir T. Mortality-related risk factors of COVID-19: a systematic review and meta-analysis of 42 studies and 423,117 patients. BMC Infect Dis. 2021;21(1):855.

2. Haniffa R, Pubudu De Silva A, Weerathunga P, Mukaka M, Athapattu P, Munasinghe S, et al. Applicability of the APACHE II model to a lower middle income country. J Crit Care. 2017;42:178-83.

Figure 1.

Cumulative receiver operating characteristic curves for mortality rates of Covid-19 patients during hospitalization for the final prognostic model. Abbreviation: LASSO, Least Absolute Shrinkage and Selection Operator; LR: logistic regression.

Figure 2.

Calibration curves for the four predictive models. (A) LASSO, Least Absolute Shrinkage and Selection Operator; (B) Full logistic regression; (C) Logistic regression with automated likelihood-ratio-test-based backward selection; (D) Logistic with AIC-based backward selection.

Figure 3.

Nomograms for the prediction of hospital mortality based on the final prognostic models for COVID-19 patients. To derive a prediction, locate the value of each predictor on the corresponding variable line, read the corresponding points assigned on the 0-100 scale, and sum all of these points to a total point score. Then read the result on the “Total Points” scale and its corresponding prediction below. Abbreviations: Restrate, Respiratory rate, breaths/min; Temp, Temperature, °C; WBC, White Blood Cells count, x103/uL; L, Lymphocyte count, x103/uL; HCT, Hematocrit, %; TC, plaletes, x103/uL; DDmer, D-dmer, ug/mL; Bloodglucose, Blood glucose, mmol/L; CREAT, Creatinine, umol/L; Na, Sodium, med/L; AST, AST, U/L; CRP, C-reactive protein, mg/L; comor, Comorbidities.

5351

Introducing SSTORCC- Simulation for Stress Testing and Operational Readiness in Critical Care

Priyanka Uppal¹, Ruth Tighe², Abduelbagi Altayb³

¹ Guys and St Thomas’ NHS Foundation

²East Kent Hospitals University Foundation Trust,

³ -

Introduction: Hospitals are dynamic healthcare environments adapting to challenges including increasing demand, through the design and construction of new clinical areas. In-situ simulation has been used effectively in clinical settings to assess the strength and suitability of these clinical environments prior to their use.¹ Additionally, simulation has been more recently used in critical care settings to evaluate adaptations required in response to new challenges, including the COVID-19 pandemic.² We ran a one-day simulation session, SSTORCC, to evaluate the operational readiness of a new twenty-four bedded critical care unit built at our hospital, William Harvey Hospital in Ashford Kent, prior to its official opening to patients and staff.

Objectives: The aim was to assess the operational readiness of the new critical care unit and evaluate its safety for patients, with the objective being to identify problems that would affect this. The attendees were key members of the team and stakeholders so that issues that arose from the session were addressed in a timely fashion.

Methods: This in-situ simulation session followed a patient’s journey from admittance to the new critical care unit and incorporated all aspects of patient care, including accessing the unit, the ergonomics of the bedspace and equipment availability. We simulated several emergency situations including emergency intubation and cardiac arrest, and a transfer from the unit to another area of the hospital.

Results: The session identified key areas of development and modifications required prior to the move of patients and staff to the new critical care unit. These included ensuring access to the unit for relevant staff at the hospital, clear labelling on each equipment trolley, assembly of emergency drug boxes for each of the four areas of the unit and raising awareness about the location and opening of the new unit to the wider hospital.

Conclusions: In-situ simulation is a constructive tool to use in stress testing a new critical care unit and allows for efficient recognition of areas which require immediate action prior to being considered ready for operational use.

References

1. Frommelt J, Noeller T, In situ Simulation to Evaluate the Readiness of a New Clinical Space. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557872/

2. Fregene T.E, Nadarajah P, Buckley J.F, Bigham S, Nangalia V. Use of in situ simulation to evaluate the operational readiness of a high-consequence infectious disease intensive care unit. In: Anaesthesia Volume 75, issue 6 June 2020 Pages 733-738. Available from: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/toc/13652044/2020/75/6

5421

Morbidity and Mortality reviews in critical care: The need for persistent continuous improvement and process evaluation

Zoe Brummell¹, Ryan Berman², Pervez Khan²

¹ University College London Hospitals

² King’s College Hospital

Introduction: Morbidity and Mortality meetings (M&Ms) are an under-utilised resource for improving patient safety governance and professional learning.¹ There is considerable variation in the review process and structure of M&Ms.² In 2019 Guidelines for the Provision of Intensive Care Services (GPICs) included M&Ms guidance.³

Objective: To improve the effectiveness and governance of M&Ms within a large critical care unit through continuous Quality Improvement (QI).

Methods: The QI methodology used in this project was a Plan, Do, Study, Act (PDSA) cycle.⁴ A literature review ascertained the key components for effective M&Ms (table 1).

Table 1. Key components for effective M&Ms.

Key stakeholders (M&M lead, lead medical examiner and trust quality and safety lead) were engaged. A service evaluation was undertaken (Feb – May 2022) to review if M&Ms included the identified key components, using a six-week observational study and informal discussions.

Results: Regular weekly video-linked critical care M&Ms were well attended, however there was poor representation across the MDT and from other specialties. The format for the meeting, presentations and case note review was not standardised, all deaths/incidents were not discussed, often no clear reason was given for case selection, the M&M process was not linked to other governance processes, ‘Learning’ was not always clearly identified, there was no written meeting record or dissemination of learning. There was a lack of clearly identified actions to improve care or prevent future deaths, with no evidence of action follow-up and minimal discussion about relevant national M&M issues. These findings were presented to the Consultants Forum and Quality and Safety committee.

Changes: Changes to improve the governance and effectiveness of the M&M process were made:

• Standardised written guidance for both clinical leads and presenting doctors

  ○ Structure of presentation and review methodology⁵

• Guidance to discuss total number of deaths, to highlight purpose of presenting particular cases with focus on learning and actions to improve future care

• Trainee/Clinical Fellow assigned to act as M&M assistant lead

• Encouragement of MDT and other relevant clinical teams to attend

• Guidance for clinical leads to keep ’minutes’ and attendance record

• Clinical lead for M&M to circulate monthly learning outcomes

Evaluation of changes: A survey was sent to all critical care doctors to evaluate the changes made (6 months after introduction). This indicated some improvements (for example figure 1 and figure 2), but also areas that need further attention (for example figure 3). Comments from the survey for further improvement included ‘Focus on the take home message’ and ‘relevant team members involved in the patients care are not present’. We have now developed an M&M checklist tool to assist in following the recommended guidance (figure 4).

Figure 1.

Has the M&M focused on Learning and/or Actions to improve future care?

Figure 2.

Are total number of deaths discussed as part of the M&M?

Figure 3.

Are other members of the critical care MDT attending the meetings?

Figure 4.

King’s College Hospital M&M checklist.

Conclusions: Improving patient safety through M&M meetings requires dedication to a continuous improvement process. Ongoing efforts to engage everyone in the change process it is not easy. We will continue to evaluate changes made to the M&Ms to ensure that these changes are improvements to both governance and effectiveness of these meetings.

References

1. Higginson J, Walters R, Fulop N. Mortality & Morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Quality & Safety 2012; 21:576-585.

2. Royal College of Surgeons. Morbidity and Mortality Meetings: A guide to good practice, https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/good-practice-guides/morbidity-and-mortality-meetings/ (2018, accessed 14 Jan 2023).

3. The Faculty of Intensive Care Medicine. Guidelines for the provision of intensive care services (v2), https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/gpics-v2.pdf (2019, accessed 14 Jan 2023).

4. NHS England and NHS Improvement. Plan, Do, Study, Act (PDSA) cycles and the model for improvement, https://www.england.nhs.uk/wp-content/uploads/2022/01/qsir-pdsa-cycles-model-for-improvement.pdf (2021, accessed 14 Jan 2023).

5. Royal College of Physicians. Using the structured judgement review method: A guide for reviewers (England), https://www.rcplondon.ac.uk/sites/default/files/media/Documents/NMCRR%20guide%20England_0.pdf (2016, accessed 14 Jan 2023).

5482

An audit of anticoagulant use for continuous renal replacement therapy in intensive care at the Royal Free, and its effect on filter lifespan

Harriet Hall¹, Dimitra Enslin¹, Aleksandra Kulikowska¹, Bryan O’Farrell²

¹ Royal Free NHS Trust

² -

Introduction: 10% of patients admitted to intensive care (ICU) require continuous renal replacement therapy (CRRT), whether presenting with acute kidney injury, severe metabolic disorders, or refractory fluid overload.¹ Clotting of the CRRT filter leads to decreased treatment efficacy, blood loss, increased expense and workload. Concurrent administration of anticoagulation may be carried out to prevent clotting. This audit carried out at the Royal Free NHS Trust sought to compare CRRT anticoagulant choice, onset and dose titration with established local protocol, as well as to establish mean duration of filter patency and main causes for filter change before the target 72 hour filter lifespan. Given that citrate-based anticoagulation is rapidly replacing heparin-based anticoagulation for CRRT, an audit of current management with heparin and epoprostenol was indicated to assess whether a change of therapy could be warranted.²

Objectives:

1. Compare anticoagulant choice, time of onset and dose titration with local protocol.

2. Assess mean duration of filter patency.

3. Review main reasons for premature filter change (before 72 hour maximum lifespan).

Methods: The data was collected retrospectively over a period of two weeks and included all patients undergoing CRRT regardless of indication across the 46-bedded ICU. Electronic patient records were used to retrieve data on anticoagulant choice and dose, and timing of anticoagulation onset, as well as patient eligibility for CRRT anticoagulation according to local protocol. Data was also collected on filter lifespan and reasons for filter change or cessation of treatment.

Results: This audit included 21 patients, with 126 separate treatment episodes (defined by filter changes) included in the final analysis. Anticoagulation was indicated according to the protocol for 72/126 filters. The correct anticoagulant (heparin, epoprostenol, or none when contraindicated) was prescribed in 76/126 (61%). Anticoagulation was given despite being contraindicated in 16 cases.

Local protocol specifies that anticoagulation, when indicated, should be started at the onset of filtration. This was correctly carried out in the vast majority of cases (98.7%).

Anticoagulant dose titration following clotting was rarely carried out, with only 5/34 (14.7%) being followed up with a change in dose. Episodes of clotting for patients where anticoagulation was contraindicated did not prompt mandated consultant review in any cases.

The mean duration of filter patency was 18.15 hours, with only 6% of filters running to their maximum 72-hour lifespan. Clotting was the main factor responsible for reduced duration of patency, in 55/126 filters.

Conclusions: Anticoagulant choice and dosing adjustments were frequently not in line with local protocol. Anticoagulation was started at the onset of treatment in the vast majority of cases. Clotting of the filter circuit was the primary reason for interruptions to CRRT, resulting in frequent filter changes at well below the 72 hour potential filter lifespan. The need for further staff education on the importance of protocol adherence was highlighted, especially anticoagulant dose titration following an episode of clotting. Given the lack of adherence, the results of the audit do not give weight to a change to citrate-based anticoagulation at present.

References

1. Jones SL, Devonald MA. How acute kidney injury is investigated and managed in UK intensive care units–a survey of current practice. Nephrol Dial Transplant. 2013;28(5):1186-90.

2. Gould DW, Doidge J, Sadique MZ, et al. Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study. Southampton (UK): National Institute for Health and Care Research; 2022 Feb.

5578

Pregnancy testing in ITU

Nithya Padmanapan, Thomas Naismith, Mohammed Arshad, David Fotheringham, Emily Croft

UHB NHS Foundation Trust

Introduction: Pregnancy testing for women of child-bearing age should be carried out at the earliest possible time during the course of a hospital admission to minimise any potentially embryotoxic or fetotoxic therapies or investigations. The risk is potentially higher with ICU admissions, given the greater likelihood and frequencies of a patient undergoing radiological investigation and interventions in an ICU setting. While many scans do require clearance prior to their undertaking (as displayed in request forms and in questionnaires), a definitive method to ensure this risk is avoided could involve routine checks or testing at the point of ITU admission. Commonly used drugs in ITU such as antibiotics can have unwanted effects on a developing foetus and on the gestation itself.

Objectives: Audit conducted to assess compliance with trust protocol on pregnancy testing, which states that routine testing for all admissions should be done at point of care (unless emergency) for all women of child-bearing age (11-55years), especially before undergoing the following :

- general anaesthetic

- surgical procedure

- conscious sedation

- Uterine instrumentation

- Imaging examinations (xray, CT, MRI, nuclear medicine tests)

- if the patient’s treatment is determined /affected by pregnancy

- if the patient’s medical team or umbrella clinician has requested pregnancy test to determine treatment pathway

Methods: Data collection over the course of 1 month (November 2022), including all female ITU admissions. Data collected by case-note review using electronic patient records. Results tabulated and analysed to assess area-based and overall compliance on ITU. Data was also collected on pharmacological and radiological exposure in relevant patients.

Results: 109 total female admission in ITU over 1 month, of which 45.9% were of child bearing age. We have found non-compliance in testing and a lack of documentation on PICS in 54.9% of female admission of child-bearing age, with no documented reason to omit testing. 92% of the female admissions of child bearing age had radiological exposure of some degree, and 64.1% of the child bearing age group had pharmacological exposure to potentially fetotoxic drugs. Finally, the average time from the point of ITU admission to pregnancy testing was found to be 65 hours.

Conclusions: Given these results which demonstrate less-than-ideal compliance rates, we would like to plan for intervention including education of ITU staff colleagues emphasizing checking if point of care pregnancy testing has been done and documented, or documenting reasons to omit testing if testing is not required.

References

1. Wiles R, Hankinson B, Benbow E, Sharp A .Making decisions about radiological imaging in pregnancy. BMJ (Practice Pointer). Published 25 April 2022, accessed 18th February 2023. Available from https://www.bmj.com/content/377/bmj-2022-070486

2. Ngan Kee WD, Khaw KS. Vasopressors in obstetrics: what should we be using? Curr Opin Anaesthesiol. 2006 Jun;19(3):238-43. doi: 10.1097/01.aco.0000192816.22989.ba. PMID: 16735804. Accessed 20^th January 2023

3. Tsamantioti ES, Hashmi MF. Teratogenic Medications. [Updated 2022 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553086/ Accessed 20^th January 2023

5593

Consider the switch – IV vs Enteral administration of medicines in Critical Care (a quality improvement project)

Ellen Jenkins, Jemima Platt

University of Birmingham

Introduction: Many critically ill patients require IV medications as they are unable to enterally absorb medication. However, once they can feed and absorb through the enteral route there are many benefits to switching to enteral route medication. Enteral administration is simpler, saving nurses’ time. It also reduces infection and thrombophlebitis risk associated with cannulation. Most enteral drugs are less expensive than the equivalent IV medication, whilst demonstrating equal bioavailability.^1-3

Objectives: It was hypothesized that patients in Intensive Care, at the Queen Elizabeth Hospital Birmingham, eligible for enteral route medication remain on IV route despite its drawbacks. Therefore, this Quality Improvement Project aims to assess the frequency of these events and apply interventions to benefit both the patient and the trust.

Methods: Electronic records were used to access records of patients admitted to Critical Care. Across 100 patient days, eligibility of patients for enteral delivery was determined by their absorption status. Patients who were eating and drinking or, alternatively, absorbing prescribed feed were deemed eligible for the enteral route. For these patients, medications delivered via the IV route without clinical justification were recorded. From this data, Paracetamol and Levetiracetam were identified as drugs delivered inappropriately via the IV route frequently across the Critical Care department. After completing this first audit, educational interventions have been implemented to improve this. Posters were displayed outlining the IV/enteral switch in the department, figures were entered into the Governance newsletter and emails were sent to nursing and junior doctor staff.

Results: For the 100 patient days audited, 34 doses of paracetamol and 11 doses of levetiracetam were found be given via the IV route with no clinical justification. This equated to a potential cost saving of £43.04 for paracetamol, and £126.95 for levetiracetam if all of these doses were given via the enteral route.^4,5 Extrapolated across the year, this is a large cost for the department. Using an estimated number of patient days per year across the Critical Care department (22000 days per year), a yearly cost saving of £37397.80 has been calculated. This refers to a total saving if all doses of each of these drugs were delivered via the enteral route.

Conclusions: Once these interventions have been in place for a month, a second audit will take place. The results of the two audits will then be compared to determine the efficacy of the intervention. If no benefit is seen, cycles of audit and quality improvement will continue. Future interventions may consist of in person discussions with members of staff and designing an intervention using electronic records.

References

1. Cyriac JM, James E. Switch over from intravenous to oral therapy: A concise overview. J Pharmacol Pharmacother [Internet]. 2014 [cited 2022 Oct 18]; 5(2):83. Available from: /pmc/articles/PMC4008927/

2. McCarthy K, Avent M. Oral or intravenous antibiotics? Aust Prescr [Internet]. 2020 Apr 1 [cited 2022 Oct 18];43(2):45. Available from: /pmc/articles/PMC7186270/

3. Emami S, Hamishehkar H, Mahmoodpoor A, Mashayekhi S, Asgharian P. Errors of oral medication administration in a patient with enteral feeding tube. J Res Pharm Pract [Internet]. 2012 [cited 2022 Oct 18];1(1):37. Available from: /pmc/articles/PMC4076851/

4. BNF. Paracetamol- medicinal forms. [internet]. [cited 2022 Nov 25]. Available from: https://bnf.nice.org.uk/drugs/paracetamol/medicinal-forms/

5. BNF. Levetiracetam- medicinal forms. [internet]. [cited 2022 Nov 25]. Available from: https://bnf.nice.org.uk/drugs/levetiracetam/medicinal-forms/

5612

Medication management during transfer of care in post-operative cardiac critical care patients

Rhona Sloss, Halima Chaima

Barts Health NHS Trust

Introduction: Existing research shows medication errors often occur during transfer of care of patients into the intensive care unit (ICU) [1]. At St Bartholomew’s Hospital, patients are admitted to ICU post-cardiac surgery, however their regular medications prescribed on hospital admission may not be appropriate in the immediate post-operative period. The Trust electronic prescribing system has no automatic mechanism for these prescriptions to be suspended, relying on ICU doctors to actively review and amend the drug chart on ICU admission. This study evaluates the prevalence of inappropriate medication continuation and aims to determine relevant recommendations to improve de-prescribing and reduce the risk of medication-related harm.

Aim: To determine the prevalence of patient’s regular medications being continued inappropriately* in ICU in the first 24 hours following cardiac surgery.

Objectives: In the first 24 hours post-cardiac surgery -

1. Determine percentage of patients who have at least one prescription for a drug history medication continued inappropriately *

2. Determine the number of doses of patients’ drug history medications which are prescribed inappropriately*

3. Determine the number of doses of patient’s drug history medications prescribed inappropriately* that were administered to patients

*Medications considered inappropriate will be a defined list of antihypertensives, oral anti-diabetic agents and regular insulins.

Methods: Data was collected retrospectively for all patients admitted to two ICUs during October 2022. A password-protected data collection form was created, piloted and optimised. Data was collected from the Trust EPMA system and included patient demographics, prescription and basic observational data. Microsoft Excel was used to input and analyse data, with the trainee pharmacist being the only data collector. Patients excluded were deceased patients, ICU readmissions and those with incomplete data. Ethics approval was not required as data collection was retrospective and no patient-identifiable data was recorded. Final determination on medication appropriateness was made by the lead critical care pharmacist.

Results: Data was collected for 216 patients, with 131 patients included in the service evaluation. 81 patients had at least one of the listed medications as part of their drug history and 62% (50) of these patients had at least one drug history medication prescribed inappropriately in the first 24 hours post-op. During this period, 71 medication doses were continued inappropriately from patients’ drug histories and 43 of these doses were administered, representing 4.5% and 2.7% respectively of all prescribed medication doses. A summary of the results analysed by medication group is shown in Figure 1.

Figure 1.

Conclusions: Results show almost two thirds of critical care patients with an antihypertensive, oral anti-diabetic agent or regular insulin as part of their drug history, have at least one of these prescriptions continued inappropriately in the first 24 hours following cardiac surgery, with significant potential for patient harm. To reduce this risk, informatics solutions to facilitate automatic de-prescribing on transfer from theatre to ICU must be explored, and education of ICU doctors on the importance of drug chart review and optimisation on admission should be delivered. Practice should be audited 6 months after implementation of these recommendations.

Reference

1. Bravo PH. Study finds medication errors common after intensive care unit transfer. Evidence-Based Nursing 2020; 23: 61.

5627

Streamlining pathology orders on a 50-bed teaching hospital intensive care unit to reduce financial wastage: a service improvement project and Lean initiative

Tessa O’Hanlon¹, Anna Fishwick², Grace Newton-Livens², Maya Vio², Baven Balendran², Chee Hwai Lim², Freya Glover²

¹ Royal North Shore Hospital

² Royal Free London NHS Trust

Introduction: Intensive care patients require extensive and frequent blood testing. However, irrelevant testing is associated with several problems. Firstly, this practice is cost- and time-inefficient; secondly, unnecessary blood sampling risks worsening anaemia in critically unwell patients;¹ thirdly, data generated by these tests can potentially obscure the clinical picture. Evidence suggests that up to 48% of laboratory test results in the ICU are normal,² and that tests are often not ordered in accordance with guidelines for minimum retesting intervals.³ At the Royal Free Hospital (RFH), a routine blood test ‘bundle’ is ordered daily by nursing staff. The tests included within this may be clinically irrelevant or unnecessary. In times of increasing economic difficulty, it is essential to reduce financial waste. We propose doing so, in accordance with Lean principles,⁴ by tailoring blood testing to both patients and their disease processes.

Objective: To investigate the financial cost of unnecessary blood tests in the RFH ICU in order to design and implement targeted blood test bundles.

Methods: Having registered the study with the RFH Quality Improvement Department, we collected data over five days, from 25 patients, on their diagnoses, and the frequency, type, and clinical necessity of all requested blood tests. Clinical necessity was determined retrospectively by comparing collated data against trust guidelines for pathology testing of specific disease processes, or, if unavailable, by a panel of ICU doctors with guidance from minimum retesting interval guidelines.³ Using Microsoft Excel, this was transformed into a binary output: ‘clinical necessity=yes/no’.

Exact costings of tests were obtained from the RFH Finance Department and used to calculate the overall sum of unnecessary testing over the five days; this was extrapolated to produce an estimated annual cost of non-indicated blood tests in the ICU.

Results: A total of 429 individual laboratory tests were performed with a mean cost-per-patient of £293. One hundred and ninety-two tests (45%) were deemed unnecessary, with a resultant cost of £1396. Coagulation screens were the most commonly ordered unnecessary test: 82/192 (41.5%). The extrapolated annual cost of unnecessary testing across the ICU was £102,000.

Conclusions: Preliminary investigation into pathology testing in the RFH ICU suggests significant expenditure on non-indicated blood tests. Creation of novel, streamlined testing bundles could allow for significant savings. As a result of our study, work has begun to design and institute targeted, pathology- and patient-specific blood test bundles. Consensus has been reached for the implementation of five new bundles: ‘General Admission’, ‘Severe Sepsis Admission’, ‘Level 3/Liver Patients’, ‘Post-Liver Transplant’ and ‘Stable’.

Once instituted, we will re-audit the departmental cost of blood testing to ensure that financial savings are being made and that our less-liberal testing strategy does not impact patient safety. Data will be collected over a longer timeframe to increase accuracy. We hope that reducing unnecessary testing by introducing our new bundles will be a simple and effective method of making vital financial savings in our ICU.

References

1. Thavendiranathan P, Bagai A, Ebidia A, et al. Do blood tests cause anemia in hospitalized patients? Journal of General Internal Medicine 2005;20(6): 520–4.

2. Peixoto AA, Meneses FA, Barbosa BP, et al. Laboratory routine in the ICU: A practice to be abolished? Critical Care 2013;17(S3).

3. Lang T, Croal B. National minimum retesting intervals in pathology. Royal College of Pathologists 2021.

4. D’Andreamatteo A, Ianni L, Lega F, et al. Lean in healthcare: A comprehensive review. Health Policy 119(9):1197–1209.

5003

Pharmacists’ role in medication review in critical care: a resilient healthcare perspective

Franki Wilson¹, Jane O’Hara², Beth Fylan³, David Alldred²

¹ Leeds Teaching Hospitals NHS Trust

² School of Healthcare, University of Leeds

³ School of Pharmacy and Medical Sciences, University of Bradford

Introduction: Critical care is a complex system, with interdependencies that make it challenging to apply linear ‘Safety I’ mechanisms of risk identification and minimisation. A complementary approach, ‘Safety II’ is grounded in Resilient Health Care (RHC) theory, which focuses on how performance adjustments maintain system functionality despite unexpected conditions.¹

Critical care pharmacists contribute to medicines safety and quality in the intensive care unit (ICU),² particularly when part of a multidisciplinary team (MDT);³ however, little is understood about how their everyday actions contribute to system resilience. This study examines one of the pharmacist’s core roles: medication review on MDT ward round (WR).

Objective: To apply Hollnagel’s four resilience potentials (responding, monitoring, learning, anticipating)⁴ to identify how critical care pharmacists adjust to system variability when undertaking medication review on MDT WR in their daily work.

Methods: Five critical care pharmacists, with 5-35 years’ experience, were observed on general ICU MDT WR in a large teaching hospital from September – November 2022. A semi-structured observation guide and field notes were used to collect data. Data were analysed deductively using the four resilience potentials as a framework. The study was assessed as service evaluation by the Trust’s Research Governance department and needed no further approval.

Results: Pharmacists were observed for 11.5 hours (52 level 2 and 3 patients) in total. Resilience potential in each category was observed:

Responding accounted for the majority of observed activity. Pharmacists adjusted their mode of functioning in response to variability, including staff shortages, challenges accessing clinical and medicines information, interruptions and distractions, and competing demands of other roles. They reordered tasks, found alternative information sources, used alternative equipment (including personal smart phones) and communicated changes to the MDT.

Monitoring was undertaken through patient acuity assessment and task urgency, allowing pharmacists to prioritise activities with the greatest potential to affect the system’s function, such as calculating antibiotic dosage for a patient with sepsis on renal replacement therapy. All pharmacists self-checked performance using written lists to track task completion.

Learning was observed within the pharmacy team and wider MDT. Junior pharmacists contacted seniors for advice and there was dedicated time to share learning post-WR. On WR itself, medics shared pathophysiological expertise, whilst pharmacists’ provided education around prescribing and monitoring.

Anticipating was observed both from a clinical perspective, through preparing for changes required in patient care, planning for multiple outcomes and re-assessing following intervention; and from a team perspective, through attending huddles and assessing skill mix.

Conclusion: More activities were mapped to responding than any other potential, indicating that resilience potential may be less well-developed in other categories. Understanding interdependencies between potentials could explain how proficiency in monitoring, anticipating and learning might further improve responding and, in turn, system performance. For example, improving self-check of performance (monitoring) may allow pharmacists to more efficiently reorder tasks (responding), increasing the opportunity for medication safety interventions. This would require knowledge of what has previously been effective (learning).

References

1. Hollnagel E, Wears R, Braithwaite J. 2015. From safety I to safety II: a white paper. [online] Available at: http://resilienthealthcare.net/onewebmedia/WhitePaperFinal.pdf [Accessed 17 Feb 2023].

2. Rudall N et al. 2017. PROTECTED-UK- Clinical pharmacist interventions in the UK critical care unit: exploration of relationship between intervention, service characteristics and experience level. International Journal of Pharmacy Practice; 25(4): 311-19.

3. Lane D et al. 2013. A systematic review of evidence-informed practices for patient care rounds in the ICU. Critical Care Medicine; 41: 2105-2029.

4. Hollnagel E. 2011. Prologue: the scope of resilience engineering. In: Resilience engineering in practice: A guidebook. Ashgate Publishing Ltd.

5412

Accuracy of documentation of the ‘do not attempt CPR’ decision on the intensive care unit

Ahmed Abdelaziz Elmahdy¹, Abdul Rahim Bakhsh², Nagaraja Ravishankar¹

¹ The Royal Oldham Hospital

² HEE North West

Introduction: Cardiopulmonary resuscitation (CPR) was introduced in the 1960s as a treatment to try to re-start the heart in the event of a sudden cardiac arrest from a heart attack. Since then, attempts at CPR have become more widespread in a variety of clinical situations. CPR is often undignifying and traumatic for patients, relatives and health care professionals. As such, decisions regarding attempting CPR are an important part of clinical care and help to avoid interventions that would be inappropriate or unsuccessful. Policies and documents for recording decisions about CPR have been established across the UK, the purpose of a ‘Do Not Attempt CPR’ (DNACPR) decision is to provide immediate guidance to those present on the best action to take (or not take) should the person suffer cardiac arrest or die suddenly.

Objectives: The aim of the project was to evaluate DNACPR decision forms from the intensive care unit to measure compliance with the Trust and National DNACPR Policy with the aim to improve the accuracy of completion of DNACPR Forms, promote safe practice and compliance with legal requirements and encourage improvements in communication around DNACPR issues.

Methods: The project was conducted on the Royal Oldham Hospital Intensive Care Unit which is a 22 bedded unit in a secondary district general hospital. This involved reviewing medical records and the unified DNACPR decision forms of patients where a DNACPR decision had been established between February 2022 and November 2023. The information was collected on a proforma and subsequently evaluated.

Results: There were 50 cases identified in the ICU between November 2022 and February 2023 where a DNACPR decision had been established. The accuracy of patient details, date of decision, reason of for establishing the DNACPR decision and explanation as to why DNACPR would not be successful was documented accurately in all of the cases. In all of the cases, the decision had been discussed with and communicated to the patient if they had capacity (10 out of 50 cases). There were no cases where CPR was attempted in presence of a DNACPR decision. In 40 out of 50 cases, the patients capacity was not assessable or they lacked capacity. In 45 cases, the DNACPR decision had been taken by a consultant, out of which, 40 decision were by an ICU consultant. The remaining 5 decisions were taken by a registrar and all of these had been countersigned by a consultant in 72 hours. Of note, none of the forms had sections for ongoing monitoring and review of DNACPR decision completed. Similarly, none of forms had documentation of communication of the DNACPR decision to primary health services or information on any further specifics about ceiling of care, end of life care or tissue/organ donation preferences.

Conclusion: This project serves as a tool to continually audit the compliance of this important medico-legal decision with trust and national guidelines in the critical care environment wherein mortality is unfortunately quite high. There are still deficiencies in communication of these decisions to primary care providers and this needs improvement.

5012

Introducing a New Novice Critical Care Course for Intensive Care Doctors

Yang Min Ng¹, Andrew Pinder², Niyesha Ranasinghe², Fatima Eltinay³, Benjamin Heeley², Martyn Jones³, Nicholas Reynolds³, Christopher Beet³

¹ Sherwood Forest Hospitals NHS Foundation Trust

² Health Education East Midlands

³ University Hospitals of Derby & Burton NHS Foundation Trust

Introduction: University Hospitals of Derby & Burton NHS Foundation Trust has 2 Intensive Care Units (ICU), regularly receive rotating doctors from diverse backgrounds and base specialties. The Covid-19 pandemic had disrupted regular teaching programmes, and there was no established novice training for doctors. Anecdotal experiences suggest that doctors with no prior experience in Intensive Care endure a steep learning curve when rotating into Intensive Care.

Objectives: Our aim was to improve the experience of doctors starting in Intensive Care, improve core knowledge, teach procedural skills, and accelerate skills acquisition.

Methods: We developed a new Novice Critical Care Course which consisted of a written manual and a full day course containing tutorials, simulation, and practical skills. We obtained permission from Dr Andrew Georgiou (Royal United Hospitals Bath NHS Foundation Trust) and Dr Melanie Cockroft (University Hospitals Bristol & Weston NHS Foundation Trust) to adapt a written manual from the New-2-ICU Course being taught at Severn Postgraduate Medical Education.¹

We allocated tutorials to be delivered by Senior Registrars and Consultants. We had a medium-fidelity simulation suite, and we acquired model necks and forearms for a session on practical procedures (see Table 1).

Table 1.

Timetable for the Novice Critical Care Course.

Time	Session		Duration
	Group A	Group B
0900	Airway equipment and tracheostomies		30 mins
0930	Ventilator settings		30 mins
1000	Sedation & delirium		30 mins
1030	Break		15 mins
1045	Workshop: - Central line - Arterial Line	Sim: - Preparing for an RSI - Tracheostomy displacement	90 mins
1215	Lunch		60 mins
1315	Sim: - Preparing for an RSI - Tracheostomy displacement	Workshop: - Central line - Arterial Line	90 mins
1445	Break		15 mins
1500	AKI & Renal Replacement Therapy		30 mins
1530	Epidural management & analgesia		30 mins
1600	Haemodynamic assessment & vasoactive drugs		30 mins
1630	Q&A, feedback

Results: The course was conducted in August 2022 at Royal Derby Hospital, 2 weeks after rotation of doctors. Eligible doctors were released from the rota to enable attendance. 10 attended the course, including Foundation Year, Acute Care Common Stem, Core Anaesthetic, and Internal Medicine trainees. All sessions in the timetable were delivered. We also intended to teach ultrasound guided vascular access, however there was insufficient time to do so.

The course was well received. A pre and post course questionnaire demonstrated significant improvement in confidence with knowledge and procedural skills in core ICU areas. All attendees agreed that the course was useful. All recommended conducting it as a Regional training course in the future. Several attendees commented that there was insufficient time allocated for the practical procedures session.

Conclusion: A Novice Critical Care Course is vitally useful for rotating doctors with little prior experience in Intensive Care, and may diminish the steep learning curve experienced by these clinicians. A written manual relevant to the department, as well as training sessions focusing on procedural skills and simulation, would work well for future courses.

Reference

1. Georgiou A, Garcia Rodriguez M, Cockroft M, Challifour C, Jarvis S. New-2-ICU Safety in Training Candidate Manual 2020. Available from: www.new2icu.co.uk/candidate-manual [Accessed 24 December 2022].

5366

Simulation as an educational tool in critical care novices

Rotimi Latinwo

University College Hospital, London

Introduction: Junior doctors in Critical Care departments come from varied backgrounds, with Critical Care novices being those with minimal to no experience of Critical Care Medicine. Bespoke simulation for novices can help bridge the skill gap between them and their more experienced counterparts in Critical Care by improving knowledge and confidence.

Objectives: To introduce a simulation programme to improve knowledge and confidence across a range of acute clinical scenarios in Critical Care novices.

Methods: The simulation faculty comprised of Intensive Care Medicine Registrars, Core Trainees and Junior Clinical Fellows. Stations were written by faculty using a template in the following domains: airway management, non-invasive ventilation (NIV) and shock secondary to major haemorrhage. There were 6 simulation participants, all were doctors with minimal Critical Care experience. Low-fidelity simulation took place within a simulation suite with manikins, equipment and monitors. The programme consisted of three stations with 15-20 minutes for the scenario and 20-25 minutes for formal debriefing. Each station had two participants each, with rotation between stations separated by five-minute breaks. Participants completed self-assessment questionnaires before and after course attendance; ranking their knowledge, confidence and usefulness in different clinical scenarios. Quantitative feedback was collected from participants using a five-point scale (1-5). Qualitative feedback was collected regarding the simulation programme overall.

Results: Content was deemed relevant to the target audience of Critical Care novices, with 89% of responses rating scenarios as either “useful” or “very useful”. Simulation resulted in an improvement in 100% of the questionnaire domains. The mean change across 12 assessed domains was an improvement of 1 point following simulation. The largest improvement was observed in the following domains: confidence using NIV (+2.3 points), satisfaction with NIV training (+1.8 points), and usefulness during airway management (+1.5 points). Minimal improvement was seen in the shock/major haemorrhage scenario, with a mean change of +0.5 points across the domain.

Participant feedback remarked that “hinting” from simulation faculty detracted from the simulation experience, although “access to [senior help]” was considered realistic. Qualitative feedback corroborated findings that airway and respiratory scenarios were most beneficial; as simulation provided a safe space to use unfamiliar equipment. The duration of the programme was considered appropriate with adequate time for debriefing, but not too “tiring”.

Conclusions: Critical Care novices may represent a neglected group within the Critical Care setting. Simulation is a useful educational tool for novices which reliably produces improvement in knowledge and confidence.^1,2 Attention should be drawn to topics unencountered by this group, for example airway management and NIV. These are areas with the most scope for development. Novices should be trained in critical care equipment and devices, alongside technical procedures and processes. Our project has demonstrated that simulation can be a powerful tool to empower novices to be more skilled team members. Further quality improvement work should explore the benefit of repetitive higher-fidelity simulation involving wider members of the multidisciplinary team.

References

1. Schroedl CJ, Corbridge TC, Cohen ER, et al. Use of simulation-based education to improve resident learning and patient care in the Medical Intensive Care Unit: A randomized trial. Journal of Critical Care 2012; 27:219.e7-219.e13.

2. Umei N, Nishimura M, Ichiba S, et al. The need for an adult intensive care unit boot camp for residents and fellows: A cross-sectional survey among intensive care unit directors. Journal of Nippon Medical School 2022; 89: 443–453.

5452

The ‘Resuscitation Workshop’ - Building Confidence and Professionalism Amongst Junior Doctors with Challenging Resuscitation Discussions

Scarlett Tankard, Divya Kanakalingam, Jennifer Thornley, Luke Bradshaw, Jamie Tabor

Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust

Introduction: Effective communication around resuscitation decisions is essential for good quality patient care.¹ Junior doctors are frequently required to lead these discussions but lack the confidence and skills to do this effectively due to inadequate training.²

Objectives: The ‘Resuscitation Workshop’ was designed to raise awareness of current ‘Do Not Attempt Resuscitation’ (DNACPR) guidance and improve junior doctors’ skills and confidence in leading resuscitation status conversations (RSC) using role-play scenarios.

Methods: Over 12 months, 6 workshops were provided for 125 junior doctors (two groups of foundation year 1 (Ai)(AiI), foundation year 2 (B), two groups of general practice speciality trainees and international trust-grade doctors (Ci) (Cii), and internal medicine trainees (D)). Quantitative and qualitative data were collected using structured feedback forms with self-reported confidence ratings (SrCR) (1-10) before and after the workshop. Paired t-test scores compared mean SrCR and qualitative data were analysed using deductive thematic analysis.

Results: Fifty-two junior doctors (41.6%) received RSC training during medical school, but only thirty-five (28.0%) received training during postgraduate education. Despite this, many (63.2%) had led RSC with patients and relatives; most reported doing this monthly (66.7%) or weekly (27.6%). Only 20.8% had received feedback from a senior clinician on their RSC communication skills during postgraduate training. Groups Ai, Aii, B, Ci, Cii and D showed a statistically significant increase in SrCR when leading RSC of +1.87 (t(22)=4.3236, p=0.0003), +2.00 (t(22)=9.1833, p=0.0001), +1.30 (t(19)=7.9348, p<0.0001), +2.04 (t(23)=4.2241, p=0.0003), +1.45 (t(19)=4.3130, p=0.0004), and +1.93 (t(14)=3.0049, p=0.0095) respectively. There was a statistically significant increase in SrCR of current guidelines: +3.31 (t(22)= 6.6955, p<0.0001), +1.83 (t(22)=5.6262, p=0.0001), +2.30 (t(19)=10.5095, p<0.0001), +2.46 (t(23)=4.9174, p<0.0001), +1.85 (t(19)=4.7956, p=0.0001), and +2.33 (t(14)=3.5381, p=0.0033). There was no statistically significant difference between each group’s confidence ratings before the session. Trainees reported enhanced knowledge and skills by practising challenging communication skills in a safe and supportive simulated environment with constructive feedback from senior clinicians.

Conclusions: The study demonstrated that the ‘Resuscitation Workshop’ improves confidence in RSC and increases awareness of guidelines. Role-plays have been increasingly prevalent in medical education and are a great tool to provide junior doctors with opportunities to practice challenging discussions with professional and direct feedback. This study has identified the need for further postgraduate training in complex communication skills with a greater emphasis on feedback from senior clinicians.

References

1. Etheridge Z, Gatland E. When and how to discuss “do not resuscitate” decisions with patients. BMJ. 2015 May 20;350.

2. Heil K, Reid C. P-40 Preparing junior doctors for discussing DNACPR with patients-a ‘bit of trial and error’?. BMJ Supportive & Palliative Care. 2017 Mar 1;7:A15.

5478

Is Blended learning delivery as effective as 100% face-to-face delivery for qualified critical care nursing programs – an evaluation of the outcomes?

Heather Kincaid, Siby Sikhamoni

Kingston University

Introduction: The provision of healthcare education has rapidly evolved in response to the COVID-19 pandemic, highlighting the shortage of qualified critical care nurses in the UK. Health Education England (HEE) identified the need to train 11,000 critical care nurses over the next 3-4 years, leading to the launch of a national blended learning framework for critical care education.¹ The overarching aims of this initiative were to train more qualified critical care nurses to the minimum standards outlined in the Guidelines for the Provision of Intensive Care Services and permit flexibility with study leave rostering.² The guideline stipulates that at least 50% of nurses should have a post-registration award of 60 credits accredited at least at level 6, encompassing the knowledge and skills competence in Steps 2 and 3 of the National Competency Framework of Registered Nurses in Adult Critical Care.³ Higher Education Institutions (HEIs), Critical Care Networks and Acute Trusts faced the challenge of adapting to a blended learning programme as contracted through the HEE national framework.

Previously, the critical care course delivery was 100% face-to-face (F2F). As an HEI on the HEE blended delivery framework, the alignment between ‘on campus’ synchronous learning activities to digitally enabled asynchronous learning was weighted towards 70% asynchronous learning. The theoretical underpinnings of the ‘Community of Inquiry Model’ were applied to the blended learning pedagogy⁴. This included using enhanced learning technology applications such as; MS Teams®, Canvas®, Padlet® and Mentimeter® to create social, cognitive and teaching presence. ABC Learning Design, which includes six different learning types, were incorporated to support active learning through meaningful dialogue and collaboration⁵.

Objectives: The objective was to evaluate if delivering a qualified programme using blended learning would result in similar academic achievements compared to the 100% F2F delivery method.

Methods: The study compared students’ academic achievements between those that completed a 60-credit module using 100% F2F and blended delivery within the same academic year. The assessment methods, unseen exam and written essay, and marking criteria were kept the same for both delivery methods. The marks in each delivery method were compared using Excel® and analysed for each assessment.

Results: F2F delivery mean marks: exam = 57% (n=26), and essay = 63% (n=29). Blended delivery mean marks: exam = 63% (n=46) and essay = 59% (n=46). Occurance of F2F exam resits = 19.2% (n=5) and essay resits = 13.8% (n= 4). Comparatively, the occurrence of blended delivery exam resits = 8.7% (n=4), and the essay resists =15.2% (n=7).

Conclusions: The study showed similar academic achievements between the different modes of delivery. Conclusions regarding statistical significance could not be applied due to the small cohort size. However, it was reassuring that the change in delivery mode did not affect overall student outcomes. With the increase in demand for critical care nurses, it is crucial to continue exploring effective educational delivery methods to meet current and future workforce needs.

References

1. Health Education England. New programme to boost critical care workforce launches [Internet]. 2021 [cited 2023 Feb 26]. Available from: https://www.hee.nhs.uk/news-blogs-events/news/new-programme-boost-critical-care-workforce-launches

2. The Faculty of Intensive Care Medicine and Intensive Care Society. Guidelines for the provisions of the intensive care services, Version 2.1. [Internet] 2022 [cited 2023 Feb 26]. Available from: https://ficm.ac.uk/sites/ficm/files/documents/2022-07/GPICS%20V2.1%20%282%29.pdf

3. CC3N. Step competency framework [Internet]. 2018 [cited 2023 Feb 26]. Available from: https://www.cc3n.org.uk/step-competency-framework.html

4. Garrison, R., Anderson, T. and Archer, W. Critical inquiry in a text-based environment: computer conferencing in higher education. The Internet and Higher Education. 1999; 2(2): 87-105. DOI: 10.1016/S1096-7516(00)00016-6.

5. Laurillard, D. Rethinking university teaching: A conversational framework for the effective use of educational technology. 1st edn. London: Routledge. 2002.

5506

MDT approach to medicine safety incidents on ICU – improving knowledge and awareness through simulation training based on real life incidents

Lily Shaw, Lizzie James, Daniele Giudici, Cherry Lumley, Laura Vincent

Oxford University Hospitals NHS Foundation Trust

Introduction: Nationally, medication-related incidents account for 10% of patient safety incidents.¹ At Oxford University Hospitals, from April 2021 to March 2022, this was 13.5%.² The MDT Medicines Safety Group at Oxford Critical Care (OCC) discuss themes raised on Ulysses (Incident Reporting System) to identify areas for development. MDT in-situ simulation training,^3-5 is delivered on OCC weekly, with content driven by clinical governance priorities, providing a continuous, in-house loop of reflection and learning. This provides a safe, but realistic environment for team training.

Objectives: To address medication safety incidents through a practical, MDT, learning experience for junior ICU staff in their work environment.

• Drugs prescribed for unavailable route

• Duplicate medication prescriptions on different electronic prescribing systems

• Missed time-critical medications and unfamiliarity with re-ordering process

• Blood product administration errors

Methods: An MDT-facilitated simulation scenario was centred around a patient handover from theatre to ICU, incorporating a series of tasks generated through initial assessment:

• Noradrenaline infusion needing replacement. Verbal handover was that concentration was 8mg/50ml, but labelled syringe was 4mg/50ml.

• Microbiology advised antibiotic change to meropenem (out of stock in OCC) and gentamicin (given in theatre).

• Paracetamol required for patient weighing 48kg with no enteral route.

• Prescription and administration of red blood cells.

The scenario was facilitated by medics, nurses and pharmacists, including debrief and electronic feedback collection.

The scenario was run 6 times for teams of nurses and doctors on clinical duty.

Results:

Tasks

• Noradrenaline: no group checked the syringe concentration; 8mg/50ml noradrenaline was double-pumped resulting in hypertension. All groups performed independent checking.

• Microbiology: most groups recognised meropenem as a time-critical medication and contacted pharmacy for supply. Only groups including an anaesthetist checked for gentamicin on anaesthetic chart.

• Paracetamol: At least one member of each group realised IV paracetamol was needed and the dose needed weight-adjustment.

• Blood: All groups correctly prescribed blood.

Scenario

• Large groups found the task-based nature of the scenario lacked realism.

• Debriefing was more positively received when feedback was given by facilitator from the same professional group.

Feedback

• 100% of participants reported improvement in knowledge and awareness of medication-related hazards (64% strongly agreed, 36% agreed).

• No participant suggested any improvements.

• The facilitators detected the debrief had potential to be perceived negatively as most tasks were completed by individuals, such that criticism may feel personal.

• The scenario structure and debrief were revised according to feedback.

• 100% of participants strongly agreed that the revised approach improved their knowledge and awareness. The debrief was more positively received, leaving participants more confident in their abilities.

Conclusions: We demonstrated the effective use of MDT simulation to tackle an increase in medication-related incidents on OCC. Participants all felt that their knowledge and awareness had improved and it provided an opportunity for junior members of MDT staff to train together. Careful judgement and adaptability is required to maximise the team learning experience for task-focused simulation, to ensure participant engagement with the scenario and to provide constructive debriefing that is not perceived negatively.

References

1. NHS England. Medication Safety [online]. NHS England: London. [Accessed 25 February 2023]. Available from: https://www.england.nhs.uk/patient-safety/patient-safety-alerts/enduring-standards/standards-that-remain-valid/medication-safety/

2. NHS England. Organisation patient safety incident report up to March 2022 [online]. NHS England: London; 2022 [Accessed 25 February 2023]. Available from: https://www.england.nhs.uk/publication/organisation-patient-safety-incident-report-up-to-march-2022/

3. Aggarwal R, Mytton OT, Derbrew M, et al. Training and simulation for patient safety. BMJ Qual Saf. 2010; 19: i34-i43.

4. So HY, Chen PP, Wong GKC, et al. Simulation in medical education. J R Coll Physicians Edinb [online]. 2019; 49(1): 52-57. [Accessed 25 February 2023]. Available from: doi:10.4997/JRCPE.2019.112

5. Health Education England. Simulation [online]. Health Education England: London; 2017 [Accessed 25 February 2023]. Available from: https://www.hee.nhs.uk/our-work/simulation

5515

Introduction of an In-Situ MDT Critical Care Simulation Programme

Venkata Sukesh Pelluri, Laura Coleman, Nagaraja Ravishankar, Rachel Diskin

Royal Oldham Hospital

Introduction: Education within ICU to develop new cognitive psychomotor skills, understanding of the environment and human factors can enhance the practice of critical care physicians and nursing staff. Many students or trainees who rotate through the intensive care unit deal with challenging situations which they have not encountered before. ICU Simulation is a teaching model which can be described as any training that duplicates artificially the conditions that are likely to be encountered in the critical care environment and may include simulated patients, computer based simulation and whole-body realistic patient simulation.

We developed an in-situ MDT–Simulation programme in our ICU where emergency ICU scenarios are simulated twice a month with a Laerdal SIM-MAN among the critical care MDT team including trainees, nurses, medical and nursing students which is followed by a formal feedback with learning points.

Objectives:

1. To analyse system, processes and environmental challenges of the ICU, identify human factors and team working elements which can impact an emergency situation.

2. Provide training experience to enhance the knowledge, skills of the ICU MDT team for emergency critical care scenarios.

3. To generate a simulation scenario bank which can be taught regularly, provide learning outcomes and action plan feedback from the simulation sessions.

Methods:

1. Formed a simulation working group comprising of ICU consultants, junior doctors, Nursing team, practice-based educators, and simulation faculty.

2. Established twice monthly simulation sessions within the Intensive Care Unit as in situ to ensure it is realistic and within our own environment.

3. MDT simulation in ICU made a Standard Agenda item on the Critical care Governance meeting.

Results: Regular in-situ simulation sessions improved response to simulation based training with increased attendances and participation. It has improved team working skills amongst the MDT and help them familiarise with the existing emergency protocols such as dislodged tracheostomy tube, major haemorrhage and advanced life support. By making the ICU simulation sessions in-situ we could identify the human factors which can negatively and positively impact an emergency crisis. Upgraded the emergency bleep system for ICU, ensured the emergency resuscitation trolley had appropriate equipment. Improved the Handover process for night shift by identifying the emergency roles for each team member. We formed a simulation working group where we discuss the learning outcomes and action plan for the sessions. We are working towards building a scenario bank where the sessions can be conducted regularly for the new staff recruited to the ICU.

Conclusions: Our in-situ Multidisciplinary Simulation programme have helped enhance the technical and non-technical skill response to emergency situations in the ICU and also helps identify factors which can negatively impact a real-life emergency situation. These factors can then be rectified for improved and safe patient care¹. It is challenging to develop an in-situ ICU simulation however with buy-in from all MDT staff groups and levels and adapting with innovations when the unit is full, sessions can be conducted without disrupting the regular work.

Reference

1. Seam N, Lee AJ, Vennero M, Emlet L. Simulation Training in the ICU. Chest. 2019 Dec;156(6): 1223-1233.

5615

Simulation-based learning for newly recruited nurses in critical care

Kashish Dhawan, Avinash Jha, Kanika Arora, Shashi Chandrashekaraiah

Royal Preston Hospital

Introduction: We report a survey of the newly recruited nurses in critical care and focus on scenarios commonly encountered. We conducted multiple simulation scenarios including handover, critical incident, and communication with colleagues and families. We evaluated the impact of learning using pre and post-simulation sessions.

Objectives: Simulation-based learning must be a part of induction for all nurses being recruited in critical care. The international nurses will benefit the most from the simulation sessions and it will not only help them in understanding health care but also gain more confidence in the areas of communication.

Methods: A total of 15 nurses attended the simulation session in the simulation suite. 80% of them had experience working in anaesthetics and other specialities. Only 20% of the recruits had worked in critical care in the last two years. A total of 15 nurses attended the simulation session in the simulation suite. 80% of them had experience working in anaesthetics and other specialities. Only 20% of the recruits had worked in critical care in the last two years.

80% had work experience in the United Kingdom (UK) of less than 12 months and a significant proportion of 40% had spent less than 3 months working in the UK. None of the nurses had attended simulation courses before working in the UK. None of the nurses had attended simulation courses prior to working in the UK.

3 nurses had attended advanced life support, and none of the nurses had attended a course on human factors. We obtained responses pre and post-simulation by rating them from 1- 10. 1 being the worst and 10 being the best.

Results: It was evident that the nurses were more confident with the handover; 93% scored more than 7. Similarly, in the domain of telephonic discussions with consultants, 80% scored more than 7. Furthermore, there was a significant improvement in the regular communication and discussion involving patients and their families.

At the end of the simulation, 80% of the nurses mentioned that the simulation helped them by implementing changes in practice and also helped them improve their confidence. 86% of the attendees mentioned that similar simulation sessions would be helpful for nurses in the future.

Conclusions: Simulation-based learning is an essential part of learning and is being incorporated into the majority of professional courses. Royal college of nursing has recommended that across the UK,simulation-based learning is necessary to ensure the safety, effectiveness, and consistency of care provided¹.

A meta-analysis found that simulation-based nursing has strong educational effects, with significant effects in the psychomotor domain².

References

1. Royal college of nursing. RCN position on the use of simulation-based learning in pre and post registration education, www.rcn.org.uk/about-us/our-influencing-work/position-statements/rcn-position-on-use-of-simulation-based-learning-in-pre-and-post-registration-education (2021, accessed 20 Jan 2023)

2. Kim J, Park JH, Shin S. Effectiveness of simulation-based nursing education depending on fidelity: a meta-analysis. BMC Med Educ. 2016 May 23;16:152.

5237

Evaluate the effect of the Renal Link nurses’ educational programme on the development of critical care nurses’ confidence and clinical decision making

Peachiammal Subramanian¹, Nicola Thomas²

¹ Royal London Hospital,BartsHealth NHS trust

² London SouthBank University

Introduction: Acute kidney injury (AKI) is a complication of critical illness that occurs in 57.3% of critically ill patients. Approximately 8-12% of patients presenting with AKI require some form of renal replacement therapy.¹ Continuous renal replacement therapy (CRRT) is the most prevalent mode of renal replacement therapy used for managing critically ill patients with AKI. CRRT is a treatment requiring complex and highly challenging critical care nursing interventions which requires extensive knowledge, skills, experience, and ongoing training. CRRT is a highly specialised therapy, and due to its beneficial impact on the outcome of patients, the implementation of specialised education and training is essential for efficiency and safety.²

The CRRT link nurses programme (CRRT LNP) was developed to improve Critical Care Nurses’ (CCNs) skills, knowledge, clinical decision making and confidence in delivering CRRT therapy. This study explored the effect of CRRT LNP on the development of CCNs’ self-reported confidence and clinical decision-making on CRRT.

Objectives: The service evaluation aims to evaluate the effect of the CRRT LNP on the development of critical care nurses’ perception of confidence and clinical decision-making. The main objectives are to explore how the CRRT LNP improves CCNs’ perception of their confidence when caring for patients with CRRT therapy in critical care and enhances CCNs’ perception of clinical decision-making when caring for patients with CRRT therapy in critical care.

Methods: A descriptive qualitative study was performed. Semi structured face to face interviews were conducted with 12 CCNs. All interviews were audio-recorded and transcribed verbatim for thematic analysis. Braun and Clarke’s³ six-phase thematic analysis was used.

Results: The main themes identified were confidence, clinical decision making, professional development in practice and taking the programme forward. The additional theme which was found outside the study aims was professional development in practice. This theme has shown additional benefit of the CRRT LNP such as increased autonomy of CCNs, development of juniors and provided a supportive working environment. A supportive working environment can in turn have an impact on the retention of staff, and in-house education such as CRRT LNP can be attractive for the recruitment of experienced staff. The programme provided a framework for a CRRT educational strategy that can be used in other critical care units.

Conclusions: The key findings suggested that the programme improved CCNs’ knowledge and advanced troubleshooting skills. Improved team working and making collaborative decisions on CRRT has allowed the nurses to be more efficient and autonomous in their decisions. Advanced skills such as troubleshooting alarms and vascular access management enhanced their confidence and clinical decision making in delivering CRRT therapy. This has translated into clinical support they provided in the unit for their colleagues, junior staff, and doctors. So, the recommendation is that the programme continues to be run regularly to support CCNs with subject-specific knowledge and skills and to provide safer CRRT therapy to patients.

References

1. Hoste, E.A.J., Bagshaw, S.M., Bellomo, R., Cely, C.M., Colman, R., Cruz, D.N., Edipidis, K., Forni, L.G., Gomersall., Govil, D et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study, Intensive Care Medicine, 2015; 41(8): 1411-23.

2. Joannes-Boyau, O., Velly, L. and Ichai, C. Optimizing continuous renal replacement therapy in the ICU: a team strategy, Current Opinion in Critical Care, 2018;24:476- 482.

3. Braun, V and Clarke, V.Using thematic analysis in psychology, Journal of qualitative research in psychology, 2006; 3(2): 77-101.

5317

Completion of the Focused Ultrasound Intensive Care (FUSIC) lung ultrasound module during a novel 5-day “mini-fellowship”: a case report

Simon Hayward¹, Hannah Toghill²

¹ Blackpool Teaching Hospitals NHS Foundation Trust

² Morriston Hospital, Swansea

Introduction: During any ultrasound training programme, consistent access to a suitably qualified mentor is a significant barrier for many professional groups, including physiotherapists wishing to complete the Focused Ultrasound Intensive Care (FUSIC) lung ultrasound (LUS) module.^1-2 Methods and styles of LUS education vary depending on the resources and time available, and usually include a balance between face-to-face and remote teaching.³

Objectives: The aim of this case report was to document the experiences of one physiotherapist on a 5-day intensive FUSIC LUS accreditation “mini-fellowship” training programme. It is hoped that this novel case report will show, that by selecting an appropriate mentee and providing suitable mentor support, FUSIC LUS accreditation can be achieved in a short 5-day timeframe.

Methods: “Mentee A” was a respiratory physiotherapist with 15 years working in respiratory and critical care settings. They had completed a FUSIC introductory LUS course on two previous occasions (February 2018 and January 2020) and were therefore familiar with the concept and use of LUS. However, any subsequent post-course scanning had not contributed towards their LUS logbook as a local FUSIC lung ultrasound mentor was not available.

“Mentee A” attended 5 consecutive days at Blackpool Teaching Hospitals NHS foundation trust in December 2022. A 50-point learning objective & competency document was developed which included the following criteria: ultrasound physics & image generation, indications, knowledge of equipment, image optimisation, consent & medico-legal aspects, systematic examination, image interpretation, documentation, clinical integration and finally quality assurance & continuing professional development.

The 5-days were structured as per Table 1 (based on a 7.5 hour working day):

	Proposed daily programme	No. of scans
Day 1	Introductory theory & practice course + supervised scans	6 - 8
Day 2	Supervised/independent patient scans with direct feedback	6 - 8
Day 3	Independent patient scans with direct feedback	6 - 8
Day 4	Independent patient scans with direct feedback	6 - 8
Day 5	Independent patient scans with direct feedback & Triggered assessment	7 - 8
	Total no. of scans (as required to reach competency)	31 - 40

Results: A total of 32 scans were completed with 7 scans being completed on healthy volunteers and a Vimedix simulator on Day 1. Twenty-five subsequent scans were completed within the clinical environment with interpretation accuracy between mentor and mentee tracked using PRESUNA Dojo software application. Variation in the interpretation accuracy scores reduced and became more consistent over the 25 scans as scores approached 100% (Figure 1). All 50 of the learning objectives and competencies were met and the FUSIC “Triggered Assessment” checklist was passed on Day 5.

Figure 1.

Interpretation accuracy between mentor and mentee using PRESUNA Dojo.

Conclusions: Regular and consistent access to an appropriately qualified mentor is necessary to progress through any ultrasound training programme. Our case report of a 5-day Physiotherapy LUS mini-fellowship, is the first example of an intensive ultrasound training programme.

Through careful selection of an appropriate mentee and a structured learning programme, we have demonstrated that an intensive ultrasound training programme allows a mentee to meet the necessary competency requirements to gain FUSIC LUS module accreditation.

It is acknowledged that a 5-day mini-fellowship requires high levels of resource allocation, however, such resource allocation may be justified to allow the growth of ultrasound use when mentees return to geographical regions where mentor support is inconsistent, lacking, or absent.

References

1. Hayward S, Smith M and Innes S. Diagnostic thoracic ultrasound imaging - An exploration of respiratory physiotherapists’ interest and use in clinical practice: A national survey. Ultrasound 2022; 28(1): 14–22. DOI: 10.1177/1742271X19861131

2. Hayward S, Innes S and Smith M. Challenges and opportunities in point-of-care ultrasound: A qualitative exploration of respiratory physiotherapists’ experiences of lung ultrasound training and its adoption in critical care. Ultrasound 2022; 30(2): 126–133. DOI: 10.1177/1742271X211034199

3. Pietersen PI, Madsen KR, Graumann O, Konge L, Nielsen BU and Laursen CB. Lung ultrasound training: a systematic review of published literature in clinical lung ultrasound training. Critical ultrasound journal 2018; 10(1): 23-27. DOI: 10.1186/s13089-018-0103-6

5498

A simulation scenario for non-Critical Care specialists to improve the quality of escalation decision making

Alexander Willson, Emma Bradley, Daisy Chadwick, Emma Smith

Royal Bolton Hospital

Introduction: Intensive Care Units (ICUs) are a resource capable of life-saving benefit but can also cause significant harm to patients.¹ It is recognised that patients often lack capacity when decisions around end of life care are made¹. Given the nature of ICU practice, deciding which interventions are appropriate or inappropriate for the individual in question can be a very nuanced process.² When non-ICU colleagues provide a good quality functional baseline it enhances the decision making process, particularly when the patient is unable to communicate.

In a local audit of medical admissions it was found that over one third of patients had no functional baseline documented on admission. Many of those that were documented were unspecific and therefore not useful in the context of future decision making. It was also established through questionnaires locally that medical colleagues often have limited understanding of critical care and escalation decision making.

Objectives: To devise a teaching programme, including simulation, to improve Foundation Doctors’ understanding of ICU escalation decision making and the importance of a good quality functional baseline.

Methods: Core Trainees with ICU experience planned and delivered an ‘Introduction to Critical Care’ programme to the Foundation Doctors in a District General Hospital. The lecture programme included an interactive session on escalation decision making, incorporating extensive discussions around real case examples.

Following the lectures, participants undertook simulation scenarios with critically ill patients, one of which focused on escalation decision making. Groups had to initially assess, diagnose and manage the patient.

As the scenario developed, participants simulated phone calls, one to obtain a functional baseline from the relative of the non-capacitous patient and another to refer the patient to the ICU team.

The scenario was followed by a debrief to consolidate learning.

Results: The sessions received positive feedback and improved the participants’ understanding of ICU and escalation decision making. After the course, 96% of participants were confident in their understanding of critical care and referring patients compared to 59% before the sessions.

Participants reported they felt better placed to recognise the ICU needs of patients and also to consider the suitability of patients for those interventions. They also responded positively to being pushed to make decisions around escalation in the safe environment of simulation training.

Assessing the participants, groups in the simulated scenario came to very different conclusions around the appropriate escalation decision. This tended to correlate to the detail of the functional baseline obtained.

Conclusions: Critically ill patients are often assessed initially by non-ICU specialists, commonly junior doctors. These junior doctors will begin the discussions around critical illness and may be best placed to gain the information that can inform the appropriate escalation decision.

Junior doctors may require more education to be comfortable managing critically ill patients. A simulation scenario incorporating the skills of decision making and communication around critical illness can be a valuable tool to deliver such teaching.

Educating non-ICU colleagues in critical care can improve the quality of both referrals and the initial communications with patients and relatives.

References

1. Care at the end of life: A guide to best practice, discussion and decision-making in and around critical care [Internet]. Ficm.ac.uk. [cited 2023 Feb 24]. Available from: https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/ficm-critical-condition_0.pdf

2. Guidelines for the provision of intensive care services [Internet]. Ficm.ac.uk. [cited 2023 Feb 24]. Available from: https://ficm.ac.uk/sites/ficm/files/documents/2022-07/GPICS%20V2.1%20%282%29.pdf

5500

Does a hybrid model of cardiac education for critical care nurses improve perceived confidence in caring for cardiac patients?

Kathleen Jones, Marcello Dell’Edera

Guys and St. Thomas NHS Foundation Trust

Introduction: Healthcare education was significantly impacted by Covid-19¹ with face-to-face education for nurses in our local unit decreasing by 21% compared to pre-Covid-19 levels.

Guy’s and St. Thomas’s critical care units employ more than 400 nurses. Post Covid-19 pathways have resulted in a larger critical care footprint, which has increased the challenge of ensuring all staff are competent and confident.

Forced digitalisation during Covid-19 and during workforce recovery created an evolutionary wave toward hybrid learning² which has been argued to be more effective than traditional face-to-face education.³ Hybrid learning approaches have been shown to offer adaptive, flexible, technological sound learning.⁴

Flexible and adaptive approaches are critical to optimise skills development given the scale of our local critical care nursing workforce educational needs. Effective online learning combined with skills or simulated practice has the potential to offer better outcomes than traditional learning approaches across a large workforce. The use of innovative models may increase perceived confidence and knowledge, leading to a reduction in nurse burnout and greater job satisfaction, enhancing the quality of care provided to cardiac patients.

Objectives: The objective was to evaluate the implementation of a hybrid model of education for critical care nurses, specifically their confidence related to the care of cardiac patients.

Methods: A service improvement methodology was used to implement and evaluate a package of co-designed interventions for nurses (n=400) and the wider multi-disciplinary team (MDT) working in critical care at Guys and St Thomas’ hospitals. This abstract focuses on outcomes for the nursing staff.

The package of interventions included:

• An educational Pocket Companion, a concise and easy to reference guide for the care of post operatively cardiac patients.

• The revision of all relevant guidelines and educational material

• The reintroduction of face-to-face Cardiac Advanced Life Support (CALS) courses in line with national standards.

• A hybrid study day

• Ad-hoc face-to-face teaching

Questionnaires were used to collect data from nursing staff pre and post implementation to gauge their perceived knowledge and confidence. Additional feedback was collated from CALS and hybrid study days. Data were analysed using descriptive statistics and are reported narratively.

Results: The pre- implementation survey gathered 46 responses whilst post implementation survey gathered 45 responses. The education package resulted in a greater than 200% increase (44% vs 91%) in perceived confidence in caring for cardiac patients defined as at least moderate confidence in care provision, shown in graphs 1 and 2.

93% of those completing the program thought that the program met their educational needs with 64% rating the educational approach as good or very good (graph 3.).

Conclusion: The relationship between the size of a critical care nurse workforce and perceived confidence is complex, and effects of hybrid education models are multifactorial (5). Our data suggests our training and education program improved perceived confidence among nurses in caring for cardiac patients. It is hoped improvement in both education and confidence will translate into better patient outcomes and improved patient satisfaction.

References

1. Chidzonga MM, Haruzivishe C, Chikwasha V, Rukweza J. Health professions faculty’s perceptions of online teaching and learning during the COVID-19 pandemic. Shankar PR, editor. PLOS ONE. 2022 Nov 17;17(11):e0276170.

2. Lockey A, Bland A, Stephenson J, Bray J, Astin F. Blended Learning in Health Care Education: An Overview and Overarching Meta-analysis of Systematic Reviews. Journal of Continuing Education in the Health Professions. 2022 Sep 5;Publish Ahead of Print.

3. Thomas M, Suliman S, Allen M, Hameed M, Ghaffar A, Emara M, et al. A cross sectional survey on the effect of COVID-19 related restrictions on undergraduate and postgraduate medical education in Qatar. BMC Medical Education. 2022 Mar 29;22(1).

4. Shah S. The Technological Impact of COVID-19 on the Future of Education and Health Care Delivery. Pain Physician. 2020 Aug 14;4S;23(8;4S):S367–80.

5. Tudor Car L, Kyaw BM, Dunleavy G, Smart NA, Semwal M, Rotgans JI, et al. Digital Problem-Based Learning in Health Professions: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019 Feb 28;21(2):e12945.

5492

Use of smart glasses technology for indirect supervision of trainee learning events in University Hospitals Sussex NHS Trust critical care units

Alexa Curtis¹, James Sutherland¹, Omar Sadek², Rebecca Gray¹, Theofanis Fotis³, Fiona Baldwin¹

¹ University Hospitals Sussex NHS Trust

² Brighton & Sussex Medical School

³ University of Brighton

Introduction: Telementoring offers the potential for indirect evaluation of a trainee’s independent performance. Wearable devices enhance remote clinical skills monitoring due to portability and hands-free use.^1,2 Studies in surgery demonstrate educational uses in anatomical teaching and surgical telementoring.^3,4 Evidence regarding ICU telementoring is limited.⁴ One study conducted telementored ward rounds on a neurocritical care during the SARS-CoV-2 pandemic, reporting high user satisfaction.⁵

Objectives: Does the use of smart glasses for indirect supervision of trainees during supervised learning events (SLEs) enhance the educational experience of the trainee and trainer?

Methods: The project was approved by the research and development department. Ethical approval was not required because the protocol did not affect usual clinical practise.

Vuzix M300 smart glasses allow continuous audio-visual teleconferencing to an iPad for remote trainee supervision (RTS). The trainee wore smart glasses throughout a clinical encounter, conducting their usual clinical practice. The consultant assessor was in a private non-clinical area, observing the trainee’s clinical interaction indirectly by continuous audio-visual streaming to an iPad. The iPad used a single account on a dedicated device over hospital Wi-Fi. No material was recorded.

Both participants completed a QR code linked online satisfaction survey. User experience and technical feasibility were assessed using Likehart scales and free text answers.

Results: Ten RTS episodes were undertaken, completed questionnaires were received from 9 trainees and 10 consultants. The SLEs were 50% case based discussions and 50% mini clinical evaluation exercises. 80% of trainees were at core training level.

Question	Trainee Score/ Average	Consultant Score/ Average
Ease of device set up (1 extremely difficult – 5 extremely easy).	3.2	2.8
Quality of the digital image (1 extremely poor – 5 extremely clear).	3.5	2.4
Quality of the audio on the Zoom call (1 extremely poor – 5 extremely clear).	4.4	3.2
Were the glasses comfortable to wear? (1 extremely uncomfortable – 5 extremely comfortable)	3.2	-
Were the glasses a distraction from clinical assessment? (1 very distracting – 5 no change in focus from normal)	4.2	-
Did the use of the glasses increase your confidence in independently assessing a patient? (1 definitely not – 5 definitely yes)	3.4	-
Did the use of the glasses increase you confidence in the trainees clinical management? (1 definitely not – 5 definitely yes)	-	3.4
Overall SLE experience (1 extremely poor – 5 extremely good).	3.8	3.1
Did the use of the smart glasses enhance your experience as a trainer or a trainee? (1 definitely not – 5 definitely yes)	3.0	3.1
Would you use them again in the future? (1 definitely not – 5 definitely yes)	4.8	4.2

Thematic analysis of the free text showed prominent negative themes of inadequate Wi-Fi, causing disruption of video conferencing, and feeling self-conscious. A prominent positive theme was the innovative use of technology to capture real time events whilst still allowing the trainee to practice independently.

Conclusions: Telementoring has potential to enhance the value of feedback from SLEs, especially for trainees transitioning from directly to indirectly supervised practise. Reliable WiFi and a more intuitive smart glasses interface would allow RTS to be adopted more readily.

References

1. Carrera J, Wang C, Clark W, et al. A Systematic Review of the Use of Glass in Graduate Medical Education. J Grad Med Educ 2019;11(6):637-648.

2. Carrera J, Chiota-McCollum N, Mantri S, et al. Feasibility of Google Glass for Remote Resident Supervision and Evaluation. In: Neurology AAN Conference, Boston, USA, 22-28 April 2017, 88(16 Supplement 1) (no pagination). Minnesota: AAN.

3. Lareyre F, Chaudhuri A, Adam C, et al. Applications of Head-Mounted Displays and Smart Glasses in Vascular Surgery. Annals of Vasc Surg 2021;75:497-512.

4. Romare C and Skar L. Smart Glasses for Caring Situations in Complex Care Environments: Scoping Review. JMIR MHealth UHealth 2020;8:e16055.

5. Munusamy T, Karuppiah R, Faizal A Bahuri N, et al. Telemedicine via Smart Glasses in Critical Care of the Neurosurgical Patient-COVID-19 Pandemic Preparedness and Response in Neurosurgery. World Neurosurg 2021;145:e53-e60.

5565

Turning heads on the ICU: design and implementation of a novel manikin (‘Head Turn Harvey’) and multidisciplinary checklist for head turns in proned patients

Elizabeth Mooney, Ronan Hanratty, Caroline Ficke, Clare Hommers, Fiona Kelly

Royal United Hospitals Bath NHS Foundation Trust

Introduction: Prone positioning has been proven to improve outcomes for patients with severe ARDS¹ and was widespread during the Covid-19 pandemic. When nursed in the prone position, the patient’s head must be turned regularly to avoid pressure sores and other complications.² This procedure is physically challenging and risks kinking or displacement of the tracheal tube, invasive lines or catheters. Head-turn procedures often occur at night when there are fewer and more junior staff on duty and immediate help less readily available. In our intensive care unit (ICU), a number of ‘near miss’ incidents were reported, resulting in the ICU multidisciplinary team (MDT) expressing low confidence and high anxiety regarding head turn procedures. Checklists are proven to help improve adherence to protocols, reduce missed steps and can improve patient safety.^3,4

Objectives: We aimed to reduce complications occurring during head turn procedures and to improve the confidence of ICU MDT staff in undertaking them.

Methods: We designed and delivered a multimodal project for the whole MDT. First, a bedside checklist for head-turn procedures was designed for immediate use during the pandemic first wave. Second, a bespoke model head – named “Head Turn Harvey” – of appropriate weight and dimensions was made from fabric, filled with rice, and fitted with tubes and lines, to provide an opportunity to practice the potentially awkward physical manoeuvres required. Third, we ran a hands-on simulation programme using the “tea trolley teaching”⁵ model of bringing education to the bedside, allowing realistic rehearsal with “Head Turn Harvey” and the checklist. Feedback forms were given to all staff attending teaching sessions and included multiple choice questions and an opportunity for free text comments.

Results: The checklist was implemented immediately (March 2020) without formal feedback collection due to service pressures but was subjectively appreciated and well-received. Sixteen staff members from across the MDT participated in simulation sessions: 8 doctors in training, 4 ICU nurses, 4 Feedback form return rate 16/16 (100%). Results reported as follows: 100% found the checklist useful, 100% reported that the low-fidelity simulation was helpful with the practicalities of performing head turns. Self-reported confidence increased from 60% confident to attempt a head turn before training to 100% after training. 70% felt they would need less senior support after training. Participants praised the “realistic weight” which “was helpful in aiding thought process and grip change”.

Conclusions: Head turns in a proned ICU patient can be complex, awkward, risky and anxiety-provoking for staff. Our novel checklist and teaching model was very well received by the ICU MDT, and gave members an opportunity to rehearse head turns in a proned patient in a non-threatening environment. The head turn checklist was quick and simple to implement early in the pandemic, and remains in use in our ICU to this day – improving staff confidence as well as patient safety. Creativity and inventiveness with simple materials can produce simulators which enable staff to rehearse complex or awkward physical tasks in a safe environment. This project would be reproducible and transferable to other ICUs.

References

1. Scholten, E., Beitler, J., Prisk, G., & Malhotra, A. (2017). Treatment of ARDS With Prone Positioning. Chest, 215-224.

2. Binda, F., Galazzi, A., Marell, i. F., Gambazza, S., Villa, L., Vinci, E., et al. (2021). Complications of prone positioning in patients with COVID-19: A cross-sectional study. Intensive Critical Care Nursing, 67.

3. Kelly FE, Frerk C, Bailey CR et al. (2023) Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals. Anaesthesia; https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15941

4. Kelly FE, Frerk C, Bailey CR et al (2023) Human factors in anaesthesia: a narrative review. Anaesthesia https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/abs/10.1111/anae.15920

5. Jordan, L., McDonald, M., & Kelly, F. (2018). Combining the day job with time for training and tea. British Medical Journal .

Figure 1.

‘Head Turn Harvey’ in action during tea trolley training sessions on the ICU, plus the new head turn checklist.

5011

The launch of a dedicated Thirst Bundle in adult ICU. Can effective and safe management of thirst symptoms be achieved?

Jenny Clark, Patricia McCready, Sally Archer

Guy’s and St Thomas’ NHS Foundation Trust

Background: Patients report thirst as one of the most intense and distressing symptoms of critical illness.¹ Interventions to relieve thirst in critically ill patients is recommended by experts internationally.² A dedicated thirst intervention has been piloted at our Trust³ based on the Puntillo 2014 thirst bundle.⁴ The aim of this study was to report the outcomes of launching it in intensive care Trust-wide.

Methods: The Thirst Bundle was launched in 4 ICU units through a PDSA approach. Staff training, provision of equipment and on the ground support was provided throughout the launch period for each unit. A thirst ‘tab’ was added to the electronic notes system to allow for documentation of pre/post outcomes. Data were collected on usage reviewing efficacy and safety outcomes. Maintenance of oral hygiene rates as per local guidance was reviewed as a balancing measure. PDSA cycles were used after each unit’s launch phase to evolve the protocol and changes made to promote usage and efficacy. The launch phase for each unit was the first 100 applications of the Thirst Bundle. If patients were unable to tolerate oral hygiene measures (i.e. teeth brushing) they were not deemed appropriate for the intervention. The thirst bundle was completed by a thirst assessment using patient or clinician report of thirst severity via anchor word rating (none, mild, moderate, severe).

Results: Data were collected on 441 applications of the Thirst Bundle with 106 patients from 4 adult ICU units (54 beds). Median length of stay was 12 days. The intake and airway status of patients is shown in Table 1.

Table 1.

Airway and intake status.

Airway Status:		Intake status:
Endo-tracheal tube	8% (n=34)	NBM	56% (n=245)
Tracheostomy	40% (n=179)	Fluids only	8% (n=37)
Own airway	52% (n=52%)	Eating and drinking	36% (n=159)

Thirst was reported in 67% (n=295) of thirst assessments. Incomplete reporting led to data loss in 15% (n=67). 75% (n=171) of applications resulted in reduction in thirst following application of the bundle and none had an increase in symptoms. Reported rates of oral hygiene were maintained at the recommended frequency in local guidelines. One safety alert occurred with a patient attempting to drink from the spray bottle; the size of the spray bottle was modified and a safety banner was put on the thirst intervention leaflet in response. No further safety concerns were flagged.

Conclusion: A simple, evidenced-based Thirst Bundle can reduce thirst symptoms. We have established this intervention as feasible, effective and safe across a large ICU cohort using PDSA principals. Further work will now seek to maintain and promote usage of the bundle and offer a consistent response to thirst in the critically ill patient.

This study received ethics committee approval or equivalent. Trust Quality Improvement and Audit Committee (Project number 8316). Funding body is Guy’s and St Thomas’ Charity (Grant number TCF190907).

References

1. Puntillo KA, Arai S, Cohen NH, et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med. 2010;38(11):2155-2160.

2. Puntillo K, Nelson L, Weissman D et al. Palliative care in the ICU: relief of pain, dyspnea, and thirst—A report from the IPAL-ICU Advisory Board. Intensive Care Med. 2014; 40:235–248.

3. J Clark, J Meyer, S Archer, Development and evaluation of a Thirst Bundle for adult critically ill patients in a tertiary UK Critical Care (CC). J Intensive Care Soc. 2022 Aug; 23(1 Suppl): 1–210. Published online 2022 Aug 3. doi: 10.1177/17511437221095122 PMCID: PMC9358697

4. Puntillo K, Arai S, Cooper B, et al. A randomised control trial of an intervention to relieve thirst and dry mouth in intensive care unit patients. Intensive Care Med. 2014;40:1295-1302.

4955

Calculating the costs, both financial and environmental, of delivering Renal Replacement Therapy to critically ill patients

Lynda Cameron¹, Jennifer Harper¹, Mikaela Hjerpe¹, Linda Tovey¹, Vivek Masih¹, Victoria Wilson¹, Tahmina Choudhury², Marlies Ostermann¹

¹ Guy’s and St Thomas’ NHS Foundation Trust

² King’s College London / Pharmacy Department, Guy’s and St Thomas’ NHS Foundation Trust

Introduction: Kidney replacement therapy (KRT) is delivered commonly to critically ill patients, with up to 10% of critical care patients receiving KRT. In our centre, a London teaching hospital, local guidance advocates a prescribed dose of 30ml/kg of Ideal Body Weight (IBW) per hour in order to achieve a delivered dose of 20-25ml/kgIBW/h once treatment interruptions are discounted, in line with international guidance.^1,2

Previously published lifecycle assessment work³ has shown that the greatest contribution to the carbon footprint associated with KRT delivery is from the dialysate bags: fluid-filled 5L bags, each weighing over 5kg, with substantial packaging, requiring transport by road and sea from the manufacturing site. Other factors include manufacture, transport and disposal of machines, circuits, and anticoagulant fluids, plus energy running costs. Additionally, administration of pharmaceuticals, such as vitamins, trace elements, and higher doses of antimicrobials (adjusted for KRT) may also confer a financial and environmental burden. In total, delivery of KRT is a resource intensive process.

Objectives: We aimed to quantify the costs, both financial and environmental, of delivering KRT to critically ill patients. Further, undertaking a hypothetical calculation we estimated what could be saved (in terms of money and carbon) if all patients having continuous KRT received a maximum of 25mL/kgIBW/h.

Methods: Patients in a London teaching hospital were included if they received continuous KRT with citrate anticoagulation in August or November 2022. Data was collected from their clinical record and the KRT machine at the bedside to determine what was prescribed and delivered, both in terms of “dose” of KRT and usage of disposable products and fluids, focusing on 5L dialysate bags.

Data was extrapolated to 12 months. Prices from trust pharmacy and procurement systems were used to estimate the cost of the items used, and carbon footprint calculations were undertaken using carbon equivalent measures from the Greener NHS 2020/21 database.^4,5

The work was registered and approved locally.

Results: 56 KRT ‘days’ were included (where a patient had 24 hours of continuous KRT), across 26 patients. The median delivered rate of RRT was 27mL/kgIBW/h. The median number of 5L dialysate bags used was 10/24hrs (range 8-14), each weighing 5.64kg.

Delivery of KRT to the included patients incurred an approximated carbon cost of 3255kgCO₂e (comprising that associated with the single use equipment, fluids, transport of fluids to the hospital, and disposal of packaging of single use items).

For 70% of the RRT days, the patient received a rate of >25mL/kg/h. We estimated that reducing these rates from median 29.7mL/kg/h to 25mL/kg/h, could bring about an annual saving of the order of £50,000-£55,000 and a carbon saving of >5 tonnes of CO₂equivalent, from the fluids alone.

Conclusions: Delivery of RRT in critical care is resource intensive. Across these 56 RRT days, the associated carbon footprint was comparable to that generated by a person taking a return flight from London to Perth, Australia. Scrutiny on delivered rates, with reductions towards rates of 20-25mL/kg/h where clinically appropriate, could potentially save money and lessen the environmental impact.

References

1. Palevsky PM, Zhang JH, O’Connor TZ, Chertow GM, Crowley ST, Choudhury D, Finkel K, Kellum JA, Paganini E, Schein R, Smith MW. of the Veterans Affairs/National Institutes of Health (VA/NIH) Acute Renal Failure Trial Network. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359:7-20.

2. RENAL Replacement Therapy Study Investigators. Intensity of continuous renal-replacement therapy in critically ill patients. New England Journal of Medicine. 2009 Oct 22;361(17):1627-38.

3. https://shcoalition.org/ [Internet]. Newton Abbot, United Kingdom: Sustainable Healthcare Coalition. [December 2017]. Available from: https://shcoalition.org/wp-content/uploads/2019/10/CRRT-with-Prismaflex.pdf

4. https://www.susqi.org/ [Internet]. United Kingdom: Centre for Sustainable Healthcare. [2022]. Available from: https://www.susqi.org/templates

5. https://www.england.nhs.uk/greenernhs/ [Internet]. London, United Kingdom: Greener NHS. [2022]. Available from: https://www.england.nhs.uk/greenernhs/a-net-zero-nhs/

5404

Improving sustainability and hand hygiene in critical care through a glove use reduction strategy

Sam Clark¹, Cathy Jones², Aarthi Sancaran¹

¹ HEENW - Mersey

² Wirral University Teaching Hospitals NHS Foundation Trust

Introduction: Disposable gloves play a crucial role in infection control practices in healthcare. However, the unnecessary use of gloves can lead to a risk of cross-contamination, as well as having significant environmental impact.¹ This quality improvement initiative focuses on improving sustainability and infection control practices in our critical care unit by reducing disposable glove waste.

Objective: To identify improvement opportunities in our critical care unit, develop and implement a plan to reduce disposable glove use, and improve hand hygiene practices.

Methods: We evaluated disposable glove usage and hand hygiene practices in our critical care unit through a staff survey and utilising a validated audit tool². Based on the results, we developed and implemented an improvement plan. The impact was then re-assessed through a follow-up audit.

Results: Our baseline assessment revealed numerous misconceptions regarding what clinical activities required glove wearing, and a high proportion of staff reported suffering from dryness, itching or redness of their hands. Out of 107 observations (including 128 individual tasks), glove use was deemed unnecessary in 73%. Where gloves were worn hands were frequently not cleaned after removal (87%), and there was a high incidence of cross-contamination events (91%). Further interrogation of the latter revealed multiple incidents involving tasks which should have been performed using an aseptic non-touch technique. Exploration of procurement data revealed 583, 100 non-sterile gloves supplied over a year, at a cost of £8, 909.26, producing an estimated equivalent of 15.62 tons of carbon dioxide (costs of disposal not included). Following implementation of change we found out of 72 observations (including 116 individual tasks), glove use was deemed unnecessary in only 48%. Where gloves were worn hands more often cleaned after removal (73%), and the incidence of cross-contamination events fell (60%).

Conclusions: It is too early to re-explore procurement data following this change, but we hope that our successes demonstrated by our re-audit will be reflected in this data. Following the implementation of this initiative on our critical care unit, the principles have been incorporated in to trust policies and procedures, and practice changes adopted across the wider organisation. We have also shared our experiences with other NHS organisations who are looking to adopt similar change.

References

1. Loveday HP, Wilson JA, Pratt RJ, Golsorkhia M, Tingle A, Bak A, et al. J Hosp Infect. 2014 Jan; 86 Suppl 1:S1-70. doi: 10.1016/S0195-6701(13)60012-2.

2. Wilson J, Prieto J, Singleton J, O’Connor V, Lynam S, Loveday H. J Infect Prev. 2015 Jan; 16(1):24-31. doi: 10.1177/1757177414558673.

5539

The humble syringe: simple device, complex challenge

Rasmus Knudsen

Mid Yorkshire Hospitals Trust

Introduction: The significant use of single-use plastic products in healthcare has led to a growing interest in their environmental impact and the need for more sustainable practices. No item demonstrates this better than the humble plastic syringe. Tackling the complexities associated with reducing the environmental impact of the plastic syringe would provide an excellent basis for the widespread mitigation of single use plastic.

Having first originated in 200 CE, with the modern plastic version invented in the 1950s,¹ syringes are ubiquitous on Intensive Care units. They are used for many purposes, from preparation and delivery of drugs to the insertion of central venous catheters.

Equipment exists (TCG Solutions, Cardiff) that is capable of managing and sterilising recyclable medical waste on the hospital site, producing compressed plastic feedstock that can be more efficiently transported for further recycling.² Instead, frequent current practice is to incorrectly dispose of these products as medical or infectious waste resulting in unnecessary incineration, an approach which is not only wasteful but also harmful to the environment.³ The simple construction of syringes from two polypropylene pieces with an elastomer stopper should mean they are an excellent target for recycling.

Objectives: To understand the issue more, the usage of syringes in the Pinderfields General Hospital Intensive Care Department was audited. This first step will raise awareness about the impact of single use plastics. It will aim to provide a foundation for further work in understanding their lifecycle and guiding the implementation of mitigation strategies.

Methods: Based on the assumption of consistent stocking practices and patient cohorts, the number of syringes ordered can represent those used. Data were collected at Pinderfields General Hospital in January 2023. The real number is likely to to be higher as this did not include enteral syringes or those included within pre-assembled packs such as central venous catheter kits.

Results: A total of 3660 syringes were ordered each week. The breakdown by volume can be seen in Figure 1.

Figure 1.

Number of syringes ordered per week by volume.

Conclusions: While syringes are essential, the amount of waste generated by their use is significant and has a detrimental environmental impact.

This project provides the groundwork for further investigation and quality improvement implementations. The next stage is to increase our understanding of the use of, and unnecessary waste of, syringes and other plastics. Simultaneously, investment in on site waste recycling should be explored further.

A pragmatic approach to reducing single-use plastic use in the ICU would start at a departmental level. The syringe impact could be reduced by increasing education about their impact and encouraging individuals to consider how they are used and discarded. By ensuring the ready availability of a variety of bin types with clear signage will help in minimising inappropriate waste. Investing in a circular economy model where waste is recycled⁴ on site would likely produce the greatest effect. The implementation of both local and national recycling programs to address this should be explored and encouraged.

References

1. Craig R. A history of syringes and Needles [Internet]. Faculty of Medicine - University of Queensland. 2018 [cited 2023Feb25]. Available from: https://medicine.uq.edu.au/blog/2018/12/history-syringes-and-needles.

2. TCG Solutions. Sterimelt [internet]. Cardiff: TCG Solutions. [cited 2022 Feb 20]. Available from: https://www.tcgsolutions.co.uk/sterimelt.

3. Rasheed FN, Walraven G. Cleaning up plastics in healthcare waste: the transformative portential of leadership. BMJ Innovations. 2022

4. World Economic Forum, Ellen MacArthur Foundation and McKinsey & Company. The New Plastics Economy - Rethinking the future of plastics [Internet]. Ellen MacArthur Foundation. 2016 [cited 2023 Feb 20]. Available from: https://ellenmacarthurfoundation.org/the-new-plastics-economy-rethinking-the-future-of-plastics

5607

Exploring the Impact of Race and Ethnicity in the Assignment of Emergency Severity Index scores during Emergency Department Triage

Christopher Williams, Atul Butte

University of California, San Francisco

Introduction: There has recently been increased focus on identifying and overcoming healthcare disparities that persist across race/ethnic groups.^1,2 The Emergency Department (ED) triage system represents one potential source of racial/ethnic bias. The Emergency Severity Index (ESI) is a widely used triage system that consists of 5 levels: most acute (ESI = 1) to least acute (ESI = 5). The use of such triage systems is intended to prioritize the timeliness of medical care and determine the resource needs of patients according to the severity of their condition. However, by relying on subjective determinations made by the triage provider alongside objective measurements, these systems are fallible to conscious and/or unconscious biases. We sought to conduct a multi-center, observational study evaluating racial and ethnic disparities in the assignment of ESI acuity scores in the Emergency Department.

Objectives: To investigate the association between patient race/ethnicity and triage ESI score assigned in the Emergency Department, controlling for patients’ presenting complaints, vital signs, demographics, and other variables.

Methods: We used the Medical Information Mart for Intensive Care IV Emergency Department (MIMIC-ED v2.0) and UCSF De-Identified Clinical Data Warehouse (UCSF De-ID CDW) databases to examine whether patient race/ethnicity was associated with Emergency Severity Index (ESI) score.³ Both MIMIC-ED and UCSF De-ID CDW were deemed to not be human participants research by the relevant institutional review boards. The primary exposure was self-reported race and ethnic group, aggregated into the following categories: non-Hispanic White, non-Hispanic Black, Hispanic/Latinx, Asian and Other/Multi-race. To control for the acuity of different clinical presentations, patients’ chief complaints were extracted as free-text and clustered into categories using the BERTopic natural language processing algorithm.⁴ Multilevel ordinal logistic regression analyses were performed to estimate racial/ethnic differences in the assignment of Emergency Severity Index scores among patients presenting to the Emergency Department. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. All analyses were adjusted for chief complaint as a random effect and the following covariates as fixed effects: age, sex, mode of arrival, time of ED attendance, pain score and vital signs on triage.

Results: A total of 353,184 patients (185,975 women [52.7%]; median age, 47 years [IQR, 30-64 years]) were included in the study. 55.8% of patients were Non-Hispanic White, 13.6% were Non-Hispanic Black, 12.0% were Asian, 9.3% were Hispanic/Latinx and 9.2% were Other/Multi-race. The most common chief complaints included abdominal pain, chest pain, shortness of breath, headache and back pain. After controlling for relevant covariates, each minority race/ethnic group was associated with a significantly higher (i.e less acute) mean ESI score assigned on Emergency Department triage compared to their White counterpart: Non-Hispanic Black, OR 0.73 (95% CI, 0.72-0.75); Asian, OR 0.87 (95% CI, 0.85-0.89); Hispanic/Latinx, OR 0.96 (95% CI, 0.93-0.98); Other/Multi-race, OR 0.86 (95% CI, 0.84-0.88); p < 0.001.

Conclusion: Our study suggests that significant racial and ethnic disparities exist in the assignment of ESI scores during Emergency Department Triage. Future studies are urgently needed to identify and rectify the cause of these disparities to allow equitable healthcare for all.

References

1. Fiscella K, Sanders MR. Racial and Ethnic Disparities in the Quality of Health Care. Annu Rev Public Health. 2016;37:375–94.

2. Chokshi DA, Foote MMK, Morse ME. How to Act Upon Racism—not Race—as a Risk Factor. JAMA Health Forum. 2022 Feb 24;3(2):e220548.

3. Johnson, Alistair, Bulgarelli, Lucas, Pollard, Tom, Celi, Leo Anthony, Mark, Roger, Horng, Steven. MIMIC-IV-ED [Internet]. PhysioNet; [cited 2022 Dec 8]. Available from: https://physionet.org/content/mimic-iv-ed/2.0/

4. Grootendorst M. BERTopic: Neural topic modeling with a class-based TF-IDF procedure [Internet]. arXiv; 2022 [cited 2023 Jan 23]. Available from: http://arxiv.org/abs/2203.05794

5026

Race discrimination and the GMC

Cath Huang

University Hospitals Bristol and Weston Trust

Introduction: The GMC’s relationship with its doctors has historically represented a tightrope between adversary and protector.¹ Through its duty to safeguard patients it oversees the medical register and governs disciplinary investigations.² However, there is growing discontent that it is dispensing of its statutory purpose in a disproportionate and punitive way that neglects to empathise with the systemic pressures UK doctors face today.³

Bawa-Garba represented a watershed moment that awakened the profession’s consciousness to system failures and the pernicious discrimination that many ethnic minority doctors face through ‘Fitness to Practise’ (FTP) procedures. They are disproportionately represented in FTP and the growing realisation that the two – disproportionality and discrimination – are two sides of the same coin, saw the GMC challenged for answers. This resulted in the ‘Fair to Refer’ report,⁴ which examined issues of disproportionality and race in GMC referrals, leading to calls for support to those new to the NHS, engaged and positive leadership, and creating work environments focussed on learning. Nevertheless, whilst the GMC has made efforts to demonstrate a commitment to sustainable, just reforms in FTP, the cases of Arora and Karim revealed a denial of the depths of reform required.

Objectives: A qualitative analysis was conducted to explore the GMC’s response to accusations of disproportionality and discrimination following Bawa-Garba, assess whether this goes far enough and what more could be done.

Results & Conclusion: The GMC has made strides in attempts to eliminate the ethnicity gap in FTP procedures through expansion of its ‘Welcome to UK Practice’ scheme, steps towards reform of its FTP procedures and corporate strategy that empowers communication with system leaders and attempts to expand ethnic diversity within its own leadership as well as organisational training to actively challenge discrimination.⁵

However, the case of Karim, whereby an employment tribunal found that the GMC discriminated against Mr Karim on the grounds of race and the GMC’s adversarial response in its appeal of this judgment, deflects and disengages the GMC from opportunities to learn from the messages it is receiving towards reflective reform.

Furthermore, we have seen a punitive regulator that exerts its control over the race narrative as exhibited with Dr Arora, who was suspended over a perceived misuse of the word - ‘promised.’ This has since been overturned by the regulator but has demonstrated that it will dominates the discourse and dispense or rescind its determinations at will.

In contrast, sustainable affirmative action requires the GMC do more if their patient-safety agenda is to be successful whilst demonstrating respect and empathy towards its registrants that is crucial for repairing trust with the profession. Consequently, the most powerful step the GMC can make is to concede discrimination within the system and FTP. It is essential that the GMC leads on this admission if they are to continue to be the authority on professional conduct and patient safety, and to work towards releasing the binds of inherently discriminatory processes that burden individuals. It is time to go beyond declarative advocacy and towards anti-racist praxis.

References

1. Irvine D. (2006) A short history of the General Medical Council. Med Educ. 2006 Mar;40(3):202–11.

2. General Medical Council “What we do and why”. [online] Avaiilable at: https://www.gmc-uk.org/about/what-we-do-and-why Accessed 21 July 2022.

3. Goh S (2022) “Fitness to practise decisions must take into account pandemic factors such as fatigue, GMC says.” BMJ 376:o151.

4. Atewologun D, Kline R (2019) “Fair to refer? Reducing disproportionality in fitness to practise concerns reported to the GMC.” p. 28-29 [online] Available at: https://www.gmc-uk.org/-/media/documents/fair-to-refer-report_pdf-79011677.pdf Accessed 27 July 2022.

5. GMC (2022) “Equality, diversity and inclusion: Targets, progress and priorities for 2022.” p. 8 [online] available at: https://www.gmc-uk.org/-/media/documents/equality–diversity-and-inclusion–-targets–-progress-and-priorties_pdf-89470868.pdf Accessed 28 July 2022.

5491

Assessing the readability of patient-facing information in clinical trials in critical care

Nathan Riddell¹, Elizabeth Varghese¹, Jade Cole², Helen Hill², Matt Morgan²

¹ Wales Deanery

² Cardiff and Vale UHB

Introduction: Critical care is a complex specialty serving a highly diverse patient population within which a significant volume of research occurs. When patients are asked to participate in research trials they, or a designated consultee, are given a Patient Information Leaflet (PIL) or Relative/Consultee Information Leaflet (RIL) to explain their involvement. These form a key part of the process of informed consent. However, PIL/RILs often contain complex sentences, polysyllabic words and unfamiliar terms.

Government statistics suggest 43.4% of working adults in the UK achieve literacy skills equivalent to GCSE grades of D or below.¹ Health literacy in the UK population is considered to be worse than general literacy with one study suggesting 61% struggle when interpretation of healthcare information requires understanding of both written and numerical data.² Health literacy is also a significant predictor of health and healthcare service use.³

Objectives: Validated readability assessment tools can be easily used to estimate the lowest educational need required to read and interpret written communications. Our evaluation aims to assess the readability of PILs and RILs used for in major research trials in critical care.

Methods: 14 major national or international clinical trials recruiting patients in a critical care setting over the period of a year were identified. Patient information leaflets (PILs) and relative information leaflets (RILs) were collected for each trial and each PIL/RIL was analysed using an online readability calculator.⁴ Validated readability formula scores were produced for each using SMOG, Coleman-Liau, Gunning Fog, automated readability index, Linsear Write and Flesch-Kincaid readability tools. An online calculator was used to estimate reading time and percentage of “hard” or “very hard” to read sentences. Overall reading age was also calculated.⁵

Results: The mean ± SD overall reading age calculated by Gunning Fog was 13.3 ± 1.35 (10.7 to 15.7) equivalent to a university level student. The mean ± SD score by Flesch Kincaid Reading Ease score was 49.9 ± 6.15 (36.7 to 62.2), the reading level of a university student or “difficult to read”. The Coleman-Liau average ± SD was 10.4 ± 1.01 (8 to 12) equivalent to a sixth form student. The mean ± SD age using SMOG was 10.2 ± 1.09 (7.9 to 12.1). The mean estimated reading time was 9 minutes 22 seconds (1:01 to 17:05). The mean number of hard sentences was 27.4 ± 9.15 (4 to 77) and very hard was 36 ± 18.94 (0 to 77). The mean overall reading age was 16.7, equivalent to that of a 6^th form student (potentially beyond the general literacy skills of over 43.4% of the population). (Figure 1)

Figure 1.

Readability grade levels by PIL/RIL. Recommended reading grade range denoted (grade level 6-8).

Conclusion: There are many channels through which informed consent is gained and it is acknowledged that written PIL/RILs are only part of the process. However, in order to best complement the verbal transfer of information provided by clinicians and specialist nurses, the readability of patient and relative-facing information should be considered and adjusted in line with the estimated health literacy of the population.

References

1. Department for Business Innovation and Skills. The 2011 Skills for Life Survey: A Survey of Literacy, Numeracy and ICT Levels in England. BIS Res Pap Number 81 [Internet]. 2012 [cited 2021 Jan 15];(81): 1–425. Available from: www.BIS.gov.uk

2. Rowlands G, Protheroe J, Winkley J, Richardson M, Seed PT, Rudd R. A mismatch between population health literacy and the complexity of health information: An observational study. Br J Gen Pract [Internet]. 2015 Jun 1 [cited 2021 Jan 15];65(635): e379–86. Available from: https://pubmed.ncbi.nlm.nih.gov/26009533/

3. Baker DW, Parker RM, Williams M V., Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health [Internet]. 1997 [cited 2021 Jan 15]; 87(6):1027–30. Available from: /pmc/articles/PMC1380944/?report=abstract

4. FREE READABILITY FORMULAS: FREE READABILITY TOOLS: READABILITY CALCULATORS [Internet]. [cited 2021 Jan 18]. Available from: https://readabilityformulas.com/

5. Hemingway Editor [Internet]. [cited 2021 Jan 18]. Available from: http://www.hemingwayapp.com/

5557

An update on gender disparity in international intensive care conferences

Laura-Anne Dymore-Brown¹, Laura-Anne Dymore-Brown², Carole Dangoisse², Amrit Ahluwalia³, Jariya Sereeyotin⁴, Faryal Zaman⁵, Sangeeta Mehta⁴, Victoria Metaxa⁵

¹ King’s College Hospital

² Kings College Hospital NHS Foundation Trust

³ University of Medicine and Health Sciences, Basseterre, St. Kitts and Nevis

⁴ Interdepartmental Division of Critical Care Medicine, University of Toronto

⁵ King’s College Hospital NHS Foundation Trust

Introduction: An increased influx of women into the medical workforce is observed, with reports from the UK General Medical Council demonstrating 20% more female doctors in 2019 compared to 2012.¹ Furthermore, 48% of qualified medical practitioners are women but there is still a sparsity of women in senior roles, particularly in certain specialities. Recent data (2017) from the UK Faculty of Intensive Care Medicine (ICM) demonstrated that only 20% of ICM consultants are women.² In 2013, a commentary highlighted the underrepresentation of women in the higher echelons of academic medicine, either as heads of departments, authors of scientific papers or members of editorial boards.³ Similarly, we identified a gender gap among invited speakers at 5 international critical care conferences (2010–2016) and suggested organizational strategies to reduce this gender gap.⁴

Objectives: To identify whether female representation at international ICM conferences has improved since 2016, and to assess if there is gender difference in participation between physicians, nurses and allied health care professionals (AHP).

Methods: We audited the scientific programmes from 5 international ICM conferences: State of the Art (SOA), International Symposium on Intensive Care and Emergency Medicine (ISICEM), European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM) and Critical Care Canada Forum (CCCF) from the years 2017 to 2022. We recorded the gender of all moderators and speakers, as well as their professional role using congress programs and an internet search for each faculty member. When programmes were not available, we contacted the respective conferences for more information.

Results: Women speakers were consistently outnumbered by men in all conferences across all years (table 1). However, across the 6-year collection, all 5 conferences showed an increase in number of female speaker representation of around 10 to 18%. The total number of female speakers ranged from 23 to 49% with both SCCM and SOA achieving the highest representation. However, when evaluating professions of the female speakers in these two conferences, the proportion of female physician speakers decreased over the last 6 years, with a 9% decrease and 18% decrease in SCCM and SOA respectively. The decrease in female physicians in these two conferences was balanced by an increased inclusion of nurses and other AHPs as speakers. The remaining conferences showed static representation of nurses and AHPs over the 6-year span of our data collection. All conferences showed a notable increase in female moderators.

Conclusions: Our data has observed a trend of increasing women representation in ICM conferences, as speakers and moderators. However, the imbalance in the ratio of male and female speakers still persists. On further analysis, it appears some ICM conferences have become more inclusive and now invite a larger proportion of female nurses and AHP speakers. An unintended consequence of this appears to be a subsequent reduction in number of women physician speakers. A continued focus is needed to improve the gender gap at international ICM conferences, as well as incorporate female nurses and AHPs without penalising women physicians.

Appendix

References

1. General Medical Council. The UK workforce. Retrieved from The Changing Medical Workforce: https://www.gmc-uk.org/-/media/documents/somep-2020-chapter-3_pdf-84686032.pdf (2020, accessed 24 Feb 2023).

2. Faculty of Intensive Care Medicine. Retrieved from Women in Intensive Care Medicine: https://www.ficm.ac.uk/careersworkforceworkforce/women-in-intensive-care-medicine (2017, accessed 24 Feb 2023).

3. Metaxa, V. Is this (still) a man’s world? Crit Care 2013; 17: 112.

4. Mehta S, Rose L, Cook D, et al. The Speaker Gender Gap at Critical Care Conferences. Crit Care Med 2018; 46(6):991-996.

5000

The impact that increased critical care follow up physiotherapy has on length of ward stay and functional recovery of critical care survivors

Siobhan Wilde, Justine Theaker, David Prigg

Manchester University NHS Foundation Trust

Introduction: It has been widely documented that early mobilisation within Critical Care (CC) is safe and effective with patients achieving fewer ventilated days, a shorter CC stay, and better functional outcomes. When patients are transferred from CC onto a ward, rehabilitation is often reduced due to increased pressures for therapists to facilitate patient flow through acute services. Despite patients being less unwell and having more opportunity to be physically active on the ward,¹ they often spend large periods of time in sedentary positions.² Currently there is no clear guidance and limited-service standards on the optimisation of rehabilitation for patients following step down from CC. The aim of the project was to assess the impact on outcomes of the expansion of an existing CC follow up (CC FU) physiotherapy service.

Objective: This quality improvement project compared patients’ functional recovery (using the ICU mobility scale (IMS)), reduce ward length of stay (LOS) post CC admission, and facilitate patient discharge home, before and after the expansion of a CC FU service.

Methods: The work focused on a large teaching hospital within the North-West of England with a 52 bedded CC unit covering multiple specialities.

Previously the CC FU physiotherapists reviewed patients who had spent more than 10 days on CC. Functional recovery was calculated using the IMS which provides a quick and easy bedside method of measuring a critically ill patients’ mobility.

In June 2021, an additional Band 6 physiotherapist was appointed to the CC FU service, increasing the workforce from two part time physiotherapists (45 hours) to one part time and one full time physiotherapist (60 hours) per week. Patients yet to reach their mobility and functional baselines when discharged from CC, were selected to receive additional therapy sessions, in collaboration with the ward therapy team.

Data was retrospectively collected between January and June 2020 for a baseline group, and prospectively from June 2021 to May 2022 following expansion of the CC FU role. CC LOS, ward LOS, discharge destination and functional recovery outcomes were compared between groups to assess the impact of the role.

Results: Medical records for 30 patients were reviewed to evaluate the baseline outcomes. 69 patients were part of the QI group after CC FU expansion.

Severity of illness was calculated for the baseline and QI groups using the APACHE ll measure, which demonstrated comparable mortality rates not anticipated to affect outcomes (baseline Median 15, IQR 8 (13, 21), QI Median 16, IQR 6 (14, 20)).

Within the QI group CC LOS was 9 days longer than the baseline group yet their ward LOS was 2 days shorter.

An improvement in mobility was demonstrated in both the baseline and the QI group between CC discharge and ward discharge. Both groups demonstrated a 4-point improvement in IMS. No change in participants IMS was made from CC discharge to ward discharge by 13% of baseline and 6% of QI group participants. Within the baseline group IMS reduced from CC DC to day 1 ward IMS, meaning that on day 1 post CC step-down the QI group had a 2-point improved IMS score.

Within the QI group 60% of patients were discharged home compared with 43% of the baseline group. Of the 60% of patients discharged home from the QI group 68% required therapy input only compared with 0% within the baseline group. 28% of patients in the QI group required inpatient rehabilitation and 34% from the baseline group.

Conclusion: In the quality improvement project, CC physiotherapists delivered ongoing physiotherapy to CC step downs alongside ward-based therapy. 17% more patients were discharged home with 68% more patients discharged home with therapy input only. This has the potential to tackle long hospital stays, improve secondary care efficiencies, and increase the number of patients discharged home, in line with NHS long term plan.

References

1. Hopkins RO, Miller RR, Rodriguez L, et al. Physical therapy on the wards after early physical activity and mobility in the intensive care. Phys Ther. 2012; 92: 1518-1523.

2. Baldwin CE, Rowlands AV, Fraysse F, et al. The sedentary behaviour and physical activity patterns of survivors of a critical illness over the acute hospitalisation: an observational study. Aust Crit Care. 2020; 33: 272-280.

5355

Implementation of a Post-ICU Rehabilitation Class to improve physical and psychological outcomes following critical illness - a Quality Improvement Project

Amy Bonner

Walsall Healthcare NHS Trust

Introduction: Discharge home following a critical care stay is the only the beginning of a difficult recovery journey. Due to the advances in critical care, we have seen an increase in survivorship.¹ With this increase we recognise that following the survival of a critical illness that the discharge from critical care is only the start of a difficult journey to recovery for many as characterised by global weakness, fatigue, psychological issues, and impaired cognitive function.² The long-term sequalae of critical illness can be substantial and multifactorial, these deficits adversely affect their overall quality of life and may persist for up to 5 years after discharge from critical care. We have become increasingly aware that there is more to life than mere survival. A lack of standardised post- discharge rehabilitation strategies available often means many are left without the appropriate support to manage these lasting impairments post discharge.

Objectives: The main aims of this quality improvement project were to improve both physical and psychological outcomes following critical illness by enabling continuity of care throughout the critical care multidisciplinary team (MDT); establishing clear peer support links; and by providing a timely, open access to rehabilitation post discharge.

Method: A structured, virtual rehabilitation program encompassing both exercise and education ran by the critical care rehabilitation team was implemented and offered to patients post discharge home following a critical care stay, Each program lasted 6 weeks in total, each class lasting 1 hour made up of thirty minutes exercise delivered by a qualified physiotherapist with a background in critical care rehabilitation and thirty minutes education delivered by members of the critical care MDT. Standardised self-reported outcome measures were used pre- and post- attendance, including the 30 second sit to stand test;³ EQ5D5L;⁴ GAD-7 and PHQ-9.⁵ These were selected in order to capture the diverse physical and psychological impacts of critical illness and to have a physical measure of improvement. Following each cohort patient feedback forms were distributed to shape the service prior to completing each cycle, in line with quality improvement.

Results: Cohort 1 consisted of 5 patients who opted into the classes following attendance of an appointment in our nurse led follow up clinic, during cohort 1 all 5 participants attended all 6 sessions equaling a 100% compliance rate. Overall quality of life increased on average from 57.5/100 to 75/100. Quantitative data demonstrated positive feedback from participants of the cohort, demonstrating the classes importance of establishing clear peer support, and enhancing psychological wellbeing, with reductions in anxiety and depression across both cohorts. Depression levels decreased from moderate to mild following both cohorts.

Conclusions: Following implementation of our pilot project, we have demonstrated the qualitative and quantitative benefits that the implementation of a service delivering post-intensive care rehabilitation virtually could have on the recovery from the symptoms of Post Intensive Care Syndrome. It had a significant impact improving physical function and improving psychological wellbeing, resulting in an overall improvement in health-related quality of life in this patient group.

References

1. Maley JH, Brewster I, Mayoral I, Siruckova R, Adams S, McGraw KA, et al. Resilience in Survivors of Critical Illness in the Context of the Survivors’ Experience and Recovery. Annals of the American Thoracic Society. 2016 Aug;13(8):1351–60.

2. Overview | Rehabilitation after critical illness in adults | Guidance | NICE [Internet]. Nice.org.uk. NICE; 2009. Available from: https://www.nice.org.uk/guidance/cg83

3. O’Grady HK, Edbrooke L, Farley C, Berney S, Denehy L, Puthucheary Z, et al. The sit-to-stand test as a patient-centered functional outcome for critical care research: a pooled analysis of five international rehabilitation studies. Critical Care. 2022 Jun 13;26(1).

4. EQ-5D-5L – EQ-5D [Internet]. Euroqol.org. 2009. Available from: https://euroqol.org/eq-5d-instruments/eq-5d-5l-about/

5. Spitzer RL, Kroenke K, Williams JBW. Generalized Anxiety Disorder 7. APA PsycTests. 2006;(1).

5538

Variation in data collected from outpatient critical care follow-up clinics in an Operational Delivery Network

Jolene Galbreath, Andy Georgiou

Royal United Hospital NHS Foundation Trust

Introduction: The provision of outpatient critical care follow-up clinics in the UK has risen from 27% in 2013¹ to 74% in 2020², with a further 23% of NHS Trusts planning to introduce a new clinic by 2025². Unlike with in-patient critical care patients³, there is no agreed national dataset applicable to the out-patient critical care population. Until such a dataset is agreed, it remains unclear what data is currently being collected by critical care follow-up clinics in the UK. Understanding the data which is being collected may facilitate data pooling for collaboration, research and quality improvement between units who collect similar data at present, whilst helping to inform the discussion about what data should be collated at a national level in the future.

Objectives: To conduct a snapshot survey of the data currently being collected from outpatient critical care follow-up clinics in one Operational Delivery Network in the UK.

Methods: All units in the South West Critical Care Network (SWCCN) follow-up clinic collaborative were contacted. A structured questionnaire captured the data which units are currently collecting from their follow-up clinic. This covered demographic, physical, cognitive, quality of life, and psychosocial indices.

Results: All 8 units within the SWCCN critical care follow-up clinic collaborative responded. There was very little overlap of the type of data collected by different units. The demographic/baseline data collected varied significantly between units; the greatest concordance was length of critical care stay (collected by 7 units), time between critical care discharge and clinic appointment (collected by 5 units), interventions received whilst on critical care (collected by 5 units) and days ventilated (collected by 5 units). The maximum number of units collecting the same data in other categories was as follows: quality of life indices- 0 units; physical outcome indices- 2 units, cognitive outcome measures- 3 units, psychosocial outcome measures- 6 units. Units commonly identified important metrics in patient status, but did not necessarily collate these into a database. There was a strong desire to unify and integrate data collection.

Conclusions: Concordance in the data collected in outpatient critical care follow-up clinics in the SWCCN is very low. This makes assessment of consistency of care, research and quality improvement at a local and regional level challenging, and strengthens the argument for a nationally agreed, centrally collated, minimum dataset for outpatient critical care follow-up.

References

1. Connolly B, Douiri A, Steier J, et al. A UK survey of rehabilitation following critical illness: implementation of NICE Clinical Guidance 83 (CG83) following hospital discharge. BMJ Open 2014;4:e004963.

2. Life after critical illness. [Internet]. London (UK): The Faculty of Intensive Care Medicine (UK); [Reviewed 2021 October; cited 2023 February 25]. Available from: https://www.ficm.ac.uk/criticalfutures/life-after-critical-illness.

3. Intensive Care National Audit and Research Centre. [Internet]. London (UK): The Intensive Care National Audit and Research Centre (UK); [Reviewed unknown; cited 2023 February 25]. Available from:https://www.icnarc.org/.

5604

What do patients and relatives actually want from a post-ICU peer support group?

Lauren Cash, Phil Duggleby, Emily Cammack

Buckinghamshire Healthcare NHS Trust

Introduction: A stay on an intensive care unit (ICU) can be distressing; most patients have some unpleasant memories of their stay (Samuelson, 2011) and some may have gaps in their recollection. It is also common for individuals who have been a patient in the ICU to experience some mental health difficulties post-discharge (Needham et al., 2012).

Peer support involves reciprocal assistance between individuals with similar conditions or experiences to aid long-term recovery (Tracy & Wallace, 2016). Peer support groups have been found to provide many therapeutic benefits within the field of healthcare. Studies have shown that peer support groups can help provide emotional and informational support through sharing common experiences (Dunn et al., 2003).

Our aim was to assess the feasibility of establishing an ICU peer support group for those that have been on ICU and their relatives. We felt that listening to people who have experienced ICU would help us best design the support that we offer to patients and families within our trust, given their unique and invaluable insights and perspectives.

Objectives:

• To determine whether individuals with lived experience feel an ICU support group would be beneficial (and why)

• To establish what individuals with lived experience feel an ICU support group should involve

• To understand the potential benefits and risks of an ICU support group

Methods: 145 invitation letters were sent to a representative sample of post-ICU patients, with 10 patients and 6 relatives accepting the invitation. We ran two focus groups – one for patients and one for relatives – using a semi-structured interview and the same list of questions. This method allowed us to gather qualitative data alongside the observation of group dynamics. The groups were facilitated by a moderator and an assistant, both of whom were part of the ICU Follow Up Team. The sessions were audio recorded and transcribed, before undergoing thematic analysis to highlight the key themes. Approval was granted from the local research and development team.

Results: No patient thought that a peer-support group would be helpful, with several suggesting that an early invitation post-discharge would be frightening. The only aspect of ICU that was thought to merit peer discussion was shared experience of delirium, and one-to-one conversations were preferred for this to enable the time to tell one’s story.

In contrast, most relatives thought that a peer-support group would be beneficial, although an early group would not be practical due to the demands of caring responsibilities. All thought that it should be offered and the ideal format would be a structured group, facilitated by an ICU professional.

Conclusions: In our population, patients and relatives have very different views of the merits of peer support groups.

This was an unexpected finding, and at odds with current evidence and practice. We hypothesise that the reduced social interactions during the Covid pandemic has influenced the way that patients prefer to recover from critical illness and this may herald a change in the way that we offer such services in the future

References

1. Samuelson KA. Unpleasant and pleasant memories of intensive care in adult mechanically ventilated patients—Findings from 250 interviews. Intensive and Critical Care Nursing. 2011 Apr 1;27(2):76-84.

2. Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, Zawistowski C, Bemis-Dougherty A, Berney SC, Bienvenu OJ, Brady SL. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Critical care medicine. 2012 Feb 1; 40(2):502-9.

3. Tracy K, Wallace SP. Benefits of peer support groups in the treatment of addiction. Substance abuse and rehabilitation. 2016 Sep 29:143-54.

4. Dunn J, Steginga SK, Rosoman N, Millichap D. A review of peer support in the context of cancer. Journal of Psychosocial Oncology. 2003 Dec 24; 21(2):55-67.

5100

Standardising non-directed bronchoalveolar lavage as a method for microbiology sampling on the critical care unit

Kieran Lall, Lucy Fuller, Rachelle Schofield, Rebecca Russell, William Angus

Liverpool University Hospitals NHS Foundation Trust

Introduction: Ventilator associated pneumonias (VAPs) significantly impact patient mortality and length of stay in critical care.¹ Therefore, rapidly identifying causative pathogens and targeted antimicrobial therapy are crucial.^2,3

Bronchoscopy requires specialist training and is expensive and time-consuming if used solely for obtaining standard microbiological samples.² Other sampling methods include endotracheal aspirates (EA) and non-directed bronchoalveolar lavage (NDBAL). Evidence suggests NDBAL is more sensitive and specific than EA; it could also reduce contamination from organisms colonising in-line suction catheters and the associated challenges for antibiotic stewardship this presents.^4,5

In October 2021 a quality improvement project introduced a standardised approach to NDBAL on our unit, centred around a teaching programme delivered to nursing staff.³ Surveys taken pre and post-teaching demonstrated that their ability to perform the procedure correctly had improved. A year on, we completed another cycle to assess the impact of this change on our management of VAPs and sepsis.

Objectives: Our primary aims were to determine if microbiology results and accuracy were improved by NDBAL, together with evaluating the effectiveness of the clinical skills teaching delivered, through re-assessing nursing staffs’ knowledge of the procedure.

Methods: 42 microbiology samples obtained using EA over 3 months in 2021 were analysed, prior to introducing NDBAL as a standardised procedure. Once NDBAL had been taught to nursing staff, assisted by our practice educator team, we analysed 76 samples obtained using this up-to-date method over 3 months in 2022.

We revised the previous survey to include 13 steps needed to perform a NDBAL. 40 nursing staff were surveyed between October to December 2022; they were asked to verbalise the steps required to complete the procedure correctly, with responses recorded by a member of the team.

Results: Our microbiology data showed a reduction in known colonisers including coliforms (22.3% vs. 26.9%), yeasts (29.4% vs. 36.5%) and pseudomonas (2.3% vs. 7.6%) when comparing cultures from samples obtained post-introducing NDBAL to those obtained using EA. There was also a reduction in polymicrobial samples from NDBAL (34% vs. 60%) as well as an increased number of samples collected (76 vs. 42), suggesting increased testing due to decreased procedure complexity compared with formal bronchoscopy.

The 40 nursing staff surveyed were able to recall 72% of the steps required to perform a NDBAL. This was an improvement from October 2021 (67% of the 7 steps assessed previously).

Conclusions: Our results support the use of NDBAL as a standard technique for obtaining microbiological samples. We have demonstrated that it is simple and can be taught easily, with evidence of good retention of knowledge and skills amongst nursing staff, removing the need for formal bronchoscopy purely for sampling. Our microbiology results demonstrate less isolation of known colonisers, which together with the reduction in polymicrobial samples obtained by using NDBAL will allow us to narrow our antibiotic spectrum earlier, improving antibiotic stewardship. We will continue reviewing the impact of this procedure on our microbiology results, ensuring new starters on the unit receive training in NDBAL and supporting established staff to maintain their skills.

References

1. Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med 2020; 46(5): 888-906.

2. Bonvento BV, Rooney JA, Columb MO, et al. Non-directed bronchial lavage is a safe method for sampling the respiratory tract in critically ill patient. J Intensive Care Soc 2019; 20(3): 237-241.

3. McGow C, Reynolds J, Green V, et al. Tackling VAPs the up-to-date way. Abstracts. J Intensive Care Soc 2022; 23(1_suppl): 97.

4. Felton T, Mount T, Chadwick P, et al. Surveillance non-directed bronchial lavage allows confident use of focused antibiotics in the management of ventilator-associated pneumonia. J Infect 2010; 60(5): 397-399.

5. Scholte JB, van Dessel HA, Linssen CF, et al. Endotracheal aspirate and bronchoalveolar lavage fluid analysis: interchangeable diagnostic modalities in suspected ventilator-associated pneumonia? J Clin Microbiol 2014; 52(10): 3597-3604.

5603

Incidence of ventilator-associated pneumonia and adherence to the ventilator care bundle within the largest single-floor critical care unit in the World

Eamonn Reda, Jaimin Patel, Dhruv Parekh, Mohammed Arshad, Arlo Whitehouse, Luke Hawkins, Alice Macneill

University Hospitals Birmingham NHS Foundation Trust

Introduction: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection across adult critical care units. It’s associated with a number of adverse outcomes.¹ Herein, we present two audits, carried out as part of a wider quality improvement project aiming to reduce rates of VAP in ITU at the Queen Elizabeth Hospital Birmingham (QEHB).

Objectives: Primary objective of audit 1 was to determine VAP rates. Others included determining: time from invasive ventilation to VAP diagnosis; number of antibiotic courses used; how often VAP patients had positive sputum microbiology and the common pathogens isolated; the utilisation of procalcitonin.

The objective of audit 2 was to determine overall compliance with the entire ventilator care bundle and with each individual bundle element.

Methods: Audit 1 was retrospective over a 4-month period. QEHB utilises the patient information and communication system (PICS), unifying a patients notes, lab results and imaging into one platform. We searched PICS to identify all patients invasively ventilated ≥48 hours during this time period. Further searches were then conducted in each patient’s record for documentary evidence of VAP. We developed a list of potential VAP patients, with each record then being assessed by an ITU clinician against diagnostic criteria set out by Elliot et al². Data points for the secondary outcomes were obtained from PICS as well.

QEHB ventilator care bundle is in line with the 2007 Department of Health recommendations³ that each ventilated patient is nursed with head elevated to 30-45^o, has a daily sedation hold, has adequate gastrointestinal prophylaxis, and is given mouth care. Compliance with these elements should be checked in each nursing shift (twice a day) and recorded in the dedicated section of PICS. Audit 2 was carried out prospectively over 7-days, looking at all ventilated patients and determining bundle compliance for each ventilated-day.

Results: We identified 269 patients invasively ventilated for ≥48 hours between 1/2/22-1/6/22, 69 of whom had documentary evidence of VAP diagnosis and were included for further analysis. 68 of them met the Elliot et al² criteria, giving a generalised ITU VAP rate of 25.3%, with rates of between 15-33% when stratified by ITU sub-speciality. Of these, 79.4% of patients met all of the diagnostic criteria, whilst the remaining 20.6% of patients met 3 of the 4 criteria. 81% required more than one course of antibiotic therapy, with 10.3% receiving ≥5 courses. 85.3% had positive sputum microbiology, with most common isolates being Klebsiella pneumoniae, Pseudomonas aeruginosa and Haemophilus influenzae. Procalcitonin was sent in 44% of cases, with 87% of these being raised >0.25ng/mL. On average it took 9.03 days from intubation to development of VAP.

In the 7-day period of audit 2, 70.30% of ventilator days were fully compliant with the ventilator care bundle (n=182).

Conclusion: VAP is prevalent at QEHB. Ongoing quality improvement will target improved care bundle compliance as well as the introduction of other evidenced-based interventions, including cuff pressure monitoring¹ and subglottic aspiration¹.

References

1. Gunasekera P, Gratrix A. Ventilator-associated pneumonia. BJA Education. June 2016. Volume 16(6). Pages 198–202.

2. Elliott D, Elliot R, Burrell A, Harrigan P, Murgo M, Rolls K, et al. Incidence of ventilator-associated pneumonia in Australasian intensive care units: use of a consensus-developed clinical surveillance checklist in a multisite prospective audit. BMJ Open 2015; Volume 5(10).

3. Department of Health. Saving lives: reducing infection, delivering clean and safe care - high impact intervention No5. https://www.bsuh.nhs.uk/library/wpcontent/uploads/sites/8/2020/09/Ventilator-care-bundle.pdf [Accessed 26th February 2023]

5558

Capnocytophaga: A case of profound septic shock

Faryal Zaman¹, Antonio Bellini², Angeliki Iakovou²

¹ King’s College Hospital, London

² King’s College Hospital

Background: Capnocytophaga species are a slow-growing, facultative anaerobic, gram-negative bacilli that can cause various clinical syndromes in humans and are found commonly in mouths of mammals. They usually cause opportunistic infections in immunosuppressed patients with reported domestic animal bites.¹ Patients can present with wide spectrum of disease ranging from cellulitis at site of bite wound to DIC and fulminant septic shock and overall mortality of 30%. There have been few case reports where Capnocytophaga has presented with severe disease in immunocompetent patients. Conventional blood cultures are often negative because this is a slow-growing pathogen but 16S rRNA gene amplification and Sanger sequencing allows swift diagnostic confirmation.²

Case Presentation: 59 years old gentleman who presented to hospital after a 2-day history of malaise, diarrhoea, vomiting and subsequent collapse on floor. He was admitted to hospital with profound septic shock, DIC, subsequent PEA arrest with ROSC after 1 cycle of CPR. He was in ICU for multiorgan failure (liver, kidney, lung, cardiovascular) support (ventilatory, hemodynamic and renal filtration). Full body CT imaging on admission didn’t reveal any source of infection but showed bilateral adrenal haemorrhage typical of Waterhouse Frederickson syndrome, so he was started on high dose ceftriaxone to cover for meningococcal sepsis. On examination he had severe mottling of extremities. Procalcitonin was >100. Lumbar puncture could not be performed on admission due to coagulopathy. He was started on steroids replacement from the beginning due to adrenal haemorrhages and high vasopressor requirements. He had developed peripheral arterial and venous thrombi in his extremities, conjunctival haemorrhages, splenic infarcts and NSTEMI with Left ventricular dysfunction and regional wall motion abnormalities on ECHO and was on dual antiplatelets and therapeutic anticoagulation already for his DIC related arterio-venous thrombi and DVT. Trans-oesophageal ECHO didn’t show any evidence of vegetation. Autoimmune work up including ADAMTS-13 inhibitor was negative. Blood cultures from admission were negative initially Meningococcal and Pneumococcal PCR neg, COVID PCR were negative as well. After extensive incubation in reference lab from initial presenting blood culture “Capnocytophaga species” were isolated which is usually found in dogs and cats. We found out that our patient had a dog and a cat at home though there was no history of dog bite, but he had a mild cat scratch before getting ill.

His in-patient stay was further complicated by GI bleed and on colonoscopy he was found to have multiple ischemic ulcers in proximal transverse and ascending colon.

Patient improved subsequently and was weaned off from organ support, extubated after 3 weeks of ICU admission and completed the course of broad-spectrum antibiotics (Ceftriaxone and then meropenem).

He was stepped down to ward after 5 weeks in ICU. He then underwent Bilateral below knee amputation, bilateral hand trans-metacarpal amputation for gangrenous peripheries. He was discharged home after total of 84th day of admission and required further rehab and care support.

Conclusion: Capnocytophaga infection is often associated with fulminant septic shock, DIC and significant mortality even in immunocompetent patients. 16S rRNA gene PCR proves an important swift diagnostic tool when facing a sepsis of unknown origin. In our case initial blood cultures remained negative at for initial few days, while using the rapid diagnostic tool like 16S rRNA PCR diagnosis could prevent the delay in diagnosis. Fortunately, the empiric treatment our patient received for suspected meningococcal sepsis likely improved his outcome as Capnocytophaga is usually sensitive to ceftriaxone.²

References

1. Zangenah S, Abbasi N, Andersson AF, Bergman P. Whole genome sequencing identifies a novel species of the genus Capnocytophaga isolated from dog and cat bite wounds in humans. Sci Rep 2016; 6:22919.

2. Martins-Baltar A, Meyer S, Barraud O, Garnier F, Ploy MC, Vignon P, François B. Routine use of 16S rRNA PCR and subsequent sequencing from blood samples in septic shock: about two case reports of Capnocytophaga canimorsus infection in immunocompetent patients. BMC Infect Dis. 2022 Apr 9; 22(1):355. doi: 10.1186/s12879-022-07328-z. PMID: 35397547; PMCID: PMC8994385.

5426

Improving HIV testing among critical care inpatients through use of electronic admission proforma

Fred Fyles, Robert Parker, Lindsay Ayres

Liverpool University Hospitals NHS Foundation Trust

Introduction: In early 2019, following attainment of the UNAIDS target of a 90% diagnosis rate among people living with HIV,¹ the UK government aimed to eliminate HIV transmission within England by 2030.² While the number of annual new HIV diagnoses in England have gradually fallen since 2012, prompt identification of those within healthcare settings who may benefit from HIV testing remains a key public health goal, particularly given the proportion of late diagnoses has increased from 21% in 2019 to 26% in 2021.³

People living with HIV (PLWH), particularly those who are undiagnosed or have severe immunosuppression, are at higher risk of critical illness secondary to opportunistic infection. While there is a lack of data on long-term outcomes of PLWH who are diagnosed within critical care,⁴ the importance of testing has led some units to introduce an opt-out testing programme.⁵ We describe and evaluate the impact of introduction of a prompt to consider HIV testing within our inpatient admission electronic proforma.

Objectives: To assess the impact of introduction of an HIV testing prompt, linking out to BHIVA/BASSH guidelines, within an electronic proforma completed for every new admission to critical care.

Methods: We reviewed admissions to critical care from 10/10/21–30/11/21 (pre-intervention) and from 10/10/22–30/11/22 (post-intervention). Patient characteristics and admission diagnoses were reviewed to assess whether HIV testing was indicated as per BHIVA/BASSH guidelines.

Between the groups we compared:

• Number of admissions requiring HIV testing

• Number of HIV tests appropriately carried out

• Clinical team suggesting HIV testing

• Time from admission to HIV testing

Results: From 10/10/21–30/11/21 there were 163 admissions to our unit. Of 32 patients who met BASHH criteria for HIV testing, only 6 (18.8%) had an HIV test carried out during their admission, with half of these tests being suggested by non-critical care specialties. In comparison, from 10/10/22–30/11/22 there were 177 admissions, of whom 80.0% had a correctly-completed admission proforma. Of 23 patients meeting BASHH criteria, 13 (56.5%) had an HIV test carried out during their admission, with the majority (77%) of these being suggested by critical care physicians. Time from admission to testing improved from 3.2 to 2 days. Across both periods no HIV tests returned a positive result, in line with our hospital’s local HIV prevalence, which is below national average.

	Pre-intervention (n=163)	Post-intervention (n=177)
Indicator Condition	32 (19.6%)	23 (13.0%)
Community Acquired Pneumonia	24	17
History IV Drug Use	6	3
Hepatitis B/C Infection	0	1
Other	1	2
HIV Test Completed	6	13
Team Suggesting HIV Testing
Critical Care	3	10
Other	3	3
Time from Admission to Test (Days)	3.2	2

Conclusion: Introduction of a simple prompt to consider HIV testing for new admissions, linking out to BHIVA/BASHH guidelines, led to improved rates of HIV testing, and to testing being carried out earlier in the admission. While further work can be done to improve HIV testing within the critical care setting, simple interventions such as this may be implemented in areas with high HIV prevalence rates.

References

1. T Kirby. The UK reaches UNAIDS 90-90-90 targets. Lancet World Report. 2018;392:10163.

2. K Samuel. England on track to eliminate HIV by 2030 – the prevalence of undiagnosed HIV has halved since 2013. Aidsmap. 26 November 2021. [accessed 31 October 2022]

3. UK Health Security Agency. National HIV Surveillance Data Tables. London: UKHSA; 2022. UKHSA publication number GOV-13322.

4. F Barbier et al. Management of HIV-infected patients in the intensive care unit. Intensive Care Med. 2020; 46(2):329-342

5. J Thornhill et al. Opt-out HIV testing in adult critical care units. Lancet. 2014;383:9927.

5537

Increasing serum HIV testing in a district general hospital ICU

Finlay McMunn, Lorna Chapman, Gerens Curnow, Adam Revill

Torbay and South Devon NHS Foundation Trust

Introduction: HIV prevalence varies on a regional basis and underdiagnosis is a significant issue, with an estimated 5900 undiagnosed individuals living with HIV in 2019.¹ It is common for ICU personnel to care individuals with HIV, and 0.9% of new HIV diagnoses are made on ICU.¹ ICU mortality in the first 21 days in individuals with HIV is 2.3 times higher if they are not on active treatment.²

As part of an effort to increase HIV diagnoses, Public Health England (PHE) supported the use of expanding HIV testing to outside of the Sexual health environment in high prevalence areas.³ Expanded testing is associated with a decrease in late HIV diagnoses, and in turn reduced morbidity, mortality and onward HIV transmission.⁴ Diagnosed HIV prevalence in the Torbay area in South Devon surpasses the 2 per 1000 population threshold set by PHE required for expanded testing.³

Objectives: To increase the rate of HIV testing of ICU patients to over 95% at Torbay hospital.

Methods: Baseline rate of HIV testing was measured retrospectively using Cyberlab (the Trust online pathology reporting system). HIV serum testing was then implemented as part of the automated routine ICU admission order sets and testing rates were remeasured. Patients who were not tested despite the new implementation were identified and data analysis performed to identify the prior location and time of admission of the untested patients. These areas were highlighted to the multidisciplinary team (MDT) in the staff briefing and cheat sheets displayed in staff areas to improve rates of testing in these problem areas. HIV testing rates were then measured again. Data analysis was carried out using Microsoft Excel.

Results: HIV testing during ICU admission increased from 15% to 88.5% after HIV testing was implemented as part of the ICU admission order set. Overnight admissions and admissions from the Emergency Department were identified as areas with lower testing rates. HIV testing rates further increased from 88.5% to 96.4% after problematic areas were highlighted to the MDT and cheat sheets were displayed in staff areas.

Conclusions: Implementing serum HIV testing into routine ICU admission bloods is an effective way of increasing HIV testing in high prevalence areas. Data analysis can be used to identify system failures which can be highlighted to the MDT in order to further increase rates of testing. Further research should focus on the number of new HIV diagnoses made using routine testing in ICU.

References

1. Shrosbree J, Campbell LJ, Ibrahim F, Hopkins P, Vizcaychipi M, Strachan S, et al. Late HIV diagnosis is a major risk factor for intensive care unit admission in HIV-positive patients: A single centre observational cohort study. BMC Infectious Diseases. 2013; 13(1).

2. Ruiz GO, Herrera CF, Bohórquez JA, Betancur JE. Mortality in patients with acquired human immunodeficiency virus infection hospitalized in an intensive care unit during the period 2017–2019. Scientific Reports. 2022;12(1).

3. Public Health England. Annual Epidemiological spotlight on HIV in the South West. 2018 data [internet]. London: PHE publications; 2020. Report no.: GW-1426 [cited 2023 Feb 18]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/919909/Spotlight_on_HIV_in_the_South_West.pdf

4. Ransome Y, Terzian A, Addison D, Braunstein S, Myers J, Abraham B, et al. Expanded HIV testing coverage is associated with decreases in late HIV diagnoses. AIDS. 2015;29(11):1369–78.

5573

Diagnostic accuracy of the Clinical Pulmonary Infection Score and Bronchoalveolar Lavage Fluid Biomarkers for the diagnosis of Ventilator-associated Pneumonia

Chizi Ogbu, Anthony Rostron, John Simpson, Thomas Hellyer

Newcastle University

Introduction: Current diagnostic strategies for ventilator-associated pneumonia (VAP) involve the initiation of antibiotics upon suspicion, followed by microbiological confirmation which can take up to 72 hours, risking antibiotic overuse. Low concentrations of IL-1β and IL-8 in bronchoalveolar lavage fluid (BALF) have been validated for the rapid exclusion of VAP, although these failed to reduce antibiotic use when evaluated in the VAPrapid2 trial.^1,2 Incorporating this biomarker-based test with clinical scoring systems may expedite the diagnosis of VAP and improve prescribing practices in intensive care units (ICUs).

Objectives: To investigate the diagnostic value of integrating a modified Clinical Pulmonary Infection Score (mCPIS) with measurements of BALF IL-1β and IL-8 concentrations into a strategy for assessing VAP in critically ill patients on mechanical ventilation.

Methods: A retrospective analysis of data included in the VAPrapid2 database was performed. VAP was confirmed by the presence of pathogenic microorganism(s) in BALF at ≥10⁴ colony forming units per millilitre (CFU/ml), and patients were divided accordingly into VAP and non-VAP groups. Diagnostic accuracy of the mCPIS was determined at a threshold of >6 as previously used.^3,4 In addition, by plotting receiver operating characteristic (ROC) curves, the optimum threshold was determined using the Youden index.⁵ Sensitivity and specificity were reported at these two cut-off values. The mCPIS was combined with BALF biomarkers in a stepwise algorithm. Patients were initially ruled-in for VAP using the mCPIS and then ruled-out for VAP using the BALF biomarkers. Previously derived cut-offs were used for the BALF biomarkers.¹

Results: Paired mCPIS and BALF culture results were available for 176 patients. The mean mCPIS was 6.03 ± 0.85 and 5.26 ± 1.46 for the 66 VAP and 110 non-VAP cases, respectively. The operative indices at a mCPIS threshold of >6 were a sensitivity of 37.9% and a specificity of 75.5%. The Youden index was a mCPIS of >5, and at this threshold, the sensitivity was 62.1% and specificity was 59.1%. In the group of patients with complete mCPIS and BALF biomarker results (n= 61), an algorithm using a mCPIS cut-off of >6 and BALF biomarker test, the sensitivity and specificity were 50% and 85.7%, respectively. Using a mCPIS cut-off of >5 and BALF biomarker test, the sensitivity and specificity were 65.4% and 77.1%, respectively.

Conclusions: The mCPIS offers limited diagnostic utility as a standalone tool for diagnosing VAP. A diagnostic strategy incorporating the mCPIS and BALF IL-8 and IL-1β concentrations resulted in modest improvements in sensitivity and specificity. Combining the mCPIS and BALF biomarkers shows limited promise as a diagnostic test for VAP.

Acknowledgements

The VAPrapid project was supported by the Department of Health and Social Care and Wellcome Trust (HICF-510-078; 094949/Z/10/X).

References

1. Hellyer TP, Morris AC, McAuley DF, Walsh TS, Anderson NH, Singh S, et al. Diagnostic accuracy of pulmonary host inflammatory mediators in the exclusion of ventilator-acquired pneumonia. Thorax. 2015;70(1):41-7.

2. Hellyer TP, McAuley DF, Walsh TS, Anderson N, Conway Morris A, Singh S, et al. Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation. The lancet respiratory medicine. 2020;8(2):182-91.

3. Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit: A proposed solution for indiscriminate antibiotic prescription. American journal of respiratory and critical care medicine. 2000;162(2 I):505-11.

4. Tejerina EMDP, Esteban AMDP, Fernández-Segoviano PMDP, Frutos-Vivar FMD, Aramburu JMD, Ballesteros DMD, et al. Accuracy of clinical definitions of ventilator-associated pneumonia: Comparison with autopsy findings. Journal of critical care. 2010;25(1): 62-8.

5. Youden WJ. Index for rating diagnostic tests. Cancer. 1950;3(1):32-5.

5594

Ventriculitis following EVD and lumbar drain insertion – a 1-year audit

Mark Burgess, Fiona Baldwin, Matthew Stevens

University Hospitals Sussex

Introduction: Ventriculitis is an important complication of external ventricular drain (EVD) insertions and is associated with increased mortality and prolonged neurological sequelae in survivors.¹

Objectives: We performed a retrospective 12-month audit of all external ventricular drain (EVDs) and lumbar drain (LDs) insertions in a tertiary neurosurgical centre in order to determine:

1. The prevalence of ventriculitis.

2. Choice and duration of anti-microbial therapy.

3. Factors known to predispose to infection such as duration and sampling.

Methods: A search for the key words of ‘EVD’ and ‘Lumbar Drains’ was performed in our electronic patient record (imdSoft Metavision) to identify all patients treated with either device between 1.1.19 and 31.12.19. All relevant information was extracted from the record. Ventriculitis was deemed present if either the probable or definite criteria, as described by Humphreys et al,² were met.

Results: 35 patients were treated with either an EVD or LD during the study period. (30 EVD and 5 LD). Three patients had multiple devices inserted. All drains were inserted in the operating theatre. Median age was 64 years (range 22 – 83) and 18 of 35 (51%) patients were female. The median duration of drain placement was 9 days (range 1-24 days). Indications for drain insertion are shown in Figure 1.

Figure 1; Indications for EVD/LD insertion

Fifteen patients (42.9%) received antibiotics for ventriculitis for a median length of 8 days (range 2-19 days). Thirteen received meropenem and linezolid, and two received intra-thecal vancomycin. Overall, 11 (31.4%) met the diagnostic criteria for ventriculitis (10 EVD, one LD). This equates to 34.5 infections per 1000 EVD/LD days. Four patients treated for ventriculitis who did not meet the criteria for diagnosis were treated for a median of 4.5 days (range 2-7).

The median duration of drain placement for those meeting criteria was 11 days Vs. 9 days for those not meeting criteria. No patients meeting diagnostic criteria failed to receive appropriate antibiotics.

5 patients (45.4% of those with ventriculitis) had positive bacterial CSF cultures. Twenty-three (65.7%) of all patients had their device accessed for CSF sampling at least once, of whom seven had their drains accessed three or more times.

Conclusions: In our institution ventriculitis occurred in approximately one-third of all patients with an EVD or LD. This is above the expected range for this nosocomial infection, which is approximately five to 20%.¹ Modifiable factors known to increase the risk of ventriculitis in our data set include duration of drain placement and frequency of CSF sampling. A care bundle, which we are currently developing, may improve awareness and reduce rates of infection.

References

1. Heofnagel D, Dammers R, Ter Laak-Poort MP, Risk factors for infections related to external ventricular drainage. Acta Neurochir (Wien) 2008;150:209e214.

2. Humphreys H, Jenks P, Wilson J et al, Surveillance of infection associated with external ventricular drains: proposed methodology and results from a pilot study, Journal of Hospital Infection 95 (2017) 154e160

4983

A quality improvement project on the implementation of electronic controlled drug ordering in critical care

Priyanka Rajeevkumar, Lynda Cameron, Mike Barker

Guys’ and St Thomas’ NHS Foundation Trust

Introduction: The management of controlled drugs (CD) requires a clear audit trail due to high risk drugs involved as governed by the Care Quality Commission (CQC)^1,2 to meet fundamental standards of quality and safety. Guys’ and St Thomas’ NHS Foundation Trust (GSTT) uses a trust-wide paper based CD ordering system involving senior nurses who order and physically deliver an order book to pharmacy for dispensing. Ward staff sign for collection and receipt on the ward. However, incident reporting identified inappropriate controlled drug ordering causing delays in dispensing which could lead to patient harm.

In addition, the process had not been previously audited to confirm CDs were signed on the ward upon receipt posing the risk of missing controlled drugs. During the COVID-19 pandemic, the order books were relocated to dispensary to prevent transmission & reducing nursing time. Therefore, a quality improvement group reviewed CD process and agreed to implement and audit an electronic controlled drug ordering system. This was ratified at critical care governance committees with end user testing, both with nursing and pharmacy. Staff training occurred via SOPs and ‘watch out for notices’ circulated to the directorate alongside face to face training for key stakeholders.

Objectives: An electronic ordering system to order, dispense, deliver and record receipt of controlled drugs was implemented to streamline the paper-based system. A retrospective audit was conducted to confirm a safe and effective process as developed by the QI project. It assessed adherence of the system to standards set by the aims of the paper ordering system. The aims were to prove if the Controlled Drug Ward e-Ordering system (e-CD) was a viable process for trust-wide implementation.

Method: The critical care ward pharmacist reviewed Controlled Drug Ward e-Ordering system daily during the implementation period to ensure competency of utilising new system. A retrospective audit, approved by GSTT Pharmacy Audit Lead, was conducted in July 2020 during a 4 week trial period, reviewing 17 electronic controlled drug orders (n=17). One pharmacist collected the data reviewing the various steps of the electronic drug ordering process measured against six standards and the percentage compliance per controlled drug order. This study did not require ethics approval

Results (Number of electronic orders n=17)

Standard	% Compliance
Standard 1 - 100% compliance to order electronically for CDs	100%
Standard 2 - 100% compliance to bleep the pharm for non-stock CDs / Out of Hours (OOH) CDs	50%
Standard 3 - 100% compliance for pharmacy to dispense and check CDs within 2hrs	100%
Standard 4 - 100% compliance to sign for delivery/ collection from pharmacy in log book	n/a
Standard 5 – 100% compliance to receipt orders within 30mins	22%
Standard 6 – 100% compliance to sign CDs into register	100%

Conclusion: The results showed the Controlled Drug Ward e-Ordering was successful at ordering and dispensing e-CDs. However, due to difficulties and limited resources, the audit highlighted a key concern regarding receipting on the wards as it was time-consuming for nursing staff during the COVID-19 pandemic. There was also incomplete data for adherence to sign for delivery/collection due to resources. This will be addressed in future plans, by introducing a Prescription Tracking System (PTS) to track the movement of medications across the hospital via a scanning/barcode system. In the interim, annual re-audits are required to ensure the safe and secure handling of controlled drugs ordered electronically as it will be incorporated into Epic©, the new trust wide electronic patient record system.

References

1. Guy’s and St Thomas’ NHS Foundation Trust. Medicines Policy: Code of Practice for Controlled Drugs.

2. Guy’s and St Thomas’ NHS Foundation Trust. Medicines Policy. 07 September 2021, page 2.

3. GSTFT & RB&HH Medicines Policy – Interim Policy. September 2021.

4. CD procedure wards and departments - Ordering and Receipt of CDs. 21 August 2016.

5. Care Quality Commission, Guy’s and St Thomas’ Hospital NHS Foundation Trust Quality Report, Published 23/07/2019, [last accessed 17/12/2022 at http://www.cqc.org.uk].

5364

Optimising Information Visualisation on the ICU Ward Round to Improve Speed and Accuracy

Hugh Gifford¹, Rachel Saunders², Rebecca Finch², Mark Davidson²

¹ University of Exeter MRC Centre for Medical Mycology

² Royal Devon University Healthcare NHS Foundation Trust

Introduction: Critical care requires high-tech information support. Functional systems have been associated with improved outcomes such as ICU length of stay.¹ However, poorly implemented electronic patient records (EPR) can contribute to doctor burnout via “death by 1,000 clicks.”² The British Medical Association estimates the cost of poor IT systems in the NHS at £1 billion/yr.³

Objectives: We implemented an EPR template to improve the availability of relevant information for the ICU clinician on a ward round with the goal to reduce time spent on obtaining critical and accurate basic information, “releasing time to care.”⁴

Methods: Using the Epic EPR we made use of a departmentally integrated Physician Builder⁵ (ICU Consultant and Clinical Lead) to implement a New Timeline Visualisation (NTV) of clinical metrics, observations, lab results, therapy start/stop dates et cetera, for each system. After stable release, we asked care providers to provide feedback and to take a timed assessment of information finding typical to a daily ward round in a ventilated patient both with and without the NTV. We compared total time to completion, and percentage accuracy, using two-tailed paired t-tests. We then performed an extrapolation of any time and costs saved for 10 patients’ full review once daily using salary information for Consultant, ACCP, Registrar, SHO, Band 6 Nurse and Band 5 Nurse.

Results: Staff recruited (n = 8) included Advanced Critical Care Practitioners (n = 3), Intensive Care Consultants (n = 2), Intensive Care Medicine Registrars (n = 2) and Acute Care Common Stem Trainees (n = 1); 5 participants were male (62.5 %). The average time to find all information was 5:58 minutes and seconds (range 3:54 – 8:04) using the NTV vs 9:34 using standard clicking and information tabs (range 4:00 – 15:30, p = 0.012). Additionally, the percentage of complete and accurate information was 61.5 % using the NTV (range 61.5 % – 84.6 %) and 76.0 % using standard clinking and information tabs (range 61.5 % - 92.3 % p = 0.041).

Feedback included: “everything is in one place and easily searchable,” “more intuitive”, “much easier to see key info…including trends”, “quicker”, “helps find info faster”, “more efficient”, “great improvement”, “great system”. Constructive criticism included the need to make timing and columns consistent, the need for familiarisation, and that they are “still not as nice as old ICU paper charts”. We estimated hours saved per year in the region of 219 hours, with an estimated associated cost savings of £34,806 per year in a single ICU.

Conclusions: This care provider centred information technology design improvement showed significant time savings and higher accurate information retrieval rates. These findings demonstrate the potential of good interaction design in EPRs in the ICU to save money and minimise error or failure to retrieve or access information, with the potential to prevent patient harm. We recommend that EPR design should be continuously improved in order to address outcomes directly relevant to critical care delivery.

References

1. Levesque E, Hoti E, Azoulay D, Ichai P, Samuel D, Saliba F. The implementation of an Intensive Care Information System allows shortening the ICU length of stay. J Clin Monit Comput. 2015 Apr;29(2): 263–9.

2. Schulte F, Fry E. Death By A Thousand Clicks: Where Electronic Health Records Went WrongKaiser Health News. KHN [Internet]. 2019 Mar 18 [cited 2023 Feb 26]; Available from: https://khn.org/news/death-by-a-thousand-clicks/

3. BMA. Digital infrastructure [Internet]. British Medical Association; 2022 Dec [cited 2023 Feb 26]. Available from: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/the-future/building-the-future-healthcare-infrastructure-reports/digital-infrastructure

4. NHS Improvement Hub. Releasing Time to care, The NHS Productive Series [Internet]. 2023 [cited 2023 Feb 26]. Available from: https://www.england.nhs.uk/improvement-hub/productives/

5. EpicTogether. Physician Builder Program [Internet]. 2023 [cited 2023 Feb 26]. Available from: https://epictogetherny.org/Pages/PhysicianBuilderProgram.aspx

5597

Whispers from the Community: Differences in Primary Care Utilisation Before Critical Illness

Benjamin Post, Roman Klapaukh, Stephen Brett, Aldo Faisal

Imperial College London

Introduction: Critical illness is associated with significant mortality and morbidity including a risk of long-term disability and functional decline.^1,2 The early identification of patients at risk of critical illness may allow early preventative measures to be instigated to avoid admission and allow individuals to understand the implications of a possible future critical illness. Here we demonstrate that, across the country of Wales, interactions with primary care are significantly different for patients that suffer a critical illness compared to the general population.

Methods: We performed a retrospective observational study using the Secure Anonymised Information Linkage (SAIL) Databank^3-5 which contains billions of linked primary and secondary care, person-based health records and covers over 80% of the population of the country of Wales. We identified all adult patients aged 18-100 in the database for the years 2016-2018 and extracted all dates where at least one data point (e.g., general practice attendance, lab test, prescription, administrative action) was recorded in their primary care electronic healthcare record (EHR). We refer to these dates collectively as General Practice Events (GPEs). Our outcome of interest was emergency ICU admission in the year 2018. For all patients with an emergency ICU admission, we extracted all GPEs up to 24 months prior to their admission. For patients that did not undergo an ICU admission, a random date in 2018 was selected and all GPEs up to 24 months prior were extracted. As such, regardless of outcome, each patient was assigned an outcome date and 24 months’ worth of preceding GPEs were extracted. We calculated the total number of GPEs identified for each patient and the median time difference between all sequential GPEs. We report the median and [interquartile range (IQR)], by outcome group, for each of these values. This study was approved by the SAIL independent Information Governance Review Panel (IGRP) (ref 1323).

Results: 1,400,014 individuals met study inclusion criteria. A total of 3268 patients had an emergency ICU admission in the year 2018 (i.e., ICU admission rate of 0.23%). Patients admitted to ICU were slightly older (62 years [23] vs 60 years [27], had more GPEs in the 2 years prior to ICU admission (128 [165] vs 48 events [52]) and a shorter median time interval between GPEs (5 days [3] vs 9.5 [11]). These differences are more pronounced in younger age groups as the number of GPEs (Figure 1) and median time difference between GPEs (Figure 2) tend to converge for those aged over 85.

Figure 1.

Total GP Events Prior to Outcome Date.

Figure 2.

Median Interevent Time Between GP Events By Age Group Prior to Outcome Date.

*(In both images, patients aged >95 not displayed to minimise risk of identification).

Conclusion: We have shown that, in the country of Wales, the patterns of primary care interaction are different for 2 years prior to an emergency critical care admission. Patients interacted more frequently with primary care services if they subsequently underwent an emergency ICU admission, compared to the rest of the population. These findings suggest that the trajectory of critical illness may evolve over years, opening the possibility of very early identification of patients at risk of future deterioration from electronic healthcare records.

Declarations and Funding

BP was supported by the UKRI CDT in AI for Healthcare http://ai4health.io (Grant No. EP/S023283/1). AAF holds a UKRI Turing AI Fellowship (Grant No. EP/V025449/1). This research was also funded by the NIHR Imperial Biomedical Research Centre (BRC), and by Research Capability Funding.

References

1. McPeake J, et al. Long term outcomes following critical care hospital admission: A prospective cohort study of UK biobank participants. Lancet Reg Health - Eur. 2021 Jul 1;6:100121.

2. Morgan A. Long-term outcomes from critical care. Surg Oxf Oxfs. 2021 Jan;39(1):53–7.

3. Ford DV, et al. The SAIL Databank: building a national architecture for e-health research and evaluation. BMC Health Serv Res. 2009 Sep 4;9(1):157.

4. Lyons RA, et al. The SAIL databank: linking multiple health and social care datasets. BMC Med Inform Decis Mak. 2009 Jan 16;9(1):3.

5. Jones KH, et al. A case study of the Secure Anonymous Information Linkage (SAIL) Gateway: a privacy-protecting remote access system for health-related research and evaluation. J Biomed Inform. 2014 Aug;50:196–204.

5433

A rare presentation of acute unconsciousness - a late presentation of MCADD(Medium Chain Acyl-CoAdehydrogenase deficiency) leading to profound encephalopathy

Faisal Siddique

William Harvey Hospital, East Kent university Hospitals NHS Foundation Trust

We present the case of a young adult (19 years) with no significant past medical history except asthma, who was brought in by paramedics after 20 episodes of vomiting over a single day, with severe hypoglycaemia and low consciousness level a GCS of 5/15 (E3 V1 M1). In spite of repeated IV glucose fluid replacement, his GCS never improved and he was intubated in A&E for airway protection. While undergoing bedside ECHO, the patient had a run of self-resolving SVT in A&E. Initially to rule out causes of acute encephalopathy, toxicology was sent and a CT head thorax abdomen and pelvis was arranged, which showed no acute intracranial pathology but revealed severe fatty liver. However, his liver function remained within normal limits with raised inflammatory markers in the bloods. A provisional diagnosis of encephalitis or meningitis was made. The patient was admitted to the Intensive Care Unit due to acute encephalopathy. Further investigations for toxicology were negative and the ammonia level was found elevated (534) later during the admission. In the ITU, the patient had a further episode of SVT followed by VT cardiac arrest; ROSC was achieved after 15 mins of CPR and 3x DC shock. Renal replacement therapy (CRRT) was then initiated to reduce the level of ammonia. In less than 24 hrs, the patient was transferred to a Liver ITU in a tertiary hospital where further investigations unveiled a rare metabolic condition known as MCADD. Unfortunately, the patient died on day four after brain stem death testing.

MCADD (Medium Chain Acyl-CoAdehydrogenase deficiency) is an inherited metabolic disorder that is present from birth and generally seen in babies 1-24 months of age. It can present with weakness, vomiting or seizures and, rarely, coma or sudden death. Medium chain Acyl-coenzyme A dehydrogenase enzyme is required for breaking down fat stores in response to starvation or acute phase response.

Despite being one of the common metabolic conditions (1/10,000 patients) MCADD is often not considered as differential diagnosis in such presentations especially in District General Hospitals.

References

Late presentation of medium-chain acyl-CoA dehydrogenase deficiency S. J. Mayell · L. Edwards · F. E. Reynolds · A. B. Chakrapani J Inherit Metab Dis (2007) 30:104 DOI 10.1007/s10545-006-0488-4

Mitochondrial Fatty Acid β-Oxidation Disorders: From Disease to Lipidomic Studies—A Critical Review Inês M. S. Guerra 1,2, Helena B. Ferreira 1,2, Tânia Melo 1,2, Hugo Rocha 3,4, Sónia Moreira 5,6, Luísa Diogo 6, Maria Rosário Domingues 1,2 and Ana S. P. Moreira 1,*

Adult presentations of medium-chain acyl-CoA dehydrogenase deficiency (MCADD) T. F. Lang, J Inherit Metab Dis (2009) 32:675–683 DOI 10.1007/s10545-009-1202-0

The clinical manifestation of MCAD deficiency: challenges towards adulthood in the screened population Ulrich A. Schatz & Regina EnsenauerJ Inherit Metab Dis (2010) 33:513–520 DOI 10.1007/s10545-010-9115-5

5527

An audit of Continuous Intravenous Insulin Administration and monitoring on Intensive Care

Aleksandra Kulikowska, Amy Romanec

Royal Free London NHS Foundation Trust

Introduction: Patients on Intensive Care are at risk of hyperglycaemia which can lead to an increased risk of morbidity and mortality.¹ A continuous infusion of intravenous insulin is used to maintain blood glucose between 6-10 mmol/L following the results from the NICE-SUGAR study. Targeting this range ensured avoidance of hyperglycaemia as well as hypoglycaemia, which occurred with stricter control (4.5-6 mmol/L). A new protocol has been developed on Intensive Care at the Royal Free Hospital to allow for better glucose control and more accurate monitoring.² Monitoring requirements are based on guidelines from the Joint British Diabetes Societies for Inpatient Care guidelines.³

Objectives:

• To investigate the prescribing of variable rate insulin infusions (VRII)

• To assess whether VRII rate changes are done as per protocol

• To assess if glucose administration is as per protocol

• To investigate whether blood glucose monitoring is done as per protocol

• To assess barriers for nursing staff to following the protocol

Standards:

Prescribing

1. 100% of patients are correctly prescribed the VRII starting regimen A or B

2. 100% of patients are prescribed the correct starting dose of insulin

3. 100% of patient are prescribed glucose 50% infusion AND at least one other source of glucose alongside the VRII.

Administration

1. 100% of changes to VRII are done as per protocol

2. 100% of patients have a source of glucose running alongside VRII

3. 100% of the time insulin is reviewed when the glucose source is held

Monitoring

1. 100% of blood glucose monitoring is done as per protocol

2. 0% of patients experienced a hypoglycaemic event (BMs <4)

Method: Data was collected retrospectively for all patients on Intensive Care on VRII from 16/01/23 – 25/01/23. PowerChart by Cerner was used as a primary source of data which was supplemented by information on infusion pumps and that provided by nursing staff.

This study did not require ethics approval.

Results: 25 of patients were on VRII at the time of data collection. 20 (80%) patients were correctly started on regime A or B. Glucose co-administration was managed well at 93% standard compliance. Significantly lower compliance was observed with the rate changes and monitoring standards. Rate changes were managed correctly only 58% of the time, whilst blood glucose monitoring had only a 21% compliance. Two patients experienced hypoglycaemic episodes as a result.

Conclusions: The new VRII protocol was written with a view of increasing patient safety on the unit by ensuring more robust management and monitoring of continuous intravenous insulin administration. The results showed that the protocol has been successfully incorporated into prescribing and administration practice with high rates of adherence to standards. However, the audit showed that practice consistently deviates from protocol in terms of monitoring. A review of practice with the nursing staff has identified feasibility of hourly monitoring in practice and lack of blood glucose machines as the main obstacles which showed the need for investments if the unit is to comply with the required national standards. In conclusion the new protocol has had a positive impact on Insulin management on the unit, however with more investment required to facilitate ease of monitoring.

References

1. Godinjak A, Iglica A, Burekovic A, Jusufovic S, Ajanovic A, Tancica I, Kukuljac A. Hyperglycemia in Critically Ill Patients: Management and Prognosis. Med Arch. 2015 Jun;69(3):157-60. doi: 10.5455/medarh.2015.69.157-160. Epub 2015 Jun 10. PMID: 26261382; PMCID: PMC4500381.

2. Kulikowska, A, Moorhouse, J. Glucose Monitoring and Variable Rate IV insulin administration in Critical Care guideline. London: Royal Free NHS Foundation Trust; 2022.

3. Graveling A, Walden E, Flanagan D, The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus [Internet], 2023. Available from: https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_01_Hypo_Guideline_January_2023.pdf

5013

Devastating Brain Injury -Are we doing enough

Uma Sangameshwar¹, Uma Sangameshwar², Sandeep Gudibande², Janani Vaghani

¹ North west england

² North west England

DBI is defined as “ any neurological condition that is assessed at the time of hospital admission as an immediate threat to life or incompatible with good functional recovery and where early limitation or withdrawal of therapy is being considered.“

DBI is a time sensitive decision applied to patients with primary neurological diagnosis with an irreversible aetiology which impacts their treatment.

DBI includes traumatic brain injury, Subarachnoid haemorrhage,stroke and intracranial haemorrhage. It is an important decision which affects the outcome of ITU admission both financially and for governance purposes.

As per 12 college recommendations (FICM, ICS, RCEM, Neuro anaesthesia society.) DBI pathway has been created in Royal Preston Hospital for the management of DBI patients.

Our primary aim of this audit is to analyse the rate of occurrence of DBI patients in our unit and to assess if we have followed the trust guidelines and documented adequately.

This is a retrospective analysis of patients being admitted with bilateral dilated pupils over a period of 3 years from august 2019- may 2022. These patients were assessed based on their primary diagnosis and the DBI patients were filtered out- these patients were further evaluated in terms of length of stay, outcome, family discussion, SNODS referral and brain stem testing. We had a total of 42 DBI patients among 235 admitted with Bilateral dilated pupils during their admission in our hospital emergency department. We also assessed the number of organ donors among these 42 patients. Our results proved that we were compliant in following the trust guidelines. The physiological stabilisation was done appropriately and brain stem testing was done whenever possible, but the major drawback was documentation. We created a checklist and some changes in electronic patient recording system which would pop up once the patients have been assigned to DBI pathway in the emergency department. This would assure we have followed every step appropriately.

Contents of checklists:

• - Primary diagnosis

• - Perceived DBI by NS team at the time of admission

• - DBI pathway activated in ED/ICU/ neuroSx within 24hrs

• - CT brain findings

• - Level of support required for prognostication on admission

• - Time of family discussion

• - Brainstem testing

• - Time of SNOD referral

• - MDT discussion done

• - End of life/ best interest form

• - Patient outcome

• - Patient accepted by SNODS.

References

1. Harvey D, Butler J, Groves J, Manara A, Menon D, Thomas E, et al. Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations. Br J Anaesth. 2018;120(1):138-45.

2. statement c. Management of perceived devastating brain injury after hospital admission. Faculty of intensive care medicine2018.

5529

Audit of the Practice of Blood Pressure Augmentation in Patients with Aneurysmal Subarachnoid Haemorrhage Admitted to a Neuro Intensive Care Unit

Gemma Talling¹, Megan Fahy², Amal Almahroos², Nicholas Talbot³

¹ University Hospitals Birmingham NHS Trust

² University Hospital Birmingham NHS Trust

³ Queen Elizabeth Hospital Birmingham

Introduction: Haemodynamic optimization including blood pressure management is a cornerstone in the treatment of patients with aneurysmal subarachnoid haemorrhage (aSAH). It is known that the development of delayed cerebral ischaemia (DCI) is associated with a poor outcome and blood pressure augmentation is routinely used to maintain cerebral perfusion and to aid resolution of vasospasm.¹ Recent NICE guidelines state vasopressors may be administered to raise blood pressure, however uncertainty remains regarding optimal blood pressure targets.²

Objectives: The aim of the project was to audit the current practice of blood pressure augmentation in patients admitted with aSAH to a Neuro intensive care unit. The objectives were 1) to identify blood pressure targets prescribed for patients with unsecured aneurysms, post neurovascular intervention with secured aneurysm and in those with suspected/confirmed DCI. 2) To compare if differences existed in blood pressure targets between clinical teams (intensive care or neurosurgical). 3) To assess if aSAH grade or pre-existing comorbidities affected blood pressure targets. 4) To identify the doses of vasopressors used to achieve targets. 5) To retrospectively review if adverse systemic complications developed. 6) To assess the use of haemodynamic monitoring (including use of troponin and cardiac output monitoring) during induced hypertension.

Methods: Patients included were those admitted to a Neuro intensive care unit with aSAH who were actively managed over a 12-month period. Retrospective data was collected using electronic patient records of their intensive care admission.

Results: In total 68 patients were identified, 29% had a target blood pressure recorded prior to neurovascular intervention. 63 of the 68 patients underwent neurovascular intervention for their aSAH. 53% of patients who had secured aneurysm had a blood pressure target recorded. Blood pressure targets varied significantly and did not appear to be related to pre-existing hypertension, grade of aSAH or clinical team setting the target. 17 patients were suspected of developing DCI, in all cases blood pressure augmentation was used in the management plan. 14 required noradrenaline to elevate blood pressure, of these 11 patients required NA > 0.5mcg/kg/min and 5 patients required noradrenaline above 1 mcg/kg/min. In those 5 patients who received a noradrenaline dose of >1mcg/kg/min 3 experienced an adverse ischaemic systemic event during treatment. Regarding monitoring during blood pressure augmentation for treatment of DCI only 31% had a troponin level measured and 1 had cardiac output monitoring with LiDCO.

Conclusions: There was a lack of specified blood pressure targets recorded pre and post neurovascular intervention. Where blood pressure targets were recorded there existed significant variation in practice between clinicians. During treatment of DCI high dose vasopressors were frequently administered and adverse ischaemic events were recorded. The development of local guidelines is required for joint decision making between clinical teams on blood pressure targets which consider individuals’ comorbidities and provide guidance on increased monitoring. Other recommendations include recording the dose of noradrenaline in mcg/kg/min to individualise doses to the patient, the use of femoral arterial lines when noradrenaline doses exceed 0.5mcg/kg/min and potentially setting limits on vasopressor doses for this indication.

References

1. Connolly, E. S. Jr. et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012; 43(6): 1711–1737.

2. National Institute for Health and Care Excellence (NICE). Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management. NG228. Published 23 November 2022. Available from: Overview | Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management | Guidance | NICE.

5534

Status epilepticus secondary to seronegative autoimmune encephalitis – A diagnostic challenge!

Rachel Molyneux, Saibal Ganguly

The Royal Wolverhampton NHS Trust

Introduction: Autoimmune encephalitis is becoming increasingly recognised as a cause of encephalitis, and is thought to account for approximately 20% of the encephalitis cases in the UK.¹ Seronegative autoimmune encephalitis is a subtype of autoimmune encephalitis which can pose significant diagnostic challenges. Early recognition and appropriate treatment is crucial, as early treatment can impact prognosis.² Here two cases of patients with seronegative autoimmune encephalitis admitted to the ICU in status epilepticus are presented.

Case description: Patient 1 was a 66-year-old male with no previous neurological history, who presented to the hospital after having ‘dizzy spells’ and ‘jerking movements’ at home. He developed status epilepticus in ED and was intubated and transferred to ICU. He was initially treated for meningoencephalitis with secondary seizures. All viral and bacterial screens were negative, and both his CT and MRI brain were unremarkable. He had a raised protein in CSF. He failed four sedation holds due to ongoing seizure activity. The presumed diagnosis of autoimmune encephalitis was made nine days into his admission, and a course of pulsed methylprednisolone was trialled. His condition improved, and he was successfully weaned off ventilation and discharged from ICU on day twenty-one, on oral prednisolone and quadruple anti-epileptic drug therapy. His mobility improved, but he had short terms memory loss and increased emotional lability on follow-up. The limbic and paraneoplastic antibody screens were negative, leading to a diagnosis of seronegative autoimmune encephalitis.

Patient 2 was a 62-year-old female with no previous history of seizures, who was admitted to hospital with a history of behavioural changes and collapse. She was initially treated for alcohol withdrawal but was admitted to ICU on day ten due to low GCS and EEG confirming non-convulsive status epilepticus. She was treated for meningoencephalitis, with MRI brain appearances being highly suspicious of temporal encephalitis. She was discharged from ICU on day eighteen. Viral PCR, limbic antibodies and paraneoplastic antibodies were all negative. She also had a slightly raised CSF protein. Pulsed methylprednisolone was started on the ward for suspected autoimmune encephalitis because of ongoing seizure activity. She was readmitted to ICU with low GCS despite steroid treatment, and the decision to start plasma exchange (PLEX) for presumed seronegative autoimmune encephalitis was made. She underwent five sessions of PLEX and was discharged from ITU on day seventy-five. She was later discharged and transferred to a rehabilitation hospital for neurological rehabilitation on day eighty.

Conclusions: Autoimmune encephalitis is becoming increasingly recognised with advances in antibody recognition and testing. However, seronegative autoimmune encephalitis remains a diagnostic challenge, and often a syndromic diagnosis must be made based on clinical criteria before full antibody results are available.³ Presentations of autoimmune encephalitis are variable and can often be subtle, but recognition and maintaining a low index of suspicion for autoimmune encephalitis as a cause of new-onset status epilepticus is vitally important.⁴ An MDT approach to management is required as autoimmune encephalitis often results in prolonged hospital stay and recovery period.

References

1. Ellul A, Wood G, Van Den Tooren H, Easton A, Babu A, Michael BD: Update on the diagnosis and management of autoimmune encephalitis. Clinical Medicine. 2020;20(4):389-392. Available from: DOI: 10.7861/clinmed.2020-0241

2. Lee WJ, Lee HS, Kim DY, Lee HS, Moon J, Park K, et al. Seronegative autoimmune encephalitis: Clinical characteristics and factors associated with outcomes. Brain. 2022;145(10):3509-3521. Available from: DOI: 10.1093/brain/awac166

3. Graus F, Titulaer MJ, Balu R, Benseler S, Bien CG, Cellucci T, et al. A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol. 2016;15(4): 391-404. Available from: DOI: 10.1016/S1474-4422(15)00401-9

4. Sculier C, Gaspard N. New onset refractory status epilepticus (NORSE). Seizure. 2019;68:72-78. Available from:https://doi.org/10.1016/j.seizure.2018.09.018

5574

One-year outcomes of patients with subarachnoid haemorrhage admitted to a neurosurgical ICU

Panayiotis Stavrinou¹, Parjam Zolfaghari²

¹ Barts and The London School of Medicine & Dentistry/ William Harvey Institute/ Queen Mary University London

² Barts Health NHS Trust/ Queen Mary University London

Introduction: Subarachnoid haemorrhage (SAH) is defined as bleeding into the subarachnoid space as a result of ruptured cerebral aneurysms or vascular malformations (Macdonald & Schweizer, 2017). It is associated with significant mortality and morbidity as a result of blood extravasation and perfusion disruption, hydrocephalus and delayed cerebral ischemia (Geraghty & Testai, 2017). Patients with high grade SAH often present with seizures and coma, and require ICU admission (Claassen & Park, 2022). The aim of this study was to identify predictors of mortality and long-term outcomes of patients following SAH admitted to the adult critical care unit (ACCU) at the Royal London Hospital.

Methods: This was a single centre, retrospective study of SAH patients admitted to the Royal London Hospital (RLH) ACCU in a 4-year period (2018-2021), and was registered as an audit with the local quality improvement office. Patients’ data were obtained from the ICNARC database and from follow-up clinic letter. Long-term neurological outcomes were scored using the Glasgow Outcome Scale (GOSE).

Patients were then divided into two groups: GOSE outcome of 1-4 (poor outcome group) and GOSE 5-8 (good outcome group). Patient demographics and treatments between the two groups were then compared to identify associations with long-term outcomes. Statistical analysis was carried out using Student’s T-test for normally distributed data, Mann-Whitney U for non-parametric data and Chi-squared test for categorical variables.

Results: From the 152 patients identified, 80 had a poor outcome (52.6%) and this included 55 patients (36%) who died (fig.1). Sixty-six (43.4%) had a good outcome. Six patients (3.9%) were lost to follow-up. The median time to follow-up after discharge was one year. Low GCS on admission, higher World Federation of Neurosurgeons Score (WFNS), the need for external ventricular drains (EVD), mechanical ventilation and increasing organ support were associated with worse long-term outcomes (p<0.05) [table 1]. The length of hospital and ICU stay were significantly longer in the poor long-term outcome group after removing patients who died in the ICU.

Figure 1.

Participants’ Flow diagram.

Patients treated with endovascular coiling were more likely to be in the good outcome group (p<0.001). Patients who had a good outcome were also younger (p=0.006).

Discussion/ Conclusion: This study confirms that SAH is associated with significant mortality and poor neurological outcomes if there is a need for ICU admission (Virta et al., 2021). Patients with poor outcomes were older and had significantly worse GCS on admission, with many having devastating brain injuries. Whilst higher WFNS scores were seen in the poor outcome group, patients with high WFNS scores also had good outcomes. Conversely, a number of patients with low WFNS scores of 1-2 had a poor outcome. Further study is needed to look at outcomes in these patients and the factors that influence these outcomes.

Furthermore, patients who were coiled were more likely to have a good outcome compared to those who were clipped, but multiple factors went into decision making to offer one treatment versus the other. Closer look at these decision-making challenges are needed to determine how they influence outcome.

References

Claassen, J., & Park, S. (2022). Spontaneous subarachnoid haemorrhage. The Lancet, 400(10355), 846-862. doi:10.1016/s0140-6736(22)00938-2

Geraghty, J. R., & Testai, F. D. (2017). Delayed cerebral ischemia after subarachnoid hemorrhage: Beyond Vasospasm and towards a multifactorial pathophysiology. Current Atherosclerosis Reports, 19(12). doi:10.1007/s11883-017-0690-x

Macdonald, R. L., & Schweizer, T. A. (2017). Spontaneous subarachnoid haemorrhage. The Lancet, 389(10069), 655-666. doi:10.1016/s0140-6736(16)30668-7

Virta, J. J., Skrifvars, M., Reinikainen, M., Bendel, S., Laitio, R., Hoppu, S., Raj, R. (2021). Trends in mortality after intensive care of patients with aneurysmal subarachnoid hemorrhage in Finland in 2003–2019: A finnish intensive care consortium study. Neurocritical Care, 37(2), 447-454. doi:10.1007/s12028-021-01420-z

5350

What proportion of individuals with body-mass index >25kg/m² are malnourished on non-elective admission to intensive care?

Kate McCully, Alice Extance

Royal Surrey NHS Foundation Trust

Introduction: It is well established that malnutrition in an ICU setting leads to muscle wasting, reduced function, impaired wound healing, increased risk of pressure injuries and increased length of stay.¹ Individuals with higher body-mass index (BMI), defined as 25.0-29.9kg/m² (overweight) and ≥ 30.0kg/m² (obese), are often assumed to be well nourished therefore may not be prioritised for nutritional support. A previous audit at Royal Surrey Hospital ICU showed that time until enteral or parenteral feeding was not statistically significantly different between obese and non-obese patients. However, there were individual cases where feeding had been delayed for patients with high BMI, possibly due to this assumption. Another external study demonstrated that malnourished obese patients were less likely to receive additional nutrition support than lower weight individuals.² This audit was therefore undertaken to assess proportion of individuals with body-mass index >25kg/m² are malnourished on non-elective admission to ICU and would benefit from timely nutrition support.

Objective: To assess nutritional status and malnutrition risk of all non-elective individuals admitted to ICU with BMI>25kg/m².

Methods: All non-elective admissions to ICU between 1^st April 2022 and 30th June 2022 underwent a baseline dietetic assessment within 48 hours of admission. Dietitians recorded participants’ weight, height, BMI, weight history and diet history from the past 2 weeks.

Participants with BMI >25kg/m² were screened for malnutrition and risk of malnutrition, using the GLIM criteria and NICE Clinical guideline [CG32]. These screening tools were chosen due to ease of use and inclusion of both etiologic and phenotypic criteria. The NUTRIC score was not used, despite being developed specifically for ICU patients, as this score assesses nutritional risk during stay, rather than pre-existing malnutrition.

Results: 45 patients were identified for analysis, with 3 excluded due to incomplete data. Average BMI was 30.4kg/m2 (range 25.0-56.7 kg/m²). According to the GLIM criteria 71% of participants were “malnourished”. Using NICE Clinical guideline [CG32] 12% of patients were “nourished”, 78.5% were “at risk of malnutrition” and 9.5% were “malnourished”.

Conclusions: This audit demonstrates that BMI alone is a poor indicator of nutritional status in ICU patients. Criteria for malnutrition for the GLIM criteria and NICE Clinical Guideline were very different, which emphasises the need for a validated nutritional screening tool specific to ICU.

However, both criteria highlighted that a high percentage of the overweight population are either malnourished on admission or at high risk of developing malnutrition during their stay.

This audit challenges the assumption patients with a high BMI are well nourished, and are in less need of nutrition support. It highlights the need to improve the equity of nutritional care for patients across the weight spectrum as previous studies have shown that this patient group is frequently overlooked.²

Given the lack of validated screening tool, this audit supports ESPEN guidance that every critically ill patient staying for more than 48 hours in the ICU should be considered at risk for malnutrition,³ and be provided with timely and equitable nutrition support regardless of body weight.

References

1. Elia M, on behalf of the Malnutrition Action Group of BAPEN and the National Institute for Health Research Southampton Biomedical Research Centre. The cost of malnutrition in England and potential cost savings from nutritional interventions. Redditch: British Association for Parenteral and Enteral Nutrition; 2015. http://tinyurl.com/ybzeoahd (accessed 27 April 2022)

2. Agarwal E, Ferguson M, Banks M, Vivanti A, Batterham M, Bauer J, Capra S, Isenring E. Malnutrition, poor food intake, and adverse healthcare outcomes in non-critically ill obese acute care hospital patients. Clin Nutr. 2019 Apr;38(2):759-766. doi: 10.1016/j.clnu.2018.02.033. Epub 2018 Mar 10. PMID: 29559233.

3. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, Hiesmayr M, Mayer K, Montejo JC, Pichard C, Preiser JC, van Zanten ARH, Oczkowski S, Szczeklik W, Bischoff SC. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019 Feb;38(1):48-79. doi: 10.1016/j.clnu.2018.08.037. Epub 2018 Sep 29. PMID: 30348463.

5395

Auditing achievement of nutritional targets and the factors that affect those in a tertiary intensive care unit without dietician input

Mariyam Mujeeb¹, Nikitas Nikitas²

¹ University of Plymouth

² University Hospitals Plymouth NHS Trust

Introduction: Critically ill patients who do not achieve the recommended nutritional intake are at risk of adverse outcomes such as increased mortality, prolonged ventilation and longer hospital-stay. Achieving optimal nutritional targets in critically ill patients can be challenging. Underfeeding and overfeeding compared to recommended targets, suboptimal total daily protein intake and defining the optimal daily caloric intake in patients with body mass index (BMI) over 30 are the main challenges ICU clinicians face. Evidence-based national and international recommendations exist to help with the management of these challenges.^1,2

Objective: This audit’s objective was to test the compliance of the local nutritional practices to national and international guidelines (in the absence of national guidelines) and to identify factors that affect these practices in a tertiary intensive care unit without dietician input.

Methods: Single centre, retrospective audit collecting data on all adult medical and neuro-ICU patients who were intubated and enterally fed via nasogastric (NG) tube, over a 4-month period (Oct-Jan 2021). Data was collected from the electronic patient database and patient records. Patients’ demographics, admission details, total/mean daily caloric intake, total/mean daily protein intake, interruptions in enteral nutrition, reasons for interruptions and total/mean daily propofol intake were collected. Descriptive statistics were used in the data analysis.

Results: Data from 67 ICU participants were collected and analysed. Among audit participants, 63% were male and 37% female, the median age was 58. Enteral nutrition was provided for ≥ 20 days in 28% of the cohort.

When propofol administration-related non-nutritional calories were not included in the analysis the recommended daily caloric intake was not achieved in all participants. Median daily propofol intake was 311 mls (range: 0-888 mls). When the propofol-related calories were included, 50% of participants with BMI <30 and 32% of participants with BMI >30 exceeded the recommended daily caloric intake. Recovery rate enteral nutrition was provided in 38% of participants. Of these, 69% were NG fed for longer than 20 days. In 97% of the participants including those with BMI >30, the recommended daily protein intake target was not met. Length of stay (LOS) < 5 days led to a median duration of interruptions of 4 hours (range: 0-15 hours), LOS between 6-15 days led to a median duration of interruptions of 10 hours (range: 0-54 hours), LOS between 15-25 days led to a median duration of interruptions of 18 hours (range: 0-99 hours). The most common indications for interruptions were NG tube dislodgement, high aspirates, and transfers for imaging. In 79% of cases, the interruptions in enteral nutrition were not corrected.

Conclusions: Variable factors affect the achievement of nutritional targets in critically ill patients. These results highlight some of those factors and their effect on ICU nutrition targets. Considering national recommendations, interventions will address optimising caloric/protein intake, calculating additive calories due to propofol administration and using adjusted body weight in nutrition calculations for patients with BMI >30. These could potentially attenuate the effects of these factors and optimise nutritional intake for critically ill patients, being at the same time generally applicable.

References

1. Baldwin A, Baruah R, Bassford C, et al. Guidelines for the provision of intensive care services, version 2.1. London Fac Intensive Care Med. 2022.

2. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, Hiesmayr M, Mayer K, Montejo JC, Pichard C, Preiser JC. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical nutrition. 2019 Feb 1;38(1):48-79.

5461

Indirect Calorimetry: Dynamic Nutritional Supplementation for the critically unwell

Venkata Sukesh Pelluri, Bethany Wilshaw, Jayaprakash Patil

Royal Oldham Hospital

Introduction: An integral part of care on intensive care unit (ICU) is to provide appropriate and adequate nutrition to the critically ill. Conventionally, delivery of this crucial element is made with the use of predictive equations to determine the caloric requirements of patients. Calculations done by these methods can potentially be inaccurate and lead to either underfeeding or overfeeding patients during critical illness¹. Current ESPEN guidelines strongly recommend the use of indirect calorimetry to determine energy expenditure in mechanically ventilated patients². In our unit, predicative equations were the traditional method used by the dieticians to calculate energy needs. We conducted a service evaluation followed by an improvement project in our ICU to determine the difference between predictive and measured (using indirect calorimetry) caloric requirements in critically unwell patients on mechanical ventilation.

Objective: We audited caloric requirements of critically unwell patients in the ICU at Royal Oldham Hospital by predictive equations in comparison to indirect calorimetry.

Methods: The project was registered with and approved by the local audit department. Over a 5-month duration from September 2022 to January 2023, 34 mechanically ventilated patients in ICU were included in the project. The caloric requirements of all these patients were calculated simultaneously using both predictive equations and indirect calorimetry on day 1 and day 7 after admission to ICU. We chose two different time periods because the aim on day 1 is hypocaloric nutrition and full caloric supplementation on day 7. Data from 26 patients on day 1, and 19 patients on day 7 were included in the data analysis. We excluded data in situations such as module assessment error, early extubation (<7 days) and highly unstable patients (e.g., oxygen requirements >60%).

Results: On day 1, data analysis showed that indirect calorimetry recommended higher (ranging from 2-588 kcal) caloric requirements in 62% (16/19) of patients in comparison to predictive equations. On day 7, conversely, the data showed that indirect calorimetry recommended lower (ranging from 9-1120 kcal) caloric requirements in 63% (12/19) of patients in comparison to predictive equations. In summary, delivery of nutrition to patients purely based on predictive equations leads to underfeeding during the initial phase of critical illness and potentially overfeeding during the later stages.

Conclusion: Measured caloric requirements using predictive equations in critically ill patients are inaccurate in comparison to indirect calorimetry. Energy expenditure of ICU patients is dynamic and using predictive equations alone can lead to either undernutrition or malnutrition. Following this project, we have introduced indirect calorimetry as the default method for the calculation of caloric requirements in our unit.

References

1. Graf S, Pichard C, Genton L, Oshima T, Heidegger CP. Energy expenditure in mechanically ventilated patients: the weight of body weight! Clin Nutr 2017; 36:224.

2. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition [Internet]. 2019 Feb;38(1):48–79. Available from: https://www.sciencedirect.com/science/article/pii/S0261561418324324

5499

A retrospective cohort study to ascertain fasting time in enterally fed critically ill patients undergoing tracheostomy

Manan Bajaj, Nick Murphy, Shraddha Goyal, Martin Le Breuilly

University Hospitals Birmingham

Introduction: In ICU, enteral feeding is often paused before any surgical procedure. This results from the generally applied “6-2” rule for perioperative fasting. The rule is often applied irrespective of the procedure or if the patient is intubated before surgery or not. Planned pauses in enteral nutrition prior to a procedure significantly cause underfeeding in critically ill patients. (ref [DOI: 10.1002/ncp.10051])

Objectives: The primary aim was to determine fasting time for patients planned for tracheostomy–percutaneous (PT) compared to surgical (ST). The secondary purposes were the incidence of aspiration, hypoglycaemic episodes, and inulin dose modifications.

Methods: Data was collected from 73 patients admitted to the critical care units of Queen Elizabeth Hospital Birmingham who received a tracheostomy during the COVID pandemic. Forty-two patients had percutaneous tracheostomy from January 2021 to February 2021, and 31 had surgical tracheostomy from January 2021 to July 2021. The total duration of fasting was taken as the cumulative fasting periods before the anticipated procedure. This included feed pauses prior to previous cancelled procedures. Evidence of aspiration was defined by new/progressive infiltrates on chest x-ray, leukopenia (WCC <4,000/) or leucocytosis (>10,000), temperature >38.5°C or <35.5°C, purulent tracheal aspirates and degradation in oxygenation for 48 hours post-procedure. Changes in blood glucose and insulin dosage were also noted during the periods of fasting.

Results: The duration of enteral feed fasting was prolonged (see graph) and significantly different when ST was compared to PT. This was due to considerably more delays and theatre cancellations in the ST group. No evidence of aspiration or hypoglycaemia was found in either group.

Conclusion: Enteral feeding of intubated patients planned for tracheostomy is often paused for prolonged periods. This is significantly longer for ST in theatre due to uncertainty in the timing of surgery and cancellation. There is little evidence that fasting prior to tracheostomy benefits the patient and yet is engrained into clinical practice. Evidence-based guideline on pre-procedure fasting for critically ill intubated patients is needed to avoid unnecessary interruptions in nutrition.

References

1. Varghese JA et al., Fasting practices of enteral nutrition delivery for airway procedures in critically ill adult patients: A scoping review. J Crit Care. 2022 Dec;72:154144.

2. Agarwal A, Chari P, Singh H. Fluid deprivation before operation. The effect of a small drink. Anaesthesia. 1989; 44(8):632-4.

3. Segaran E, Lovejoy TD, Proctor C, et al. Exploring fasting practices for critical care patients - A web-based survey of UK intensive care units. J Intensive Care Soc. 2018 Aug;19(3):188-195.

5533

Adding dietetics into the mix – a recipe for multidisciplinary team success: the inclusion of a specialist critical care dietitian improves nutritional adequacy

Narbhla Donnelly, Georgia Hardy, Danielle Bear

Guy’s and St Thomas’ NHS Foundation Trust, London UK

Introduction: Guidelines for the Provision of Intensive Care Services 2022 (GPICS)¹ recommends 0.05 – 0.1 Whole Time Equivalent (WTE) dietitian per critical care bed to optimise patient outcomes. Prior to approved funding for a 0.6 WTE specialist ICU dietitian, a 13 bedded medical-surgical central London ICU had limited input from dietitians who lacked specialist training in critical care nutrition. Including a specialist ICU dietitian as part of the multidisciplinary team may help achieve nutritional adequacy.

Objectives: To compare the adequacy of nutrition support pre- and post-0.6 WTE specialist ICU dietitian commencement by determining: the number of patients who received dietetic input and; the adequacy of energy and protein delivery.

Methods: A retrospective evaluation of electronic medical records for patients admitted from May – July 2018 (pre-ICU dietitian) and May-July 2019 (post-ICU dietitian) was undertaken. The first 62 adult ICU admissions (>18 years old) with a length of stay >72 hours were included during each period. Cumulative energy and protein balances were calculated for patients receiving enteral and/or parenteral nutrition. Adequate energy and protein delivery were defined as meeting 80-110% of estimated targets, inclusive of non-nutritive energy sources (e.g. intravenous glucose and Propofol). Anonymised data were statistically analysed using SPSS V26 where appropriate. Data for nutritional adequacy were too small to perform statistical analysis, so these results focus on clinical significance instead of statistical significance. Data are presented as number (%) or median (interquartile range: IQR).

Results: Patient characteristics were similar between the pre-ICU dietitian group (n = 62) and the post-ICU dietitian group (n = 62) [Table 1].

Significantly more patients were reviewed by the dietitian in the post-group compared with the pre-group [45/62 (72.6%) vs. 31/62 (50%), p = 0.016].

Nutritional adequacy analysis was performed for 26 (42%) patients in the pre-group and 21 (34%) in the post-group. Energy delivered from all sources shifted patients from inadequate energy delivery in the pre-group [78.5% (57.7% - 88.9%)] to adequate in the post-group [91.3% (71.5% - 97.6%)]. After removing the non-nutritive sources, the post-group still had adequate energy delivery [83.9% (61.2% - 91.1%)], compared to inadequate in the pre-group [67.5% (51.4% - 84.9%)]. Protein delivered was also adequate in the post-group [81.6% (68.9% - 93.2%)], in contrast with the pre-group [68.2% (52.4% - 87.7%)].

The percentage of feeding days where both energy and protein delivery were adequate was higher in the post-group [25.0% (5.0% - 55.2%) vs. 16.0% (0% - 45.5%)]. The percentage of days where energy and protein underfeeding occurred separately reduced from the pre-group to the post-group [Energy: Pre: 48.8% (22.3% -75.0%) vs. Post: 29.7% (16.2% - 56.7%); Protein: Pre: 50.0% (25.0% - 80.0%) vs. Post: 33.3% (15.7% - 78.3%)].

Conclusion: Nutritional adequacy was improved with the addition of the 0.6 WTE specialist ICU dietitian, notably more patients received adequate energy and protein and days of underfeeding were reduced. However, this dietetic provision remains below the GPICS standards and an increase should be explored to ensure continued adequate provision of nutrition support.

Reference

1. Faculty of Intensive Care Medicine and Intensive Care Society. Guidelines for the Provision of Intensive Care Services (GPICS). Version 2.1. 2022.

5576

Nutrition therapy and prevalence of enteral feed intolerance in critically ill patients receiving extracorporeal membrane oxygenation: a service evaluation

Terpsichori Karpasiti, Alice Brown, Rhiannon Lewis

Royal Brompton & Harefield Hospitals, Guy’s & St Thomas’ NHS Foundation Trust

Introduction: The use of extracorporeal membrane oxygenation (ECMO) is rapidly growing worldwide. Observational studies support that achieving adequate nutrition during ECMO is possible,¹ but challenged by frequent nutrition interruptions and complications such as enteral feed intolerance (EFI).^1,2 It remains unclear whether EFI is more prevalent in ECMO compared with non-ECMO patients.

Objectives: The primary outcome of this study was to identify differences in nutritional adequacy and underfeeding reasons between ECMO and non-ECMO patients within a tertiary cardiorespiratory ICU. Secondary outcomes included the comparison of EFI prevalence between ECMO vs non-ECMO patients, and associations between nutritional adequacy and ICU/hospital LOS, ECMO duration and mortality.

Methods: Data were retrospectively collected for consecutive adult patients (≥18 years) admitted with respiratory and/or cardiac failure for ECMO between August 2021-August 2022, and compared with consecutive non-ECMO ICU patients with respiratory/cardiac failure. Patients with an ICU length of stay (LOS) ≥72hrs who were commenced on artificial nutrition within 48hrs of admission were included. Patients admitted for any form of mechanical life support other than ECMO, those admitted to high dependency, receiving artificial nutrition for <72hrs or not assessed by the dietitian were excluded. Adequate nutrition was defined as receipt of 80-110% of nutritional targets³, and EFI as gastric residuals >400ml or ≥2 consecutive vomiting episodes. Categorical data were compared between groups using the Chi-squared test (Fisher’s exact where cell counts <5). The Mann-Whitney U test was used to analyse normally distributed continuous data, and the independent samples t-test for non-normally distributed data.

Results: Fifty ECMO (88% VV-ECMO; 12% VA-ECMO) and 50 non-ECMO patients were included. Seventy percent of patients were male, and mean age was 41(12) vs 61(16) years for ECMO vs non-ECMO patients, respectively (p<0.001). ECMO patients had a significantly lower ICU admission SOFA score (7[6-9] vs 10[7-12], p<001), and higher ICU LOS (28[14-44] vs 18[10-36], p=0.04). Day 7 energy delivery was significantly higher in ECMO patients (86.5[81-94]% vs 75[68-88]%, p<0.001), with a higher caloric provision from propofol (251[125] vs 114[109]kcal/day, p<0.001). Total protein delivery was significantly higher in ECMO patients (89[80-94]% vs 81.5[66-90.5]%, p=0.02), with no significant difference in total energy delivered. VV-ECMO patients received significantly more energy (94[89.75-98.25]% vs 84[79.75-86]%, p<0.01) and protein (90[82.75-94]% vs 71.5[65-78]%, p=0.001) than VA-ECMO patients. Notably, more ECMO patients suffered EFI (58% vs 36%, p=0.03) and required first-line prokinetics (72% vs 52%, p=0.04) or post-pyloric tube placement (8% vs 2%, p=0.043) with no associations between EFI prevalence and age, gender, ECMO modality or SOFA score. Underfeeding resulting from EFI was significantly higher in ECMO than non-ECMO patients (46% vs 22%, p=0.01), with no significant difference in underfeeding resulting from other reasons. There was no significant difference in LOS, ECMO duration or mortality between patients receiving adequate vs inadequate nutrition.

Conclusions: Achieving adequate nutrition is possible for both ECMO and non-ECMO ICU patients; however, ECMO patients suffer more frequent EFI resulting in underfeeding. More research is warranted on the potential impact of EFI on nutrient absorption/utilisation and clinical/functional outcomes, as well as strategies to overcome EFI in ECMO patients.

References

1. MacGowan L, Smith E, Elliott-Hammond C, et al. Adequacy of nutrition support during extracorporeal membrane oxygenation. Clin Nutr. 2019;38(1): 324-331. doi: 10.1016/j.clnu.2018.01.012.

2. Ridley EJ, Davies AR, Robins EJ, et al; Australian and New Zealand Extracorporeal Membrane Oxygenation Nutrition Therapy. Nutrition therapy in adult patients receiving extracorporeal membrane oxygenation: a prospective, multicentre, observational study. Crit Care Resusc. 2015;17(3):183-9.

3. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. doi: 10.1016/j.clnu.2018.08.037.

5581

Retrospective analysis assessing the barriers in enterally fed patients in a tertiary critical care

Shraddha Goyal¹, Nick Murphy¹, Manan Bajaj¹, Martin Le Breuilly¹, Sukhchain Bansal²

¹ University Hospitals Birmingham

² -

Introduction: Suboptimal enteral nutritional compliance in critically ill patients remains a concern. Studies¹ have recommended that analyzing the barriers is essential to optimize the delivery of enteral nutrition. We conducted an audit to identify and understand the barriers to delivering optimal enteral nutrition at a tertiary Queen Elizabeth Hospital in Birmingham.

Methods: We conducted an audit on 30 patients to understand different barriers that were identified a priori. The patients admitted to the intensive care unit and enterally fed were included. The data was collected until patients met their prescribed nutritional targets.

Results: Patients were from different specialities, including general medical, general surgery, trauma, neurointensive care, cardiac surgery, and liver surgery/transplant patients—the average time to start enteral feed since intubation was 25 hours. The average time to maintain target feeding for more than 24 hours was 4.5 days (range 2-11 days). The total time feed was with-held averaged 26 hours (range 2-117 hours).

Identified barriers to long pauses and delay in achieving the nutritional targets were (graph) displaced nasogastric tubes and time taken to re-establish NG access (time to reinsertion, x-ray and radiographic reporting).

36% of the patients had feed stopped due to gastrointestinal intolerances, vomiting and ileus. The average gastric residual volume (GRV) was 270ml. There was a delay in initiating feed after high GRV. Other reasons identified were incorrect nutrition prescription and advancement in feed, extubation, sedation holds, return to theatre for procedures, bedside procedures like tracheostomy, transoesophageal echocardiogram, bronchoscopy and nasojejunal feed insertion and radiological procedures. Another less common reason was feed pauses for medication administrations.

Conclusions: There are prolonged pauses in enteral nutrition delivery, impeding the achievement of the feed target. A multidisciplinary approach is needed to create local guidelines such as initial prescription and appropriate advancement of enteral feed, increasing the threshold for GRV in accordance with ESPEN² to establish standardization.

References

1. Kozeniecki et al. “ICU and process related barriers to optimizing enteral nutrition in a tertiary medical intensive care unit.” Nutr Clin Pract 31:80-85

2. Singer, et al. 2019. “ESPEN guideline on clinical nutrition in the intensive care unit.” Clinical Nutrition 38: 48-79.

5586

Retrospective analysis of Enteral Nutrition Compliance in a tertiary Intensive Care Unit

Shraddha Goyal, Nick Murphy, Martin Le Breuilly, Manan Bajaj

University Hospitals Birmingham

Introduction: Adequate nutrition is vital management in intensive care unit patients with critical illness and injury.

ESPEN (European society for clinical nutrition and metabolism) guideline¹ on clinical nutrition in the intensive care unit recommends that every patient in the intensive care unit (ICU) for more than 48 hours stay should be considered at risk of malnutrition. Nutritional intervention should be considered at the same level as any other organ support in ICU. Minimizing malnutrition should be the aim for every patient in the ICU.

The audit aimed to review compliance with enteral nutritional targets in ICU at Queen Elizabeth Hospital, Birmingham (QEHB).

Methods: The rolling audit was set up through informatics at QEHB to collect the enteral nutritional targets achieved daily across different ICU specialities, namely liver, trauma and general, neurointensive and cardiac ICUs. The data analyzed is from August 2022 to January 2023. Compliance was calculated from day 1 of the initiation of feed to day 5. The goal of compliance being to achieve 25% of the target feed by day 1, 50% by day 2, 75% by day 3 and 100% by days 4 and 5.

Results: There was a noticeable downward trend in compliance from day 2 to day 5 (graph 1). On days 4 and 5, only 13% achieved the target feed. Compliance differed within specialities, with reduced compliance in liver ICU (graph 2).

Graph 1.

Graph 2.

Conclusion: The compliance of achieving enteral nutrition in critically ill patients in ICU is significantly lower than the suggested targets². We propose increasing awareness and educating nurses and doctors about nutrition in critically ill patients is essential.

References

1. Singer, et al. 2019. “ESPEN guideline on clinical nutrition in the intensive care unit.” Clinical Nutrition 38: 48-79.

2. Zanten et al. 2019. “Nutrition therapy and critical illness: practical guidance for the ICU, post ICU, and long-term convalescence phases” Critical Care 23: 368.

5519

Pooled prevalence of lymphopenia in all-cause hospitalisations and association with infection: a systematic review and meta-analysis

Zeynep Elcioglu¹, Linda Errington², Bogdan Metes², Wezi Sendama³, John Simpson³, Anthony Rostron⁴, Thomas Hellyer³

¹ RVI

² Newcastle University

³ Newcastle University/Newcastle Hospitals

⁴ Newcastle University/South Tyneside and Sunderland NHS Foundation Trust

Introduction: Lymphopenia is defined as a decrease below normal value (often 1.5 x 10⁹ cells/L) of blood circulating lymphocyte count.¹ Lymphopenia is associated with various pathologies including sepsis, trauma, and major surgery.² In the general population, lymphopenia is associated with an increased risk of hospitalisation secondary to infection, independent of traditional clinical risk factors such as age and co-morbidities.² In hospital, lymphopenia has been associated with increased risk of healthcare-associated infection and mortality.³ By summarising prevalence of lymphopenia and its impact on clinical outcomes, we can identify an at-risk population and inform future studies of immune dysfunction following severe illness.

Objective: To conduct a systematic review and meta-analysis to determine the pooled prevalence of lymphopenia in all-cause hospital admissions.

Method: A peer-reviewed search strategy was performed on MEDLINE, Embase and CENTRAL databases. Studies that allowed prevalence data of lymphopenia to be extracted were included. The primary objective was to summarise the pooled prevalence of lymphopenia. Primary outcome was infection including pre-existing lymphopenia as a risk factor for admission with infection and as an in-hospital risk factor for healthcare-associated infection. Secondary outcomes were length of stay and mortality. Mortality data extracted included in-hospital mortality, 28/30-day mortality (defined as ‘early’), and 90-day/1-year mortality (‘late’). The definition of lymphopenia used was according to individual papers analysed. Meta-analysis was carried out using random-effects models for each outcome measure. Heterogeneity was assessed using I² statistic and visual assessment of funnel plots for each outcome was carried out for determination of potential publication bias. The Joanna Briggs Institute checklist for cohort studies was used to assess risk of bias.⁴ The protocol was published on PROSPERO.⁵

Results: Fifteen observational studies were included. Lymphopenia was variably defined, with thresholds of 0.5 to 1.2 x 10⁹/L. Of the 70519 patients studied, a total of 29337 patients demonstrated lymphopenia, giving a pooled prevalence of 38% (CI 0.34-0.42, I² = 97%, p< 0.01). Lymphopenia was associated with an infection diagnosis at hospital admission, but this was not statistically significant (RR 1.03; 95% CI 0.26-3.99, p=0.97, I² = 55%). Lymphopenia during hospital admission was associated with healthcare-associated infection, but this was not statistically significant (RR 1.31; 95% CI 0.78-2.20, p=0.31, I² = 97%). Lymphopenia was associated with higher in-hospital mortality and higher early mortality rates (RR 2.44; 95% CI 1.71-3.47, p < 0.00001, I² = 89% and RR 2.05; 95% CI 1.64-2.56, p < 0.00001, I² = 29%, respectively). Similarly, lymphopenia was associated with higher late mortality (RR 1.59; 1.33-1.90, p < 0.00001, I² = 0%).

Conclusions: This meta-analysis demonstrates the high prevalence of lymphopenia across all-cause hospitalisations and associated increased risk of early and late mortality. There is a paucity of high quality evidence due to the nature of observational studies, where there is a high likelihood of uneven distribution of variables with residual confounding factors. Lymphopenia is a readily available marker that may identify immune dysfunctional patients who may benefit from novel immune modulatory therapies. A greater understanding of immune trajectories following survival may provide insights into longer-term poor clinical outcome.

References

1. Adrie C, Lugosi M, Sonneville R, Souweine B, Ruckly S, Cartier JC, Garrouste-Orgeas M, Schwebel C, Timsit JF; OUTCOMEREA study group. Persistent lymphopenia is a risk factor for ICU-acquired infections and for death in ICU patients with sustained hypotension at admission. Ann Intensive Care. 2017 Dec;7(1):30. doi: 10.1186/s13613-017-0242-0.

2. Warny M, Helby J, Nordestgaard BG, Birgens H, Bojesen SE. Lymphopenia and risk of infection and infection-related death in 98,344 individuals from a prospective Danish population-based study. PLoS Med. 2018 Nov 1;15(11):e1002685. doi: 10.1371/journal.pmed.1002685.

3. Andreu-Ballester JC, Pons-Castillo A, González-Sánchez A, Llombart-Cussac A, Cano MJ, Cuéllar C. Lymphopenia in hospitalized patients and its relationship with severity of illness and mortality. PloS one. 2021 16(8). doi: 10.1371/journal.pone.0256205

4. JBI Critical Appraisal Checklist for Cohort Studies. 2020. Available from: https://jbi.global/critical-appraisal-tools.

5. Elcioglu ZC, Errington L, Beyer F, Simpson AJ, Rostron A, Hellyer TP. Prevalence of lymphopenia in all hospitalisations and its association with infection: a systematic review. PROSPERO 2022 CRD42022327031 Available from:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022327031

5541

An environmental scan of online resources for family caregivers of intensive care survivors

Emily Flowers, Sian Saha, Louise Rose

King’s College London

Introduction: Many ICU survivors experience new or worsening physical, cognitive, or mental health issues, termed “post-intensive care syndrome” (PICS). Almost a quarter of ICU survivors (22%) require assistance with activities for daily living 6 months after discharge. Most (80%) of this assistance/care is provided by family caregivers.¹ Family caregivers also experience sequelae of having a family member admitted to ICU referred to as PICS-family (PICS-F). This affects up to 52% of family members 6 months after their relatives’ ICU discharge or death.^2,3 However, families receive limited informational support on caring for their relatives, or themselves.

Objectives: To conduct an environmental scan to collate a comprehensive repository of online resources (website, webpage, online PDF or similar) for families of ICU survivors. Resources will be provided to informal family caregivers participating in a virtual peer support programme and added to a bespoke critical care recovery website; https://gstt.criticalcarerecovery.com.

Methods: To identify relevant information categories and guide our scan, we held two online consultation meetings with experts and service users. To conduct the scan, we used the Canadian Agency for Drugs and Technologies in Health (CADTH) methods.⁴ We searched social media, professional society websites, and the internet using Google. We also contacted our professional networks to identify additional resources.

Results: Our consultation meetings identified 14 potential information categories. Our search identified 325 online resources. Of these, 24 were subsequently excluded, mostly due to the content being specific to COVID-19 lockdown or furlough. We grouped the remaining 301 online resources into 16 information categories. The information categories and number of online resources (n) were: physical, emotional and cognitive symptoms of PICS-F (n=1); how to interact with primary care (n=2); medical deterioration (how to recognise and what to do) (n=2); driving and accessing the community (n=3); end of life and bereavement (n=5); physical strain and carer support (n=6); what to expect from your relative and the practicalities of being at home (n=7); access to equipment and home adaptations (n=7); social networks (n=7); physiotherapy, exercise, and activities for ICU survivors (n=15); social and welfare benefits, and financial support (including care and return to work) (n=21); stories of lived experience (n=23); symptoms of PICS (n=44); information specific to conditions necessitating an ICU admission (i.e., asthma) (n=49); how to look after yourself/notice signs of anxiety or posttraumatic stress disorder, and where to get mental health support (n=63); and multiple category resources (n=46).

Conclusions: Our environmental scan identified a substantial number of online resources relevant to the informational needs of family caregivers of ICU survivors. The majority focused on aspects of mental health, or recognition of symptoms experienced by the ICU survivor. Fewer focused on practical issues caregivers face, such as how to interact with primary care, recognise medical deterioration, and carer physical strain and support. This highlights a need for further resource development in these areas.

Grants received:

Burdett Trust. Reference number: SB\LG\101010662\736880

References

1. Griffiths J, Hatch RA, Bishop J, Morgan K, Jenkinson C, Cuthbertson BH, et al. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study. Crit Care [Internet]. 2013 [cited 2022 Oct 26];17(3):R100. Available from: http://ccforum.biomedcentral.com/articles/10.1186/cc12745

2. Johnson CC, Suchyta MR, Darowski ES, Collar EM, Kiehl AL, Van J, et al. Psychological sequelae in family caregivers of critically ill intensive care unit patients a systematic review. Vol. 16, Annals of the American Thoracic Society. American Thoracic Society; 2019. p. 894–909.

3. Kentish-Barnes N, Chaize M, Seegers V, Legriel S, Cariou A, Jaber S, et al. Complicated grief after death of a relative in the intensive care unit. Eur Respir J [Internet]. 2015 [cited 2022 Dec 30];45: 1341–52. Available from: http://ow.ly/DCqjB

4. Canada’s Drug and Health Technology Agency (CADTH). Environmental Scan Process. 2015 [cited 2022 Oct 26]; Available from: https://www.cadth.ca/sites/default/files/pdf/ES%20External%20Audience%20Process%20Doc.pdf

5555

A MDT project to improve the patients experience of weaning from mechanical ventilation measured by the time taken for return of speech and swallow

Helen Torry, Laura Coleman, Sally Moncrieff

Royal Oldham Hospital - Northern Care Alliance

Introduction: Respiratory weaning is a significant part of ICU care and is described as the process leading to discontinuation of mechanical breathing support.¹ Problems with the weaning process had been identified including a lack of structure and direction, frequent changes in plans depending on the lead clinician for day and non-compliance with completion of paperwork.

An opportune moment came to look at improving the weaning process due to the covid-19 pandemic, in particular a greater volume of patients requiring a prolonged time of mechanical ventilation. A fortuitous purchase of V60 ventilators enabled us to consider novel ways of weaning.

Objectives: To improve the respiratory weaning experience for patients as measured by a reduced time to achieve speech and swallow.

Methods: A quality improvement project was embarked on to analyse what would make a difference to this area of care. It was launched with a rapid improvement event to enable education and development of a specific vision. The time to achieve speech and swallow were identified as being meaningful, measurable and significant steps in improving the patients experience.

“Weaning” was process mapped with input from speech therapy (SaLT), physiotherapy, dietetics, pharmacy, medics and nursing staff. Each speciality considered essential elements to weaning success, key milestones to reach and collectively identified three phases of weaning. A document was produced with showed horizontal streams of work from the different specialisms which sat within the three columns depicting the three phases.

Launched in November 2021 this weaning guide (fig 1) became the suggested protocol to enable successful and patient focused care, in conjunction with this a new booklet (fig 2) was produced which allowed for plans to be easily set and followed with real-time feedback. It also provided the means for the SaLT team to record the return of speech (date) which was defined as “reliable voice production using ACV or cuff down” and the ability to swallow which was classified as “being able to have meaningful oral intake e.g. normal fluids and /or diet”. Pre intervention data for time to speech and swallow was obtained retrospectively to enable comparison.

Results: The results showed median days to voice of 17.9 in pre-implementation and 10.03 post implementation. At 7 days in the pre-intervention group 21.4% had return to speech and in the post-intervention this had increased to 55.9%. Similarly the median return to swallow was 26.7 days pre-intervention and 24.8 days post. At 14 days 28.6% of the pre-intervention group had the ability to eat and drink compared to the 35.3% in the post-intervention group.

Conclusions: Limitations are from the difficulties of obtaining data retrospectively meaning the sample size was much smaller in the pre-intervention group (n=14) as compared to the post-intervention (n=34).

The project was deemed a great success. As well as the measurable improvements in the speed at which patients were able to meaningfully communicate as well as eat and drink there was also a massive cultural change in weaning delivery. This has resulted in a much more structured and consistent approach, following agreed protocols as recommended in GPICS 2² as well as improved team working.

References

1. Blackwood B, Alderdice F, Burns K, Cardwell C, Lavery G, O’Halloran P. Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis. British Medical Journal. 2011, 342 c 7237.

2. The Faculty of Intensive Care Medicine & The Intensive Care Society. Guidelines for the Provision of Intensive Care Services 2^nd Edition. 2019 Accessed from https://www.ficm.ac.uk/standards-research-revalidation/guidelines-provision-intensive-care-services-v2

5595

A quality improvement project to improve understanding of MHA & MCA among junior doctors working in critical care department

Romassa Siddiq Ali¹, Ruby Viney², Megan Lois Thomas¹, Leo Khoo¹

¹ Royal Liverpool University Hospital

² Warrington General Hospital

Introduction: Dealing with critically ill patients in intensive care department is the primary role of an intensivist. Patients with existent or newly developed psychiatric issues can add extra challenge to junior critical care staff who have little or no experience in dealing with acute psychiatric challenges and the legal issues involved in these scenarios.

Aims and Objectives: This quality improvement project was designed to aim at educating the members of the staff working in critical care area to use a simplistic and efficient way to approach scenarios concerning mental health and mental capacity issues in the admitted patients.

Methods: This quality improvement project was based on a unique learner-centred educational approach to participants learning in the form of lecture series and visual aid posters in the department. Formal feedback was taken through an anonymous survey using Google forms. Baseline data was collected before the interventions and loop was completed after taking feedback from the participants who have completed the formal teaching with lectures and an opportunity to use visual aids (Poster display) in the department.

	Before Intervention (N=28)			After intervention (N=12)
	Agree %	Neutral %	Disagree %	Agree %	Neutral %	Disagree %
Understanding the use of MHA & MCA	46.2	21.4	32.4	75	16.7	8.3
Treatment under each act	32.2	25	42.8	75	16.7	8.3
Application of MHA section2,3,5(2),136	21.4	28.6	50	91.7	8.3	0
Understanding of section 5(2)	53.5	25	21.5	83.4	8.3	8.3
Application of section 5(2)	14.3	17.9	67.8	66.6	16.7	16.7
Application of DoLS	53.6	32.1	14.3	66.7	8.3	25
Access to psyche services in working hours	42.9	21.4	35.7	91.7	8.3	0
Access to psyche services out of hours	32.1	28.6	39.3	58.4	33.3	8.3

Results: Feedback was based on the understanding of the individual participants about the use of MCA and different sections of MHA in acute psychiatric scenarios, trust based mental health and capacity pathways, issues related to consent, DoLS, relevant paperwork and point of contact in different working hours. Participants have shown improvement in comprehension in all domains of common scenarios.

Conclusions: A simple and effective learner-based strategy can help equip junior doctors in intensive care with relevant knowledge to effectively manage critically ill patients with mental capacity and mental health issues.

Reference

1. Department for Constitutional Affairs. The Mental Capacity Act 2005. http://www.opsi.gov.uk/acts/acts2005/20050009.htm

5406

Persistent ventilation following emergency laparotomy – a retrospective data analysis to guide decision making

Joanna Dearden¹, Patrick Thorburn²

¹ East Sussex Healthcare NHS Trust

² University Hospitals Sussex NHS Foundation Trust

Introduction: Patients who have required an emergency laparotomy are often admitted to intensive care, and a significant number of these undergo a period of persistent ventilation post-operatively. The reasons for this are often varied and complex, and the decision of whether to extubate a patient or continue to ventilate them following an emergency laparotomy requires careful consideration by the anaesthetist. There is currently little research in this area to support decision making. Practice therefore varies considerably between individuals, and is dependent on the individual clinician’s judgement at the end of the case.

There are many risks associated with prolonged mechanical ventilation, including (but not limited to): ventilator acquired pneumonia;¹ delirium(2);² diaphragmatic weakness and associated respiratory complications;³ and pressure ulcers.⁴ Therefore, where early extubation is possible it should be considered in order to reduce the risk of exposing patients to these complications and prolonging the duration of their hospital admission.

Objectives:

Primary objective: To summarise the clinical details and patient demographics of patients who were persistently ventilated on ITU following an emergency laparotomy in order to gain a better understanding of the decision making process, and to subsequently create a guideline around extubation prior to transfer to intensive care.

Secondary objective: To establish whether other surgical or anaesthetic factors (for example, time of surgery, use of regional anaesthesia, etc.) play a statistically significant role in the decision to extubate patients following an emergency laparotomy.

Methods: This study was conducted at Worthing Hospital in West Sussex, and consisted of a retrospective analysis of data submitted to the National Emergency Laparotomy Audit (NELA), in combination with data from Philips IntelliSpace Critical Care and Anaesthesia (ICCA) and any scanned physical notes (anaesthetics charts) available on Evolve Live. All data were collected and analysed using Microsoft Excel.

Results: Our results showed that between the 5th of December 2018 and the 11th of November 2021 161 patients were admitted to Intensive Care following an emergency laparotomy. 79 of these patients were persistently ventilated (49%), and the remaining 51% were not. Of the ventilated group, 58% (46 patients) were admitted to intensive care overnight (between 8pm and 8am).

The mean duration of length of stay on ICU was considerably higher in the ventilated group (5.6 days), compared with the non-ventilated group (2.2 days).

Conclusions: The prevalence of persistent ventilation following emergency laparotomy at this centre was relatively high (49%). Recent data from a collaborative study in a similar DGH identified a prevalence of 28%(5), however the reasons for this difference are unclear. The decision making process is consistently poorly documented and further development of this decision tree would be valuable, particularly as persistent ventilation appears to be associated with increased duration of ICU stay in this patient group.

References

1. Spalding MC, Cripps MW, Minshall CT. Ventilator-Associated Pneumonia: New Definitions. Crit Care Clin. 2017 Apr;33(2):277-292.

2. Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med. 2021 Feb;42(1):112-126.

3. Dres M, Goligher EC, Heunks LMA, Brochard LJ. Critical illness-associated diaphragm weakness. Intensive Care Med. 2017 Oct;43(10):1441-1452.

4. Cox J. Pressure Injury Risk Factors in Adult Critical Care Patients: A Review of the Literature. Ostomy Wound Manage. 2017 Nov;63(11):30-43.

5. Boyer N et. al. Incidence of persistent ventilation following emergency laparotomy – admissions to an intensive care over 2 years. [Poster]. 2022. ISICEM.

5572

Emergency drugs on trial: improving efficiency and accuracy in emergency drug retrieval in the intensive care unit

Charlotte Spiers, Sharon Maughan

Craigavon Area Hospital Intensive Care Unit

Introduction: Emergency drug accessibility is essential to managing any intensive care unit (ICU). Responding rapidly to emergencies irrespective of staff experience is crucial to delivering good patient care. This includes the acquisition of correct emergency drugs. Human errors form a considerable proportion of preventable mistakes in healthcare and implementing strategies to minimise these within the ICU is vital to improving patient management.¹

Objectives: The aim of this quality improvement project was to expedite and standardise the drug retrieval process, to limit variation in the time taken between different staff and minimise drug errors. Using a systems-based approach, we hoped to implement change that would have long-term benefits.²

Methods: Four doctors and four nurses were randomly tasked with retrieving a list of medications and bringing them to a bedspace. The drugs included: ampoules of 2x5ml rocuronium (10mg/ml) and 1x20ml 1% propofol, and pre-filled syringes of 1x10ml ephedrine (3mg/ml), 2x5ml metaraminol (0.5mg/ml) and 1x5ml atropine (0.1mg/ml).

To achieve this, the nurse in charge had to be located and keys obtained. Multiple keys were needed to access the necessary cupboards and fridge. The time taken was recorded, with an arbitrary cut off time of 10 minutes whereby the time trial ended.

Retrieval of the following controlled drugs by two senior nurses was timed separately: 1x20ml ketamine (10mg/ml), 1x2ml fentanyl (50mcg/ml) and 1x5ml midazolam (1mg/ml). The average of these times was added onto the time taken to retrieve the other drugs listed.

Two emergency drug boxes were introduced in the form of plastic food containers. They were clearly labelled to indicate the drugs within and that controlled drugs must be acquired separately. They also contained syringes, needles, and appropriate labels for drawing up drugs. The boxes were stored on the intubation trolley in the centre of the ICU. Nursing staff documented daily checks of the box contents, and an audit trail was kept of rocuronium use and replacement.

The time trials were repeated using the emergency drug box (three doctors and five nurses in this cohort).

Results: Prior to implementation of the emergency drug box, drug retrieval took 4:46 minutes on average, with a range of 2:23 to 10:00 minutes. Nurses took an average of 3:12 whilst doctors took 6:20. Multiple errors ensued. These included: retrieval of incorrect drugs due to storage error, retrieval of 2% propofol, incorrect concentration of atropine pre-filled syringes and retrieval of ampoules rather the pre-filled syringes.

With the emergency drug box, retrieval was significantly faster. The average time was 1:04, with a range from 56 seconds to 1 minute 16 seconds. Nurses took an average of 1:01 compared to 1:07 for doctors. All participants reported a 100% improvement in confidence in retrieving the correct drugs in an emergency when surveyed.

Conclusions: Standardising the approach to emergency drug retrieval improved efficiency, accuracy, and staff confidence in a district general ICU. Taking a systems approach was effective in reducing potential drug errors. It should however be noted that error at the point of drug administration cannot be completely negated.

References

1. Sameera V, Bindra A, Rath GP. Human errors and their prevention in healthcare. J Anaesthesiol Clin Pharmacol. 2021 Jul-Sep;37(3):328-335. doi: 10.4103/joacp.JOACP_364_19. Epub 2021 Oct 12. PMID: 34759539; PMCID: PMC8562433. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8562433/.

2. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. doi:10.1136/bmj.320.7237.768. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/.

5490

Does Pre-transplant Frailty, Lung Function and Grip Strength Predict Dysphagia in Patients Post Lung Transplant?

Elizabeth Walkden, Elizabeth Walkden

Manchester NHS Foundation Trust

Background & Aims: The aim of this study is to explore associations between routinely collected pre-lung transplant functional scores and the development of dysphagia.

Dysphagia is common in post-surgical cardiothoracic with some studies reporting a prevalence of 94% (Plowman et al., 2021). In addition to surgical risks, this population have ICU associated risks for developing dysphagia for example; prolonged intubation (Brodsky et al., 2018), tracheostomy for ventilation (Schefold et al., 2017) and acute respiratory issues (Langmore et al., 2020). It is well documented that those post lung transplantation are at risk of silent aspiration following surgery (Baumann et al., 2017). Aspiration is a risk for this caseload and dysphagia is an under-recognised concern, in particular for the post-lung transplant population as prevalence has been reported by some studies, as high as 70% (Atkins et al., 2010; Atkins et al., 2007). Repeated aspiration has been shown to increase risk of bronchiolitis obliterans syndrome (BOS) and therefore increased risk of organ rejection or mortality (Estenne et al., 2002). Dysphagia is a well-documented risk factor for increased length of stay, morbidity and mortality in inpatient and outpatient populations. Therefore, any research to identify patients likely to develop dysphagia and subsequent aspiration, may lead to earlier identification. This may help reduce associated, potentially avoidable, complications and improve functional outcomes.

Despite acknowledging that pre-surgical abilities and medical status may have an impact on development of dysphagia, no evidence has been found that assesses pre-surgical functional or frailty scores with dysphagia development post-surgery.

Design: An observational cohort study using retrospective data collection via patient notes at Wythenshawe Hospital Cardiothoracic Critical Care Unit. The cohort included consecutive patients who underwent lung transplantation between 2017-21. Data collection included participant characteristics such as age, date of transplant, underlying diagnosis and sex. Pre-transplant functional scores were also collected including Hand Grip Strength (HGS), Short physical performance battery (SPPB) and Lung function scores Including Forced Expiratory Volume, (FEV) and Forced Vital Capacity, (FVC). These are all routinely collected by the multi-disciplinary team in pre-transplant clinics

Results: Outcomes aimed to assess the hypothesis that pre-transplant functional scores may be associated with the development of post-transplant dysphagia. However, the results suggest that this hypothesis is incorrect as HGS, SPPB and lung function scores did not have a significant association with dysphagia development post-transplant

Conclusion: Literature has previously linked poor functional scores in HGS (Hathaway et al., 2015) and SPPB (Ogawa et al., 2022) to dysphagia post-operatively but there is no current evidence about the impact of pre-operative function. This current study suggests that the potentially more influential aspects on development of dysphagia are those interventions that occur both intra- and post-operatively, e.g., intubation or tracheostomy presence, as these were found to have a significant association with dysphagia development post-transplant.

References

Atkins, B. Z., et al. (2010). ‘Impact of oropharyngeal dysphagia on long-term outcomes of lung transplantation’, Annals of Thoracic Surgery, 90(5), pp. 1622-8. doi: https://dx.doi.org/10.1016/j.athoracsur.2010.06.089.

Atkins, B. Z., et al. (2007). ‘Assessing oropharyngeal dysphagia after lung transplantation: altered swallowing mechanisms and increased morbidity’, Journal of Heart & Lung Transplantation, 26(11), pp. 1144-8.

Baumann, B., et al. (2017). ‘Postoperative Swallowing Assessment After Lung Transplantation’, Annals of Thoracic Surgery, 104(1), pp. 308-312. doi: https://dx.doi.org/10.1016/j.athoracsur.2017.01.080.

Brodsky, M. B., et al. (2018). ‘Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review’, Critical care medicine, 46(12), pp. 2010-2017. doi: 10.1097/CCM.0000000000003368.

Estenne, M., et al. (2002). ‘Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria’, J Heart Lung Transplant, 21(3), pp. 297-310. doi: 10.1016/s1053-2498(02)00398-4.

Hathaway, B., et al. (2015). ‘Handgrip strength and dysphagia assessment following cardiac surgery’, Laryngoscope, 125(10), pp. 2330-2. doi: https://dx.doi.org/10.1002/lary.25175.

Langmore, S. E., et al. (2020). ‘Abnormalities of Aspiration and Swallowing Function in Survivors of Acute Respiratory Failure’, Dysphagia, 36(5), pp. 831-841. doi: 10.1007/s00455-020-10199-8.

Ogawa, M., et al. (2022). ‘Impact of frailty on postoperative dysphagia in patients undergoing elective cardiovascular surgery’, JACC: Asia, 2(1), pp. 104-113.

Plowman, E. K., et al. (2021). ‘Dysphagia after cardiac surgery: Prevalence, risk factors, and associated outcomes’, The Journal of thoracic and cardiovascular surgery. doi: 10.1016/j.jtcvs.2021.02.087.

Schefold, J. C., et al. (2017). ‘Dysphagia in Mechanically Ventilated ICU Patients (DYnAMICS): A Prospective Observational Trial’, Critical care medicine, 45(12), pp. 2061-2069. doi: 10.1097/CCM.0000000000002765.

5342

Understanding the use of the National Early Warning Score 2 (NEWS2) in acute care settings: A realist review

Michelle Treacy¹, Geoff Wong¹, Mandy Odell², Nia Roberts¹

¹ University of Oxford

² Royal Berkshire NHS Trust

Introduction: Failure to recognise and respond to the deteriorating adult in a timely manner has been identified as an international patient safety concern.^1,2 Research has shown deficiencies in assessing, recording and acting on abnormal vital signs to prevent critical events, namely unplanned intensive care admissions or death.³ Despite efforts to address this concern, such as the introduction of Early Warning Scores, there is evidence that adverse events are still occurring as a result of failure to recognise and respond to acute deterioration in an effective and timely manner.⁴ The National Early Warning Score 2 (NEWS2), chosen for the focus, as it is most widely used in English acute settings, is a simple tool, however, because it relies on various resources and knowledge to ensure appropriate use, it is complex in nature when implemented in the ‘real world’ setting of the NHS.

Objectives: 1) To complete a realist review on how, for whom and in what contexts the NEWS2 helps (or not) detect patients at risk of deterioration in the acute setting. 2) To develop a programme theory that explains the role of the NEWS2 in the identification and management of deteriorating patients in the acute setting, how, for whom and in which contexts. 3) To make recommendations on how best to support the implementation of the NEWS2 in acute settings.

Methods: One way to make sense of complex interventions, such as the NEWS2, is to use theory-driven approaches.⁵ One such approach designed to make sense of complex interventions is realist reviews. The aim is to use literature to understand what helps or/and hinders the appropriate use of the NEWS2 in the acute setting. The review question is how, when, for whom, why and to what extent is the NEWS2 used in the acute setting to detect and respond to patient deterioration? A group of stakeholders were also included in the design and direction of the review.

Results: There are seven steps required for use of the tool; 1) Clinician is trained to use it. 2) Clinician knows when to use it. 3) Clinician has time to use it. 4) Clinician takes accurate and necessary vital signs needed for the tool. 5) Clinician knows what to do with vital sign results with reference to the tool, to generate the correct score. 6) Clinician increases monitoring and/or escalates as per the tool. 7) The relevant clinician(s) responds in a timely and appropriate manner. The process can break down for a variety of reasons, and at any point. The emergent findings show that the success of the tool is reliant on clinical judgment, clinician concern, culture, environment, and communication. The findings are presented as context-mechanism-outcome configurations (CMOCs), alongside a programme theory explaining the mechanisms that result in outcomes (both desired and undesired).

Conclusions: The review has identified how the NEWS2 may work well in one context, but not another, therefore, details for alterations required in practice and policy are provided.

References

1. National Confidential Enquiry into Patient Outcome and Death. Inspiring change a review of the quality of care provided to patients receiving acute non-invasive ventilation, 2017. Available: https://www.ncepod.org.uk/reports.html [Accessed 14 Jan 2023].

2. National Institute for Health and Care Excellence. Surveillance report, acutely ill adults in hospital: recognising and responding to deterioration, 2016. Available: https://www.nice.org.uk/guidance/cg50/resources/surveillance-report-2016-acutely-ill-adults-inhospital-recognising-and-responding-to-deterioration-2007-niceguideline-cg50-2419022845/chapter/Surveillance-decision?tab=evidence [Accessed 10 Jan 2023].

3. DeVita MA, Smith GB, Adam SK, et al. “Identifying the hospitalised patient in crisis”–a consensus conference on the afferent limb of rapid response systems. Resuscitation 2010;81:375–82.

4. Donaldson LJ, Panesar SS, Darzi A. Patient-safety-related Hospital deaths in England: thematic analysis of incidents reported to a national database, 2010-2012. PLoS Med 2014;11:e1001667.

5. Pawson R, Greenhalgh T, Harvey G, et al. Realist review–a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy 2005;10 Suppl 1:21–34.

5460

Widening Outreach Response in the Emergency Department (WORRIED): Referring to Critical Care Outreach from Within the Emergency Department

Susan Paketci, Debbie van der Velden, Rainer Bohlin, Thomas Smith

Imperial College Healthcare Trust

Introduction: In 2000, the Department of Health in England published a review, Comprehensive Critical Care, which demonstrated that the level of care received by acutely unwell patients on wards was suboptimal.¹ Since then, most UK Hospitals have implemented a Critical Care Outreach and Resuscitation Team (CCOART) to support critically unwell patients located outside the ICU. In 2018, the National Institute for Health and Care Excellence (NICE) reviewed three RCTs and one systematic review and concluded that CCOARTs have a sizable benefit on patient care; none of these studies included patients located in the Emergency Department (ED).² A collaborative guideline between the Faculty of Intensive care Medicine and the Royal College of Emergency Medicine from 2021 states that outreach services may also be involved in the resuscitation area.³

Objectives: Our aim is to determine the effects of CCOART on patient care in A&E by conducting a two-week trial in a London teaching hospital.

Methods: During the first two weeks of August 2022, CCOART at St Mary’s Hospital accepted referrals from A&E for the first time. Posters with referral criteria were circulated throughout ED. During this two-week period, data was collected on the time between patient arrival in A&E and ICU review, time waiting for a hospital bed following ICU review, and total length of ED stay for all patients who were referred (n=11). The same data was collected for all patients accepted by ICU from A&E in March and April prior to the trial (n = 43). The interventions recommended by CCOART were reviewed and CCOART members were asked to complete a feedback survey after the trial was completed.

Results: During the trial, there was a 44% and 18% reduction in time that level 2 and level 3 patients spent in ED prior to ICU, respectively. The overall waiting time for an ICU bed after referral was reduced by 42%. Of the patients during the trial who did not require ICU admission, 67% were felt to require further follow up on the wards. Of these patients, the mean days of follow up on consecutive days was 2.6 days with one patient requiring regular input for 10 days. Additionally, the trial highlighted that CCOART patient load in A&E is highest between 14:30 to 21:30. Survey respondents agreed that they would like the trial to become permanent, but some concerns were expressed over the potential impact on ward patients.

Conclusions: The trial has demonstrated reduced waiting times for ICU patients in ED. Moreover, it appears to be an effective method of identifying unwell patients who will go on to require CCOART support on the wards. As the trial was short, not enough data was collected to determine any statistical significance. There is scope for a longer and more exhaustive trial which also monitors the effect of the trial on the care of CCOART’s other patients. Our data and analysis of referral load at different hours of the day can be used to plan safe staffing in further implementations of CCOART in A&E.

References

1. Department of Health. Comprehensive Critical Care: a review of adult critical care services, 2000.

2. National Institute for Health and Care Excellence (2018). Chapter 27 Critical care outreach teams [Nice Guideline No. 94]

3. Royal College of Emergency Medicine and Faculty of Intensive Care Medicine: Better together: Collaborative working between emergency and critical care, 2021.

5301

Individualising death in the Intensive Care Unit -Introducing the 3 Wishes Project to the United Kingdom at East Kent Hospitals University Foundation Trust

Priyanka Uppal¹, Ruth Tighe²

¹ Guys and St Thomas’ NHS Foundation

² East Kent Hospitals University Foundation Trust

Introduction: The 3 Wishes Project [3WP] is a simple, proactive pathway to enhance end-of-life experiences for intensive care patients. The project focuses on individualising the dying process in the intensive care unit, an environment which can be impersonal, extremely clinical, and therefore frightening. The project aims to identify and fulfil ‘wishes’ which are reflective of the patient’s beliefs, passions, and interests. By doing so, it ensures patients’ dignity at the end of life and provides an opportunity for families to create everlasting memories. Additionally, it allows for healthcare professionals working in intensive care to provide individualised care at the end of life, with an opportunity to better connect with a patient and their family.¹

Initially set up by Canadian intensivist Dr Deborah Cook in Ontario in 2013, the project has since been adopted and adapted across intensive care units within Canada and the United States.² East Kent Hospitals University Foundation Trust [EKHUFT] is the first trust within the United Kingdom to introduce the 3WP across intensive care.

Objectives: We introduced the 3WP with the aim to improve the end-of life experience for patients, their families and healthcare professionals in the intensive care units across EKHUFT, particularly in the aftermath of COVID-19. The aim was also to provide a framework recognising the excellent end of life care that was already being delivered in our intensive care units and provide a structure for this.

Methods: We established a 3WP team, consisting of a consultant physician, a clinical fellow and two senior ward managers. Our team then hosted a meeting with the founder intensivists in Ontario Canada and UCLA, to learn more about the logistics of project set up and lessons learnt. In July 2021, we led a stake-holder meeting within the trust with an overwhelmingly positive response to the project. After fundraising, project planning and staff training, we launched the project in November 2021. A year later, in November 2022, we collected feedback about the 3WP from relatives and the healthcare professionals in intensive care. Furthermore, we assessed the costs associated with fulfilling the wishes of each patient who partook in the project.

Results: We have provided this personalised end of life experience to over 40 patients and their families, with an average cost of approximately £80 per patient. The wishes we have provided have included creating keepsakes for families such as hand moulds and fingerprint key rings, arranging for palliative extubation in our sensory garden, as well organising as a wedding. The one-year analysis of the project based on feedback collected from relatives and intensive care staff was overwhelmingly positive. Of interest, as a department we have received significantly less complaints since project initiation.

Conclusions: The 3 Wishes Project is an affordable pathway which improves the end-of-life experience for patients and their relatives. For healthcare professionals delivering care in intensive care, the project enhances well-being and vocational fulfilment. We therefore recommend this project should be adopted by intensive care units across the country to benefit both intensive care service users and service providers.

References

1. Deborah Cook, McMaster University and St.Joesph’s Healthcare, Hamilton. The 3 Wishes Project Start-up Guide.2017.

2. Meredith Vanstone, PhD, Thanh H. Neville, MD, MSHS, D Cooke et al. Compassionate End-of-Life Care: Mixed-Methods Multisite Evaluation of the 3 Wishes Project. Annals of Internal Medicine. 7.1.20 https://doi.org/10.7326/M19-2438

5562

End of life care on the intensive care unit – a nursing perspective

Sunil Shah¹, Mark Saville²

¹ The Hillingdon Hospitals NHS Foundation Trust

² Mid And South Essex NHS Foundation Trust

Introduction: In England, critical care units witness an average of two deaths every week per unit, resulting in an annual death toll of around 22,000 patients.¹ Despite this, the guidelines governing the withdrawal of treatment for adult critical care patients at Southend University Hospital Intensive Care Unit (ICU) had not been updated since 2005, prompting this study.

Objectives: The aims of this study are to gain a comprehensive understanding of the nursing perspective when it comes to managing a patient’s final days and hours of life in the ICU. Additionally, to introduce updated guidance that will facilitate better care for patients in this delicate phase.

Methods: In September 2020, a snapshot survey questionnaire was conducted among ICU nursing staff to assess their experiences with the withdrawal of care for critical care patients. The survey asked about the clarity of treatment withdrawal plans made by senior intensive care doctors, familiarity with existing guidelines, and suggestions for improving the process. Based on the findings from the initial survey, an aid memoire and a symptom management poster were introduced to assist the ICU nursing team. In April 2022, a repeat survey was conducted to evaluate the impact of these interventions on nursing experiences with withdrawal of treatment.

Results: In the initial survey, 40 members of nursing staff responded, where the majority (26, 65%) were staff nurses, followed by charge nurses (11, 27.5%) and other members of the nursing team (3, 7.5%). A clear plan by a senior intensive care doctor was reported by 77.5% of nurses, whilst 35% felt that withdrawal of treatment was delayed. However, 92.5% of nurses reported that patients received appropriate symptom control. Only 20 nurses (50%) were aware of a withdrawal of treatment guideline.

When asked about what should be included or updated in any new guidance, a general theme emerged. This included a protocol/flowchart of how to withdraw treatment, including specifics of how to adjust or cease organ support, as well as advice on symptom management.

Following the introduction of an aide memoire flowchart and symptom management poster to the ICU, a repeat survey was conducted. From the 38 responses received, 71.1% of nurses were now aware of a withdrawal of treatment guide.

Conclusions: The introduction of a flowchart for withdrawal of treatment on the ICU has had a positive impact on the wider awareness of such guidelines and increased confidence among nursing staff. The use of a flowchart has helped to streamline the process of withdrawing treatment and has ensured that all necessary steps are taken, while also providing a clear visual aid for staff. This has resulted in improved communication and greater adherence to best practices, ultimately contributing to greater patient-centred management for end of life care / withdrawal of treatment.

Reference

1. Cosgrove J et al. Care at the end of life: A guide to best practice, discussion and decision-making in and around critical care (Executive Summary) [Internet]. September 2019 [cited 20 February 2023]. Available from: https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/ficm_care_end_of_life_summary.pdf

5625

Experiences and views of MDT health care professionals regarding EOLC and withdrawal of ECMO for Severe Respiratory Failure across the UK Network

Rebecca Lewis

Guy’s and St Thomas’

Introduction: Extra Corporal Membrane Oxygenation (ECMO) is a rescue therapy for respiratory failure which allows many critically ill patients to survive a life-threatening illness. However, the mortality within this population remains high and caring for a dying patient on ECMO with irreversible lung injury can be morally distressing and the discontinuation of ECMO when deemed futile challenging. With the rapid development of this new technology it has led to health care professionals becoming increasingly confronted with unique and complex ethical situations for which traditional ethics are not easily applied and limited evidence or guidance for the best approach available.

Objectives: This study aims to elicit experiences and views of the multidisciplinary team (MDT) healthcare professionals delivering EOLC and withdrawal of care to patients with severe respiratory failure requiring VV-ECMO support across the UK ECMO network to further identify the issues and challenges experienced.

Method: Twelve participants were recruited who were healthcare professionals from the multi- disciplinary teams across the UK ECMO network with previous experiences of delivering EOLC and withdrawal of care to VV ECMO patients. Semi structured interviews were conducted via Microsoft teams video conferencing platform and the resulting data from the interview transcripts was analysed using thematic analysis.

Results: Multiple themes were identified, but the strongest and overarching theme was the challenges and difficulties of delivering EOLC and withdrawal in the “awake” ECMO patient. There were further themes and sub-themes raising issues covering areas such; difficulties in decision making due to uncertainty and benefits of consistent MDT shared decisions; difficulties in gaining acceptant of withdrawal from families due to breakdown in trust from misunderstanding and lack of continuity; Importance of communication to ensure information giving and early expectation setting; variable Palliative care involvement which was often felt to be late and underutilised; significant psychological impact on staff due to traumatic experiences with a high emotional burden often due to a relatable patient population.

Conclusions: This is the first qualitative study which explores the experiences and views of EOLC and withdrawal of care for severe respiratory failure patients across the VV ECMO network within the UK faced by MDT healthcare professionals. Delivering EOLC and withdrawal of care to the “awake” ECMO patient was identified to be overwhelmingly the most difficult and challenging aspect of participant’s previous experiences. With the identification of these issues further work can begin on developing practical and applicable solutions to help standardise the approach to these challenges.

5629

Inappropriate continuation and discontination of medications on intensive care discharge

Hannah Downing, Nandan Gautam

University Hospital Birmingham

Introduction: Medication errors are particularly common in the intensive care unit (ICU),¹ prescribing and medication reconciliation are especially challenging in this environment due to complex medication regimes, patient acuity and frequent changes in clinical condition. Inappropriate continuation or discontinuation of medication on discharge from the ICU can have serious consequences for the patient, leading to adverse drug events and potentially prolonged hospitalisation. Transitions of care are points where patients are particularly vulnerable to prescription error,² we aim to evaluate the prevalence and impact of inappropriate medication continuation or discontinuation on discharge from the ICU, and to identify strategies for improving medication reconciliation processes to prevent adverse events and improve patient outcomes.

Objectives: The objective of this study was to determine the number of patients affected by inappropriate discontinuation of medications to manage chronic conditions during ICU admission as well as identify the frequency of inadvertent continuation of medications acutely started on ICU for symptom management which are no longer indicated.

Methods: We conducted a retrospective quantitative analysis of all patients admitted to Queen Elizabeth Hospital Birmingham ICU during April 2022. Patients with an ICU stay exceeding 48 hours and surviving until at least 1 week post hospital discharge were included. Patients discharged to another hospital or admitted to cardiac ICU were excluded.

Preadmission medications were reviewed to identify patients who were prescribed specific groups of medications regularly (statins, antiplatelets/anticoagulants, levothyroxine, inhalers, psychotropic, and acid suppressing drugs) and assess if appropriately continued.

Acutely started medications were reviewed to identify any inappropriate continuation of specific classes of medications (anti-psychotics, antiarrhythmics, benzodiazepines, anti-epileptics and acid suppressing drugs). The appropriateness of prescribing was gauged through documentation on the prescription or notes.

Results: A search of electronic records yielded 143 patients admitted to ICU during the period with 73 patients eligible for review after the exclusion criteria were applied. It was found that 28.7% (21/73) patients had at least 1 class of chronic medication discontinued on ICU discharge the most common being statins and anti-platelets/coagulants. Inappropriate continuation of 1 or more classes of acute medications occurred in 46.6% (34/73) of patients. This included 11 prescriptions on ICU discharge of anti-psychotics or anti-epileptics initiated temporarily for delirium management, with 4 patients eventually being discharged from hospital on these. As well as 9 prescriptions of antiarrhythmics for sinus tachycardia of which 3 continued to community discharge. There was zero correlation demonstrated between number of potentially inappropriate medications and duration of ICU stay. However rate of error varied between admission specialty with patients admitted under neurosciences most affected with an average of 1.4 inappropriate prescriptions per patient.

Conclusions: Patients discharged from ICU are at significant risk of inadvertent continuation of acute medications and discontinuation of chronic medications. This can impact on patient chronic ondition management, contribute to unnecessary polypharmacy, increasing risk of adverse drug reactions as well as cause a financial burden to patient and the NHS. Careful medication reconciliation using a multi-disciplinary approach could avoid these potential adverse outcomes during the particularly vulnerable transition at ICU discharge.

References

1. Rothschild J, Landrigan C, Cronin J, Kaushal R, Lockley S, Burdick E, Stone P, Lilly C, Katz J, Czeisler C, Bates DW. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005; 33: 1694–1700.

2. Wang Y, Zhang X, Hu X, Sun X, Wang Y, Huang K, Sun S, Lv X, Xie X. Evaluation of medication risk at the transition of care: a cross-sectional study of patients from the ICU to the non-ICU setting. BMJ Open 2022;12:e049695. doi:10.1136/bmjopen-2021-049695.

5063

Nicorandil and ranolazine overdose management: a case report

Guilherme Movio¹, Aziza Rashid², Gemma Lee²

¹ Lancaster Medical School

² Blackpool Victoria Hospital

Case Presentation: A man in his 60s was admitted to the emergency department with chest pain following an intentional overdose of nicorandil and ranolazine. He was known to have an extensive cardiac history and had taken his prescribed medication with suicidal ideation. On presentation, he was hypotensive with a blood pressure of 70/50 mm Hg despite fluid resuscitation. He was commenced on vasopressor support and transferred to the intensive care unit. Despite an adequate blood pressure on vasopressors, he suffered a ventricular fibrillation cardiac arrest. Return of spontaneous circulation with a Glasgow Coma Score of 15 was achieved following cardiopulmonary resuscitation and three direct current shocks. Following subsequent continuous overnight significant vasopressor dependence, a dose of glucagon was given, and within 2 hours, his vasopressor requirement ceased, maintaining an unsupported normal blood pressure. He remained stable and was subsequently discharged to the coronary care unit for monitoring.

Background: There have been multiple case reports on the typical presentations of nicorandil and ranolazine overdose. The mainstay management in most cases involves fluid resuscitation and vasopressor support.^1,2 We report a case of including glucagon in the management of nicorandil and ranolazine overdose.

Nicorandil acts by multiple mechanisms, including causing a potassium efflux, resulting in membrane hyperpolarisation and nitric oxide release to cause vasodilation. In toxicity, this results in severe hypotension.³ Although the mechanism of action of ranolazine is not fully understood, the thought is that ranolazine toxicity is likely secondary to inhibition of potassium and sodium channels leading to high intracellular sodium and calcium, which interferes with oxygen supply to the cardiomyocytes, leading to ischaemia and global myocyte dysfunction, which ultimately cause hypo- tension.⁴ At present, the mainstay of treatment is supportive rather than reversal of the mechanism of action of either medication.^1,2

Discussion and Conclusion: In conclusion, as per ToxBase (the clinical toxicology database of the UK National Poisons Information Service) recommendation, we managed our patient with aggressive fluid resuscitation and early vasopressor support as recommended.^1,2 However, our case report also introduces the addition of using glucagon in ranolazine and nicorandil overdose. Although no definite benefit can be proven with this case report, perhaps earlier use in managing similar patients may be beneficial as an addition to the standards in managing shock in nicorandil and ranolazine overdose patients.

References

1. TOXBASE®. Nicorandil. [Online] UK NPIS, 2019. Available: https://www.toxbase.org//templates/Public/Pages/Toxbase/ProductPage.aspx?id=77286&epslanguage=en&print=y [Accessed 1 Jun 2021].

2. TOXBASE®. Ranolazine. [Online] UK NPIS, February 2019. Available: https://www.toxbase.org/poisonsindex-a-z/r-products/ranolazine/ [Accessed 1 Jun 2021].

3. Kukovetz WR, Holzmann S, Pöch G. Molecular mechanism of action of nicorandil. J Cardiovasc Pharmacol 1992;20 Suppl 3:S1–7.

4. Hasenfuss G, Maier LS. Mechanism of action of the new anti-ischemia drug ranolazine. Clin Res Cardiol 2008;97:222–6.

5608

Critical interventions in witnessed cardiac arrest in a sympathomimetic / metabolic uncoupling toxidrome: lessons learnt

Shah Mizanur Rahman, Martha Dimech, Ben Panamarenko, Daven Amin, Sarah Wilson

Wexham Park Hospital

Introduction: This ePoster case report highlights a cardiac arrest occurring in ED with an, as yet, unclear causative agent, but pronounced features of ‘metabolic uncoupling’ such as severe hyperthermia, refractory tetany and metabolic acidaemia; discussing the physiology of metabolic uncoupling, sub-teams needed to deliver interventions, and the rationale for these.

Clinical Narrative: A young man presented with anxiety, tachypnoea and tachycardia with initial investigations (FBC, VBG, and CT PA) being negative for any significant abnormality, and an ECG showing sinus tachycardia. TFTs and other specialised blood tests were in progress when he had a witnessed seizure episode which rapidly deteriorated into cardiac arrest.

Immediate CPR was performed while initial BVM ventilation and chest compressions were attempted, noting marked chest wall rigidity and difficulty compressing the sternum. The jaw, whilst initially loose and allowing placement of a direct laryngoscope, rapidly became difficult to open due to muscle tone which was refractory to muscle relaxant use. Video laryngoscopy became impossible due to emerging trismus and a surgical airway placed successfully in the context of a ‘can’t intubate, can’t oxygenate’ situation.

During the arrest, the patient remained extremely hot to touch, and a working presumption of sympathomimetic or metabolic uncoupling toxin was followed, with interventions including automated CPR, dantrolene, sodium bicarbonate, calcium chloride, magnesium, intralipid and adrenaline mini-jet boluses alongside intra-arrest arterial line and intraosseous access placement. Whilst extra-corporeal life support was not immediately available, a discussion was held with the nearest ECMO service to explore this potential. Dantrolene, noted for it’s marked drain on staff needed for reconstitution, was being drawn up and delivered in a medication loop, recycling 50mL luer-lock syringes given the risk of running out of stock.

Conclusion: Whilst this was an unsuccessful resuscitation attempt, it highlights the challenges around the management of cardiac arrest secondary to toxins; with this toxidrome being an uncommon and complex syndrome to treat, and the myriad of challenges involved in instigating the necessary treatments for organ support.

5611

Toxic Ethylene Glycol ingestion – treat with fomepizole, filter or famous grouse?

Shah Mizanur Rahman, Helen Blamey

Wexham Park Hospital

Introduction: This case report highlights an intentional ethylene glycol overdose with readily available anti-freeze and signs of severe toxicity; the lessons learnt in the management of the initial presentation in the ED and definitive management of pathophysiology in the ICU.

Clinical Narrative: A 28-year-old patient with previous mental health and intentional overdose history attended ED via the ambulance service, having been found by a support worker with an empty glass of pink liquid and a bottle of anti-freeze nearby with presumed intentional ingestion of ethylene glycol.

On hospital arrival, the patient appeared unwell, with tachypnoea, sinus bradycardia and hypotension. Initial GCS was E1 V2 M4 (7), with a blood gas demonstrating a high osmolar gap from the absorption of the toxic alcohol, a pH of 7.25 and a lactate of 9.

ITU doctors were called due to low GCS and intermittent agitation with sedation needed to facilitate venous access. Subsequent management included intubation and ventilation, arterial line, CVC, urinary catheter and NG tube insertion. Vasoactive support commenced (noradrenaline) and an initial ethylene glycol level of 4583mg/l (with a lag of 2 days in reporting).

Over time, the osmolar gap reduced, but a high anion gap metabolic acidosis developed, with high lactate, as the alcohol was metabolised. The metabolites; glycolic, glyoxylic and oxalic acid, are harmful through inhibiting cellular oxidative phosphorylation and forming renal crystal deposits causing renal failure.

Of note, there are several ‘measured’ and other ‘calculated’ or derived values on a VBG. For example, the presence of glycolate from ethylene glycol metabolism can interfere with assays used to measure lactate, resulting in spurious additions to actual serum lactate. Osmolality is calculated, hence subtracting the calculated from the measured value results in the Osmolar gap, which can be used alongside the anion gap, to guide treatment.

Initial management was with loading and subsequent maintenance doses of fomepizole (4-methylpyrazole inhibitor), a competitive ADH inhibitor, halting conversion of ethylene glycol to its harmful metabolites. Renal replacement therapy would have been indicated if the patient remained in severe metabolic acidosis or developed renal failure. A loading dose of 975mg was used with three subsequent maintenance doses of 860mg, and two doses of 570mg. Treatment continued until clinically well with a normal blood gas and renal function, ethylene glycol levels <50, osmolality <10mOsm/kg and anion gap <16mmol/L.

The patient developed an aspiration pneumonia, likely from airway compromise/low GCS, and was treated with high-flow nasal oxygen and antibiotics. They were discharged to a medical ward, where due to continued suicidal ideation, had a formal Mental Health Act Assessment, sectioned (Section 2), and admitted to an inpatient psychiatric facility.

Conclusion: Whilst ‘alcohol’ ingestion is a common ED complaint, the management of toxic alcohol ingestion poses several challenges in biochemical assessment, physiology management and in understanding how some of our point of care devices calculate and derive values on VBG and other investigations. Trainees should be aware of the pathophysiology of this poison, the pitfalls of biochemistry investigations and be aware of treatment options.

4998

Rapid and Reproducible Audit Systems

Rowena Johnson¹, Constance Osbourne², Ben Walton²

¹ Gloucestershire Hospitals NHS Foundation Trust

² North Bristol NHS Trust

Introduction: Best practice standards are an integral part of the audit process. In intensive care medicine clinical standards are numerous, comprehensive and can be challenging to regularly monitor. The General Medical Council requires that doctors are consistently involved in quality improvement throughout their training. However, due to the rotational nature of the job and already demanding portfolio requirements, completing meaningful audit cycles as a trainee can be difficult.

Objective: To build and deliver an online database to enhance collection and analysis of data for multiple, concurrent quality improvement projects, henceforth referred to as ‘Rapid Audit System’ (RAS). It was designed with the intensive care unit (ICU) multidisciplinary team in mind, such that any healthcare worker, in this case junior doctors, could access and input data into the system and readily handover projects when rotating departments.

Method: A standardised form was designed on Google Forms, that could collect anonymised data for North Bristol Trusts’ 48 bed ICU. The form was designed to be compatible with a personal mobile device such that a trainee could collect that data within a matter of minutes on shift. A series of spreadsheets were designed with linking formulas, meaning that on completion of a data collection form, results displayed immediately on a shared online dashboard. Junior doctors could select an existing standard or add their own initiative into the RAS. A monthly audit meeting was held to support the trainees, review results, and discuss suggestions for improvement.

In 2020, we ran a pilot version of the system; with the intervention for every audit being a teaching card left in the patient’s room, which indicated whether the audit standard had been met at the time of data collection. We identified 45 standards that required regular auditing specific to critical care including but not limited to aspects of: infection control, sedation, airway and breathing, patient comfort and nutrition. Over time the system evolved such that by 2022, each audit had its own tailored intervention, as each trainee took responsibility for the implementation of an allocated personal audit.

Results: In 2022, 19 trainees completed audits using the RAS. In total, 205 sets of data were collected across 25 different audit standards. A range of interventions were introduced to the unit including updated documentation, teaching cards and a daily update at handover. Consistent improvement was demonstrated in many of the audited standards.

Conclusion: The RAS allowed trainees to make meaningful changes to practise and complete an audit loop to demonstrate improvement within a short timeframe. It also provided the department with a record of all audit data, and a system to ensure that audits are continued after trainees have left a department. A comprehensive, standardised system for audit improved the experience for trainees and resulted in clinical improvements within the department. We believe that this system can easily be expanded to other units nationally so allowing collaborative working.

5079

Quality Improvement on ICU Discharge Summary in RAEI

Siao Yan Quek¹, Yu Hung Melvin Cheong², Harry Chan¹

¹ Wrightington, Wigan and Leigh Foundation Trust

² Manchester Medical School

Introduction: ICU admissions can be extensive and involve complex procedures and interventions. With a good discharge summary, patient care can be optimised as it facilitates continuity of care, serving as a useful communication tool between teams when a patient is stepped down from ICU. Discharge summaries which are timely, precise and relevant have been shown to reduce rates of readmission and safety incidents. This audit aims to review ICU discharge summaries using an assessment criteria adapted from Savvopoulos et al, to help inform development of policy and education to improve quality in safety and efficiency of patient transfer.

Objectives: To perform a cross-sectional study assessing whether a discharge summary was entered into the hospital’s HIS for patients transferred from ICU to general wards, the quality of ICU discharge summaries entered and the role of the author of discharge summary.

Methods: The patients’ hospital numbers were used as unique identifiers to acquire the discharge summaries on the hospital’s electronic system. A total of 74 patients were included in this audit. Inclusion criteria included patients admitted to RAEI ICU and discharged from 1 June to 31 August 2022. Exclusion criterion included patients discharged to mortuary.

10 assessment criteria were selected based on a study by Savvopoulos et al. and prior experience. They are timeliness in relation to discharge date, presenting illness documented. chronological summary of ICU stay, diagnosis on discharge listed, medications on discharge listed, pending investigations listed, advice/plans for receiving team, DNACPR status, plan for re-escalation to ICU and overall clarity of summary.

Results: 13.5% of patients had no discharge summary and mostly authored by Clinical Fellows. Most summaries (80%) were entered within 1 day of discharge, 81.3% were found to be clear, >70% of included presenting illness, plans for receiving team, >50% included chronological account, DNACPR status and re-escalation plans, <30% included pending investigations, discharge diagnoses and full list of discharge medications.

Conclusions: For this audit, it was found that most patients had discharge summaries provided during step down from ICU and also most were authored by clinical fellows. Areas often documented (>50%) were summaries being entered within 1 day of discharge from ICU, having clarity, presenting illness and plans for receiving teams. Half of the summaries audited (50%) had chronological events, DNACPR and re-escalation plans stated while only some (<50%) had pending investigations, discharge diagnoses and medications written. Following the results from this audit, the current proforma is being reviewed to address these findings and to improve standardisation of entries.

Future works to be done are repeating audit in a year to assess for effectiveness of steps taken to improve the quality of discharge summaries, meta-analysis using data from other hospitals/trusts with similar audits/projects. There are still patients in the ICU unit who were discharged without a summary and this is an area to look at so as to further improve on the good work already done for having plans for receiving teams. Develop a points-based assessment to better quantify the overall quality of each discharge summary.

References

Guidelines for the provision of Intensive Care Services (2019) Guidelines for the Provision of Intensive Care Services | The Faculty of Intensive Care Medicine. The Faculty of Intensive Care Medicine [Internet] 2019 [cited 2023 Jan 6]. Available from: https://www.ficm.ac.uk/standardssafetyguidelinesstandards/guidelines-for-the-provision-of-intensive-care-services

Overview: Acutely ill adults in hospital: Recognising and responding to deterioration: Guidance (2007) NICE [Internet] 2007 [cited 2023 Jan 6]. Available from: https://www.nice.org.uk/guidance/cg50

Overview: Rehabilitation after critical illness in adults: Guidance (2009) NICE [Internet] 2009 [cited cited 2023 Jan 6]. Available from: https://www.nice.org.uk/guidance/cg83

Sampalli, T., Savvopoulos, S., Harding, R., Blackmore, G., Janes, S., Kumanan, K., Gibson, R. and MacKnight, C. Development of a quality scoring tool to assess quality of discharge summaries. Journal of Family Medicine and Primary Care [Internet] 2018 [cited 2023 Jan 6]; 7(2):394. Available from: doi:10.4103/jfmpc.jfmpc_407_16.

5418

Improving patient experiences of intensive care post liver transplantation

Sapna Hajela¹, Sapna Hajela², Dhupal Patel³

¹ KSS

² East Surrey Hospital, Redhill

³ Addenbrookes Hospital

Introduction: Liver transplantation (LT) is the only effective treatment for end-stage liver disease. At Addenbrooke’s Hospital, Cambridge, all patients undergoing LT are routinely admitted to intensive care (ICU) post-operatively. However, ICU admission is associated with physical and psychological sequelae that continue beyond hospitalisation. Planned admission to ICU represents a ‘scheduled trauma’ and offers the opportunity to provide patients with pre-operative information, potentially mitigating the subsequent development of psychological sequelae. A focus group of 10 patients who had undergone LT at Addenbrooke’s Hospital were asked about their experiences of the ICU post-LT. Key themes emerging included delirium, discomfort and vulnerability associated with endotracheal intubation, and an incomplete recollection of events in the ICU. Patients expressed a desire for further information regarding ICU admission prior to LT.

Objective: To communicate information regarding ICU admission post-LT

Methods: Using the information from the focus group, a video was designed comprising information about (1) the immediate post-operative period, (2) extubation, (3) post-extubation pain control and physiotherapy, (4) step-down from ICU to the transplant ward, and (5) ICU-related delirium and ICU follow-up clinic. The video was created using Canva and Doodly software.

Results: The video was disseminated to the patient group for feedback. All patients found the video content helpful, informative, and reflective of ICU admission. The video subsequently received hospital approval for dissemination.

Conclusion: Post-traumatic stress disorder post-ICU admission is seen in the LT population. To improve this, we created a video providing information regarding ICU admission prior to LT with patient input. Not all patients have internet access, so the ICU follow-up nurses have created written guidance to accompany the video. We anticipate these measures will improve patient experiences in ICU post-LT.

5437

Prolonged stay ICU patients and families - What do clinicians report are the key actionable processes of care?

Laura Allum¹, Ella Terblanche¹, Natalie Pattison², Bronwen Connolly³, Louise Rose⁴

¹ Guy’s and St Thomas’ NHS Foundation Trust

² University of Hertfordshire, East & North Herts NHS Trust and Imperial

³ Queen’s University Belfast, Guy’s and St. Thomas’ NHS Foundation Trust, King’s College London, University of Melbourne

⁴ King’s College London, Guy’s and St. Thomas’ NHS Foundation Trust

Introduction: Prolonged intensive care unit (ICU) stays account for up to 72% of ICU bed days despite being a small proportion of admissions, and confer significant costs in ICU, hospital and in the community.¹ Patients with prolonged stays have different needs to those of the acutely ill, often being awake and able to experience their ICU stay, require complex ventilator weaning and rehabilitation approaches or moving towards end of life care.² Family members of prolonged stay patients are more likely to experience psychological and financial difficulties than those of short-stay patients.³

Quality improvement (QI) tools can standardise care, reduce errors and improve communication between teams and patient and family.⁴ However our previous scoping review⁵ showed that there are few bespoke QI tools used in the ICU for the needs of prolonged ICU stay patients, and very few had patient and family input in their design. This lack of clearly articulated priorities of care may contribute to suboptimal care and patient and family experience.

Objectives: To identify actionable processes of care (those that can be acted on at the bedside) from clinicians’ perspectives that may improve outcomes and experience of patients and their family members experiencing a prolonged (over 7 days) ICU stay.

Methods: Semi-structured video interviews were conducted between October 2020-August 2022. We used purposive sampling to ensure participation from a broad range of professions in the ICU interprofessional team across the United Kingdom. Using the Framework Method, actionable processes were grouped into the six themes of person-centred care (PCC):

• respect for patients’ values, preferences, and expressed needs

• coordination and integration of care

• clear, high-quality information and education for the patient and family

• physical comfort

• emotional support—relieving fear and anxiety

• involvement of family and friends

Analyses were informed by our previous scoping review and interviews with former patients and family members.

Results: 24 participants were interviewed, and we identified 36 actionable processes of care grouped under six themes of PCC. Processes relating to communication (both by and with the patient, and with family), continuity of staff and care plans, and personalising the environment and routines were most frequently identified, mentioned in all 24 interviews. These processes were perceived as having a multifaceted impact on patient and family wellbeing. For example ensuring an effective communication method for patients helped to relieve anxiety, involve them in plans for their care and participate in meaningful rehabilitation and occupation.

Conclusions: To contribute to future development of quality improvement tools, clinician participants identified 36 actionable processes of care applicable to prolonged ICU stay patients.

References

1. Cederwall, C.-J., Naredi, S., Olausson, S., Rose, L., & Ringdal, M. Prevalence and Intensive Care Bed Use in Subjects on Prolonged Mechanical Ventilation in Swedish ICUs. Respiratory Care. 2021. 66(2), 300–306. https://doi.org/10.4187/respcare.08117

2. Rose, L., Istanboulian, L., Allum, L., Burry, L., Dale, C., Hart, N., Kydonaki, K., Ramsay, P., Pattison, N., Connolly, B., & PERFORM Investigators. Patient and Family Centered Actionable Processes of Care and Performance Measures for Persistent and Chronic Critical Illness: A Systematic Review. Critical Care Explorations. 2021. 1(4), e0005. https://doi.org/10.1097/CCE.0000000000000005

3. Minton, C., Batten, L., & Huntington, A. A multicase study of prolonged critical illness in the intensive care unit: Families’ experiences. Intensive and Critical Care Nursing. 2019. 50, 21–27. https://doi.org/10.1016/j.iccn.2018.08.010

4. Leigh, J. P., Brundin-Mather, R., Zjadewicz, K., Soo, A., & Stelfox, H. T. Improving transitions in care from intensive care units: Development and pilot testing of an electronic communication tool for healthcare providers. Journal of Critical Care. 2020. 56, 265–272.

5. Allum, L., Apps, C., Pattison, N., Connolly, B., & Rose, L. Informing the standardising of care for prolonged stay patients in the intensive care unit: A scoping review of quality improvement tools. Intensive and Critical Care Nursing. 2002. 73, 103302. https://doi.org/10.1016/j.iccn.2022.103302

5445

Improving electronic ward round documentation: a quality improvement project in one of the largest intensive care units

Alice Bonnar, Ronan Murphy, Purnima Narasimhan, Anne Lim, Mohammed Arshad

QEHB

Introduction: Consultant-led daily ward rounds are an essential part of clinical care in the Intensive Care Unit (ICU). It serves as a primary communication between the multidisciplinary team and as a medico-legal record.¹ Information recorded at the ward round should make clear the thinking around the clinical decisions. Templates and checklists have been shown to improve patient outcomes.² Previously, this was ensured in our ICU through paper template for daily ward rounds. However, with digitalisation and electronic recording, junior doctors are scribing ward round entries onto blank interfaces. This increases the risk of missing information and incomplete records. Coordination of assessments, plans and communication is essential for effective and efficient care.³ An organized and disciplined approach to ward rounds in this regard, improves patient safety and experience, while promoting efficient use of time and resources.⁴

Objectives: Evaluate the quality of current ward round documentation in the largest ICU in Europe and explore areas which could be improved.

Based on data collected and feedback, create a template to standardise ward round documentation improving patient safety and communication.

Methods: The initial audit involved prospective data collection over four days across all four units of the intensive care. A daily review of the ICU Ward Round was conducted against specific parameters and a questionnaire was given out to both nursing and medical staff to gain feedback. The data were consolidated and a Ward Round template was developed and peer-reviewed in the departmental Governance meeting. It was piloted and further feedback was gained in the form of a survey from Consultants and Registrars. The recommendations from the first cycle of the quality improvement project will be implemented and re-audited to look for improvement in ward round documentation.

Results: Initial evidence of our current practice showed that there was lots of variation in Ward Round entries (N=199) on an individual level and between units. Some aspects were well-documented such as ‘issues’, ‘airway’, ‘cardiovascular support’ and ‘sedation’. Whereas others of equal importance were particularly poor including ‘impression’, ‘lines’, ‘thromboprophylaxis’ and ‘anti-microbials’. Staff satisfaction feedback (N=50) with Ward Round documentation and communication was ambivalent surrounding common themes of inaccuracy, general understanding of the plan and inclusivity. Results from a small cohort of Consultants/Registrars who peer-reviewed the template appreciated the structure and thoroughness it provided.

Conclusion: There is some variation in current practice regarding ward round documentation with some important areas not consistently being documented. The comprehensive template we developed can help improve the quality of ward round documentation and therefore patient safety and communication.

However creating an IT integrated electronic template is challenging logistically and the alternative electronic template proved to be time-consuming. Therefore, the template will be added to induction booklet for junior doctors. Laminated copies will be put up on computers-on-wheels to ensure comprehensive assessment of the patient during ward rounds. The results of the re-audit and final conclusions will be compiled and presented at the meeting.

References

1. Brown N, Horne J, Low A. Improving documentation and junior doctor confidence on COVID-19 ward rounds using a ward round pro forma. Clinical Medicine Mar 2021, 21 (Suppl 2) 17-18; DOI: 10.7861/clinmed.21-2-s17

2. Gilliland N, Catherwood N, Chen S, et al. Ward round template: enhancing patient safety on ward rounds. BMJ Open Quality 2018;7:e000170.

3. Modern ward rounds: Executive summary and recommendation. Royal College of Physicians. 2021

4. Royal College of Physicians, Royal College of Nursing. Ward rounds in medicine: principles for best practice. RCP, London2012

5502

An analysis of initial teicoplanin levels in critically ill adult patients at a large teaching hospital

Victoria Burrell¹, Franki Wilson², John Dade², Isabel Armas², Molly Watts³

¹ Leeds Teaching Hospital Trust

² Leeds Teaching Hospitals

³ Leeds Teaching Hospitals Trust

Introduction: Teicoplanin is a glycopeptide antibiotic, with bactericidal activity against gram positive bacteria. Its licensed dose, dependent on indication, is 6mg/kg (e.g. aspiration pneumonia, cellulitis) and 12mg/kg (e.g. intra-abdominal infection, bacteraemia), administered every 12 hours for 3 doses (5 doses for infective endocarditis) followed by once daily¹. A trough teicoplanin level is taken on day 5 is used to adjust further doses to achieve a target of 15-30mg/L (for 6mg/kg) or 20-40mg/L (for 12mg/kg)². This analysis was conducted following anecdotal reports of subtherapeutic teicoplanin levels on adult critical care units (ACCUs) at Leeds Teaching Hospitals (LTH).

Objectives:

• - To identify the proportion of critically ill adults with a subtherapeutic first trough teicoplanin level

• - To compare the proportion of subtherapeutic teicoplanin levels for patients:

•  • Receiving 6mg/kg vs. 12mg/kg regimens

•  • Receiving vs. not receiving continuous veno-veno haemodialysis (CVVHD)

•  • Weighing under 100kg vs. 100kg and over

Method: A retrospective list of 360 patients who received intravenous teicoplanin on ACCUs at LTH from January 2019 to May 2020 was generated. Patients were included in the study if teicoplanin was:

• Prescribed for weight and indication according to LTH guidance²

• Monitored according to LTH guidance (i.e levels taken at correct intervals)

• Administered as per prescription (i.e. no missed doses)

The sample included 63 patients. One-third received 6mg/kg dosing (n=21). Just over a quarter of patients (n=17) were receiving CVVHD. Data collected included demographics (gender, age, weight), indication for teicoplanin, target range and first trough level. Levels were deemed subtherapeutic if they were lower than the target level for the indication specified in LTH guidance.²

Results: 43 critically ill adult patients (68%) had a subtherapeutic first trough level. The mean level was 14.82mg/L (4-30mg/L).

A higher proportion of patients on 6mg/kg (81%) than 12mg/kg dosing (62%) had a subtherapeutic first trough level.

The proportion of subtherapeutic first trough levels in patients not receiving CVVHD was greater than in those receiving CVVHD (78% vs. 41%). For non-CVVHD patients (n=46), the proportion of subtherapeutic first trough levels was similar for each dosing regimen (6mg/kg: 78% vs. 12mg/kg: 79%). Whereas the difference was much greater in those receiving CVVHD (6mg/kg: 100% vs. 12mg/kg: 29%).

Patients weighing 100kg or greater (n=11), 8 had a subtherapeutic trough level (73%), compared to 35 (67%) of patients weighing under 100kg (n=52).

Conclusion: The high proportion of subtherapeutic levels illustrates that the licensed teicoplanin dose is insufficient for critically ill patients. This is supported by evidence that hydrophilic antibiotics with extracellular distribution, such as glycopeptides, require higher loading doses in order to achieve therapeutic concentrations in critically ill patients.^3,4 Following this audit, LTH has created teicoplanin guidance specific to patients on ACCUs. All critically ill adults now receive 12mg/kg, with the number of loading doses increased from 3 to 5 for higher risk indications. Since updating the guideline, first teicoplanin levels have improved. From August to October 2022, 14 critically ill patients meeting the same inclusion criteria had a mean teicoplanin level of 22.43mg/L (15-32mg/L), with 43% subtherapeutic.

References

1. Sanofi. Targocid 400mg powder for solution for injection/infusion or oral solution [Internet]. Targocid 400mg powder for solution for injection/infusion or oral solution - Summary of Product Characteristics (SmPC) - (emc). 2022 [cited 5/2/23]. Available from: https://www.medicines.org.uk/emc/product/2927/smpc#gref

2. Atack, K. and Tariq, Z. Teicoplanin antimicrobial prescribing guidance for adult patients. Leeds Health Pathways. 2022 [cited 5/2/23]. Available at: https://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=5154

3. Roberts JA, Abdul-Aziz MH, Lipman J, Mouton JW, Vinks AA, Felton TW, et al. Individualised antibiotic dosing for patients who are critically ill: Challenges and potential solutions. The Lancet Infectious Diseases. 2014;14(6) pp 498–509.

4. Shah S, Barton G, Fischer A. Pharmacokinetic considerations and dosing strategies of antibiotics in the critically ill patient. Journal of the Intensive Care Society. 2015;16(2) pp 147–53.

5512

Participant engagement and acceptability of a novel digitally enabled ICU recovery pathway using individualised goal setting

Kate Brooks¹, Chloe Apps¹, Ella Terblanche¹, Nicholas Hart¹, Joel Meyer¹, Louise Rose²

¹ Guy’s and St Thomas’ NHS Foundation Trust

² King’s College London

Introduction: With input from ICU survivors and expert clinicians, we developed a digital ICU recovery pathway using the aTouchaway e-health platform (Aetonix, Canada) to support survivors of critical illness achieve their recovery goals prior to hospital discharge and at home. The ICU digital recovery pathway assesses baseline function, supports individualised recovery goal setting and goal monitoring (weekly, monthly, and aspirational), identifies recovery barriers, and provides tailored e-resources. Recovery goals are structured within the four domains of the Canadian Model of Occupational Performance and Engagement (Townsend and Polatajko 2007).

Objective: To evaluate engagement with and acceptability of the pathway in a single tertiary centre since operationalising the pathway in June 2021.

Methods: Patients who received at least 3 consecutive days of ventilation in ICU are enrolled on to the pathway following ICU or hospital discharge and discharged from the pathway following attendance at an ICU recovery clinic appointment. We measured engagement by participation in goal setting and rating. We measured acceptability using the intervention acceptability (AIM), feasibility (FIM) and appropriateness (IAM) questionnaires. We did qualitative interviews on pathway completion. Patients also complete measures of physical, psychological, emotional and cognitive recovery up to 12 weeks.

Results: From June 2021 to June 2022, we enrolled 65 ICU survivors (14 in hospital; 51 at home) with 21 patients discharged. Median (IQR) ICU length of stay was 16 (10-32) days; hospital 32 (20-57) days. The 48 patients actively engaged in the pathway have set 195 weekly goals with 58% achieved; 213 monthly goals with 40% achieved; 100 aspirational goals with 36% achieved. Goals were most commonly set in the Self-care domain (46%) with fewer in the domains of Productivity (25%), Leisure (24%), and Person (5%). Twenty-one patients completed the AIM, FIM, and IAM with mean (SD) scores of 4.2 (0.7), 4.2 (0.6), and 3.8 (1.2) respectively indicating patients perceived the pathway as highly acceptable, feasible and appropriate. Themes identified through qualitative interviews (15 participants) were ‘promoting recovery through individualised advice’; ‘recovery coordinator accessibility for emotional support’ and ‘the positive impact of goal monitoring’.

Median (IQR) FACIT Fatigue score at week 2 was 30 (24.3-37.8) increasing to 35 (29-41) by week 12 indicating a reduction in fatigue. Measures of psychological recovery showed a reduction in score from week 2 to 12. GAD-7 median (IQR) score 6 (1-9) to 2 (0-11); PHQ-9 median IQR 5 (3-9) to 3 (1-5). Health-related quality of life scores also improved (EQ-5D-5L median IQR was 65 (50-80) increasing to 72 (52-85).

Conclusion: During the first twelve months of the digital ICU recovery pathway implementation we demonstrate a reasonable level of engagement with recovery goal setting and monitoring. Patients identified goal monitoring positively influenced their recovery and reported the pathway as highly acceptable and feasible.

Reference

Polatajko HJ, Townsend, E.A., and Craik, J. Canadian Model of Occupational Performance and Engagement (CMOP-E). In: Townsend EA and Polatajko HJ (eds) Enabling Occupation II: Advancing an Occupational Therapy Vision of Health, Well-being, & Justice through Occupation Ottawa: CAOT Publications ACE, 2007.

5606

Improving patient safety at intensive care discharge: the development of an auditable standard for medicines reconciliation

Bianca Levkovich¹, Lucy Belderbos², Parveen Hayre³, Aaliyah Yasin³, Natalie Lewis³, Navneet Kaur Gill⁴, Emma Graham-Clarke⁵

¹ Kings College Hospital NHS Foundation Trust

² University of Birmingham

³ Aston University

⁴ Sandwell & West Birmingham NHS Trust, University of Birmingham

⁵ Sandwell & West Birmingham NHS Trust

Introduction: Patients are at high risk of medication-related harm during transitions of care.¹ The use of more medications and the frequent use of intravenous and high risk medications increase these risks for patients transitioning from intensive care units (ICUs) to care on the ward.² The World Health Organisation and the National Institute of Health and Care Excellence advocate medicines reconciliation to reduce patient harm associated with transitions of care.^1,3 For patients transitioning from ICU to the ward, medicines reconciliation ensures patients safely continue the medications they need and those they no longer need are deprescribed.^2,3 There is limited evidence about which medications present most risk or the best measure of efficacy of medicines reconciliation when patients transition from ICU to care on the ward.

Objectives: This project aimed to develop an auditable standard for medicines reconciliation for patients transitioning from ICU to care on the ward.

Methods: In a metropolitan teaching trust with two ICUs, the medication orders at ICU discharge of 50 consecutive adult (>16 years old) patients transitioning to care on the ward were surveyed retrospectively. Patients were excluded if admitted to ICU for less than 24 hours, discharged directly home, died on ICU, discharged on an end-of-life care pathway or transferred to another hospital.

Medications continued at ICU discharge were categorised initially by a student researcher and two consultant pharmacists using a traffic light system:

• RED: never appropriate to be prescribed at ICU discharge

• AMBER: sometimes appropriate to be prescribed depending on certain patient, medication and ward factors. For example: stop date documented or patient care on a specialist ward

• GREEN: always appropriate to be prescribed.

Medications categorised as red or amber by any researcher were further assessed by a panel of 11 multi-disciplinary clinicians including novice and experienced critical care doctors, senior nurses, advanced critical care practitioners and ICU and generalist clinical pharmacists. Using an electronic survey tool, two rounds of a modified Delphi technique were completed. An agreement level of 75% was used. Medications where agreement was not reached were categorised as amber.

Subsequently, an audit of consecutive patients discharged from ICU over a 3-month period was conducted to quantify the number and frequency of prescribing of red list medications.

Results: A total of 225 medications were collated and initially categorised, with 10 added during the Delphi process. Agreement was reached for 23 medications never appropriate to be prescribed at ICU discharge. These were consolidated into eight medications groups (Table 1).

Table 1.

The RED list: Medications never appropriate to be prescribed for patients transitioning from ICU to ward care.

Medication group	Route of administration	Frequency of administration	Examples
Inotropes and Vasopressors	intravenous	Continuous infusion	adrenaline, metaraminol, noradrenaline, vasopressin
Analgo-sedation (opiates)	intravenous	Continuous infusion	Fentanyl, remifentanil
Sedation	intravenous	all	clonidine, dexmedetomidine, ketamine, propofol
Paralysing agents	intravenous	all	atracurium, rocuronium
Electrolytes	intravenous	all	potassium chloride (concentrated)
Fluids for flushes	arterial	infusion	0.9% sodium chloride
Renal replacement therapy	all	all	Dialysis fluids Citrate and calcium Heparin
Other ICU specific therapy	-	-	Nebulised epoprostenol

Conclusions: Multi-professional consensus was achieved for medications unsafe for prescription for patients transitioning from ICU to care on the ward. This provides an auditable standard for the safety and efficacy of medicines reconciliation at ICU discharge. Broader consultation to produce a regionally or nationally acceptable list would be beneficial for benchmarking services and increasing safety of this high-risk patient transition.

References

1. World Health Organisation. Medication safety in transitions of care. Geneva: World Health Organisation; 2019 (WHO/UHC/SDS/2019.9).

2. Bourne RS, Jennings JK, Panagioti M et al. Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis. BMJ Qual Saf 2022; 31: 609-22.

3. National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (NG5). NICE guideline, 4 March 2015 (ISBN: 978-1-4731-1057-1).

5616

Take a Medical Reconciliation Minute!

Fiona Christie, Francis Gainsborough, Pamela MacTavish

NHS Greater Glasgow and Clyde – Glasgow, Central (Scotla)

Introduction: In hospital, transitions of care are a common time for medication errors to occur.¹ Inadequate medical reconciliation during hospital admission, ward transfer and hospital discharge lead to adverse events and potential patient harm. In critical care we identified failures to recommence withheld medications, communicate reasons for starting new medications and inadequate documentation on medications which required stopping.

Objective: An accurate medical reconciliation for all critical care admissions, to reduce unintentional prescribing discrepancies. Medical Reconciliation should include home medication, new critical care and discharge medications to prevent adverse events during transitions of care.

Method: We used quality improvement methodology to design and test change, using plan-do-study-act (PDSA) cycles, in the critical care of a large teaching hospital. We created a quality improvement team of key stakeholders who developed a driver diagram to plan our improvement project initiatives. Firstly, we tested a ‘med rec moment,’ a five minute period following morning handover for junior medical staff to review each patients home medications, identifying any inaccuracies to ensure a complete and accurate knowledge of patients home medication. As part of our multi-disciplinary, daily ward round we then included a ‘daily goal’ to highlight any new medications started within the last 24 hours. During our PDSA cycles, we then focused the drug groups documented (for example: cardiovascular, anticoagulants, anti-epileptics) to medications which discharging teams required further information regarding. Finally, we updated our discharge process to include important information for downstream wards on medications intentionally stopped/ started or those which require starting in due course.

Results: Base line data collected during the first week of the project identified only 20% of critical care patients had an accurate documentation of new medications started in critical care. Only 40% of patients had a complete reconciliation of medications at point of discharge. With inaccuracies identified in restarting existing medications and communicating which current medications needed stopped prior to discharge home.

We have seen improvement in our documentation of home medications, with 100% accuracy for the recent 13 week period. We have also seen an improvement in our documentation of new critical care medications (figure 1), with a sustained improvement above the median of 85% for the last four weeks. Accuracy of medications at discharge, while improved from baseline, has remained variable without sustained improvement (Figure 2).

Conclusion: It is essential for patient safety to ensure that reconciliation of medications - at both admission to and discharge from critical care - is accurate and clearly communicated to the downstream wards. By developing a standardised, multi-disciplinary approach to medical reconciliation at the three key steps of admission, during critical care and discharge, we have been able to improve the accuracy of our medical reconciliation. By sustaining this improvement, we look to see a reduction in prescribing-related adverse reports and then further spread this improvement project to other areas within the hospital.

Reference

1. Kwan JL, Lo L, Sampson M, et al. Medication Reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158: 397-403

5313

Determining physiotherapy pathways and sternal precautions protocols for post cardiac surgery patients in the UK

Alicia Page, Charlotte Milligan

Royal Papworth Hospital NHS Foundation Trust

Introduction: Coronary artery bypass graft (CABG) and cardiac valve repair/replacement surgery are among the most common surgeries.¹ One aspect of cardiac surgical care that falls outside evidence-based practice is when a physiotherapist should review these patients, the frequency of review, and use of sternal precautions. We conducted a survey to investigate physiotherapist involvement with this patient group.

Objective: The aim of the survey was to identify physiotherapy cardiac surgery pathways and protocols at cardiac centres in the UK.

Methods: A mixed methods questionnaire was designed online, consisting of 10 questions capturing data on day one of physiotherapy review, frequency of review, if a screening tool is used and who within the physiotherapy team can use this tool. We also asked if sternal precautions were used. The questionnaire was circulated via Twitter.

Results: 17 responses from across the UK were received. 80% of physiotherapists reviewed patients on day one following cardiac surgery and 55% continued to review these once daily for their admission. 45% reported they use screening tool from day one post-surgery, most requiring a band 5 physiotherapist or above to use the screening tool. 100% of responses reported that other professionals took an active role with rehabilitation, with 64% specifically reporting that nursing staff would assist with mobilisation. 73% reported they used standard sternal precautions (no pushing, pulling, or lifting for 12 weeks), 9% using ‘Keep Your Move in the Tube’ (KYMITT) and 18% using no sternal precautions.

Conclusion: Most physiotherapists report using formal sternal precautions however there are two NHS Trusts who are starting to introduce KYMITT, which may change the frequency of physiotherapy reviews required.

This data has provided a snapshot of how physiotherapists screen and review patients following cardiac surgery in the UK. Further research is needed to establish an evidence base for physiotherapists to review and treat patients post sternotomy.

Reference

1. Gach R, Triano S, Ogalo G, Graca B, Shannon J, El-Ansary D, Bilbrey T, Cortelli M and Adams J (2021) ‘Keep Your Move in the Tube’ safely increases discharge home following cardiac surgery. American Academy of Physical Medicine and Rehabilitation 1:1-9.

5432

Standardised rehabilitation guides for patients - A network project

Lisa Hayward, Nicola Williams

Blackpool Teaching Hospitals

Introduction: As part of the Lancashire & South Cumbria Critical Care Network a Rehabilitation Task & Finish Group was set up to look at how services can be improved for patients. Within current National GPICS standards¹ it is identified that patients must be given information to explain what they can do to help their recovery.

Objective: The Task & Finish group aimed to improve patient information by the creation of a Patient Rehabilitation Guide. This guide was aimed at providing patients with information that could support their recovery on discharge from Critical Care. The guides were developed using a multi-professional approach with input from Dietetic, Occupational Therapy, Physiotherapy, Psychology and Speech and Language Therapy. The group amalgamated information guides that were already in use to create a Network wide document to enable consistency in information given out to patients. All Trusts within the Network participated in the project.

Methods: Baseline data was collected on a weekly basis for a 30-week period on the number of appropriate patients identified as requiring the Rehabilitation Guide and the number of patients who had received them. The new Rehabilitation Guide was developed and implemented, and a further 8-week data collection was completed. Feedback from patients was also collected using a questionnaire.

Results: Figure 1 below shows the data collected on the number of booklets received by patients before and after the implementation.

Figure 1.

The chart shows the improvement after the implementation of the guide with a gradual improvement initially, to above 90% after the first 3 weeks.

The patient feedback questionnaires identified that overall, patients deemed the rehabilitation booklets to be user friendly; able to answer any questions they might have; and that the terminology is all easy to understand. Most patients felt that the right amount of information was provided. There was no agreeance as to the most appropriate time to give out the booklet, some feeling it’s too early while still on critical care but others feeling the sooner the better.

Discussion/Conclusion: Across the L&SCC Network there was disparity in the information that patients were receiving. The Rehabilitation Task & Finish Group developed a new patient Rehabilitation Guide amalgamating those that were already in use to provide consistent patient information. The data shows an improvement in the provision of the Rehabilitation Guide which meets the current National GPICS standards¹ for providing patients with information that supports their recovery on discharge from Critical Care. The feedback from patients showed that the Rehabilitation Guide was well received and provided enough useful and relevant information for patients to support their rehabilitation and help them through their recovery from critical illness.

Reference

FICM. Guidelines for the Provision of Intensive Care. Services - Version 2.1 2019. Available at: https://www.ficm.ac.uk/sites/default/files/gpics-v2.pdf

5487

Frailty assessment in the critically unwell

Kavaldeep Jabbal¹, Anandh Balu¹, Martin O’Connell², Nabeel Amiruddin³

¹ The Dudley group NHS foundation trust

² The Dudley Group NHS foundation trust

³ The Dudley group NHS Foundation trust

Introduction: Frailty can be defined as a multidimensional state of depleted physiologic and psychosocial reserve as well as clinical vulnerability that is related to but variably present with advancing age.¹ With increasing knowledge and expertise in critical care more and more patients categorised as frail are being admitted to intensive care. Early recognition of frailty and more specifically the degree of frailty will allow critical care clinicians to signpost this cohort to the relevant multidisciplinary care early, potentially leading to better outcomes.

Objectives: To achieve > 90% documentation of frailty assessment on admission in all patients admitted to intensive care.

Methods: In this project we assessed fifty patients admitted to the ICU, randomly selected from a cohort of all patients admitted between December 2019 and January 2023. Each of these patients had their electronic admission clerking reviewed and documentation of their clinical frailty score (CFS) noted. Secondary parameters including World Health Organisation (WHO) performance score, number of comorbidities and mortality within thirty days was also recorded.

Subsequently a teaching session was completed with all of the doctors admitting patients to ICU, emphasising the importance of the frailty assessment.

Results: 32% of patients (n=16) had a clinical frailty score (CFS) documented on their admission documentation. Furthermore, 8% (n=4) of the cohort had their WHO performance score documented. 64% (n= 32) of these patients had two or more comorbidities documented on their initial clerking. 32% (n=16) of patients died within 30 days of admission.

Conclusions: Frailty is a multisystemic syndrome that impairs the recovery of patients from an acute insult requiring admission to critical care. It is therefore vital that we highlight the degree of frailty on admission to allow us to optimise care for each of these patients. In this project we have highlighted poor documentation on admission of the widely used CFS.

The National Emergency Laparotomy Report (NELA) 2017-2018, described the importance of frailty documentation, mentioning that documentation of frailty can lead to more comprehensive geriatric assessment which is likely to improve patient outcomes.² Whilst only a small proportion of our cohort had an emergency laparotomy, a large audit concerning critically unwell patients outlining the importance of frailty documentation must not be overlooked.

In the wake of our findings, we aim to improve frailty documentation in ICU. The next steps would be to install a poster in critical care office and desk spaces to remind people to fill out the frailty scores on admission and install a frailty assessment tab on the DNA-CPR electronic documentation as a further prompt. Furthermore, we are liaising with the geriatric physicians with a view to providing high- quality care to those patients identified as frail.

Frailty in critical care is an ever-increasing problem and processes must be put in place now to prevent worsening outcomes in the future.

References

1. Biasio et al. (2020). Frailty in Critical Care medicine: a review. Anesth Analg. 2020 Jun; 130(6): 1462–1473.doi: 10.1213/ANE.0000000000004665.

2. NELA Project Team. Fifth Patient Report of the National Emergency Laparotomy Audit RCoA London 2019.

4975

Ruptured Splenic Artery Aneurysm in Pregnancy as a Rare Cause of Maternal Haemorrhage Requiring Intensive Care Team Input

Rabiu Momoh, Olivia Kent, Roland Fernandes

William Harvey Hospital, Ashford, Kent, UK

Introduction: The risk of untoward outcomes posed to pregnant patients (and their foetuses), resulting from a spontaneous rupture of previously unidentified splenic artery aneurysm (SAA) is increasingly being documented in the literature.¹

Objectives: To describe an uncommon case of a ruptured splenic artery aneurysm (SAA) in a pregnant female requiring intensive care unit admission post-surgery.

Methods: A signed informed consent was obtained for this case report. The patient’s hospital record was reviewed afterward.

Results: We report the case of a 34-year-old female at 26 weeks gestational age referred to our institution in severe internal haemorrhagic shock who was found at laparotomy to have a ruptured splenic artery aneurysm. She had a splenectomy done after a proximal bleeding control was achieved. A Caesarean section was then done to evacuate a stillbirth foetus that was confirmed with no cardiac activity on pre-operative bedside ultrasound scan of the uterus. Patient was managed post-operatively on the intensive care unit and was discharged after three days to a post-natal ward. Patient required multiple blood products transfusions at resuscitation, intra-operatively and post-operatively.

Conclusions: The critical care team can be involved in a multidisciplinary management of this rare cause of severe maternal haemorrhage from resuscitation to the post-intervention phase on the intensive care unit. An awareness of this rare potentially catastrophic event could help shorten time to diagnosis and definitive management.

Reference

1. Pavlis T, Seretis C, Gourgiotis S et al. Spontaneous Rupture of Splenic Artery Aneurysm during the First Trimester of Pregnancy: Report of an Extremely Rare Case and Review of the Literature. doi: 10.1155/2012/528051. PMID: 23024869.

5294

MAKE outcomes after ICU dialysis - A retrospective analysis

Daniel Cottle, Oscar Lewtas, Mohsen Abdelaal

Critical Care Unit - Lancashire Teaching Hospitals NHS Foundation Trust

Introduction: Some studies suggest a higher rate of dialysis dependence following AKI treated with intermittent haemodialysis (IHD) compared to continuous veno-venous haemofiltration (CVVH),¹ but meta-analysis shows the risk to be the same. At Lancashire Teaching Hospitals Trust ICU all patients with AKI are treated with IHD placing us in a unique position to evaluate it in this setting.

Objectives: To compare the long-term renal function outcomes of patients receiving acute dialysis at Lancashire Teaching Hospitals Trust ICU and the published evidence.

Methods: Our study included all patients since September 2015 who were 16+ years old and received IHD for AKI in ICU for over 48 hours. Patients with intrinsic renal disease, pre-existing dialysis or who died within 48 hours of starting IHD were excluded.

We used MAKE 90 for our clinical outcomes. Defined as:

• Death within 90 days

• Incomplete kidney recovery (>25% decline in eGFR from baseline)

• ESRD requiring dialysis.

• MAKE 90 composite outcome.

Comparisons were made to studies which reported two or more MAKE outcomes in patients receiving IHD.

Results: Comparisons were made to studies which reported two or more MAKE outcomes in patients receiving IHD.

Graph 1.

The prevalence of each MAKE 90 outcome.

749 patients received dialysis since September 2015; 305 met the exclusion criteria, 48 were lost to follow-up leaving 396 patients for analysis. 67.2% of patients had a MAKE 90 outcome, and 32.8% had complete renal recovery (Graph 1).

Comparisons to other studies: De Corte² is the only other study to report all MAKE 90 outcomes. We had a lower MAKE 90 outcome (67% vs 86%); lower mortality (47% vs 59.2%) and the same dialysis dependence (15.2%).

Our mortality rate of 47% for IHD was the same as Bell,¹ Uchino³ and Wald⁴, and higher than Oliveira⁵ (33.5%). Eskola reported the lowest 90-day mortality (21.5%).

Our rate of long-term dialysis (15.2%) was the same as de Corte, Bell, Uchino and lower than Wald (27%) and Oliveira (33.6%). It was higher than Eskola (10.8%).

When compared to CVVH, our mortality rate was comparable to Bell, but less than other studies. Our rate of dialysis dependence (15.2%) was higher than Bell (8.3%) equivalent to Uchino (17.5%) and Wald (16.4%) and lower than Oliviera (20.3%). All were higher than Bellomo’s CVVH study (6.8%).

Conclusions:

• Our MAKE 90 outcomes were comparable to or better than most studies, but could not be statistically compared.

• The exclusive use of IHD in our ICU is safe and has not resulted in higher rates of long-term dialysis than published studies.

• Our mortality rates were the same or better than CVVH in studies that compared it to IHD, however, the variability in studies does not allow direct comparison.

• Dialysis dependence was comparable to published IHD groups but higher than the CVVH groups.

• Comparing our results to matched patients receiving CVVH in a similar unit would allow direct comparison.

Graph 2.

LTH MAKE 90 outcomes compared to studies with more than one MAKE 90 outcome and data for IHD.

References

1. Bell M, Granath F, Schon S, Ekbom A, Martling C-R. Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure. Int Care Med. 2007;33, 773-780.

2. De Corte W, Dhondt A, Vanholder R, De Waele J, Decruyenaere J, Sergoyne V, et al. Long-term outcome in ICU patients with acute kidney injury treated with renal replacement therapy: a prospective cohort study. Crit Care. 2016;20(1):256.

3. Uchino s, Bellomo R, Kellum JA, Morimatsu H, Morgera M, Schetz M et al. Patient and kidney survival by dialysis modality in critically ill patients with acute kidney injury. Int J Art Org. 2007;30(4): 281-292.

4. Wald R, Friedrich JO, Bagshaw SM, Burns KE, Garg AX, Hladunewich MA, et al. Optimal Mode of clearance in critically ill patients with Acute Kidney Injury (OMAKI)–a pilot randomized controlled trial of hemofiltration versus hemodialysis: a Canadian Critical Care Trials Group project. Crit Care. 2012; 16(5):R205.

5. de Souza Oliveira MA, Dos Santos TOC, Monte JCM, Batista MC, Pereira VG, Dos Santos BFC, et al. The impact of continuous renal replacement therapy on renal outcomes in dialysis-requiring acute kidney injury may be related to the baseline kidney function. BMC Nephrol. 2017;18(1):150.

5535

Correlation between anti-Xa activity and activated partial thromboplastin time ratio for anticoagulation monitoring during continuous renal replacement therapy

Ayesha Begum¹, Hannah Shimmin², Richard Fisher¹, Clemens Pahl¹, Reena Mehta¹

¹ Kings College Hospital

² Basildon & Thurrock University Hospital

Introduction: Within our Critical Care service, heparin is the second-line anticoagulant for patients undergoing Continuous Renal Replacement Therapy (CRRT), who are unable to receive Regional Anticoagulation with Citrate (RAC). Prior to October 2021 Activated Partial Thromboplastin Time ratio (APTTr) was measured to ensure heparin dosing was not excessive and producing clinically significant systemic anticoagulation (an APTTr value of ≥2.0 would trigger a reduction in heparin dose). In October 2021 our trust moved to measuring anti-Xa levels in all patients receiving intravenous heparin including those receiving heparin to facilitate CRRT. For CRRT an anti-Xa level of ≥0.3units/ml would trigger a reduction in heparin dose. There is limited data showing a poor correlation between anti-Xa and APTTr in the use of heparin in patients undergoing haemodialysis¹ but nothing specifically for patients undergoing CRRT.

Objective: To assess the correlation between anti-Xa and APTTr levels in patients undergoing CRRT with heparin administered into the arterial lumen of the CRRT circuit.

Methods: Retrospective service evaluation of all patients undergoing CRRT with heparin between 13/10/21 and 29/06/22. Review of electronic patient medical records was conducted. For each circuit used the first and second measured anti-Xa level were recorded. Paired APTTr measurements were recorded when samples were drawn within +/- 120 minutes of the sample used for the anti-Xa measurement. As values were not normally distributed Spearman’s rank correlation coefficient was used to describe the relationship.

Results: A total of 143 circuits were used with CRRT-specific heparin anticoagulation in 62 patients. Amongst these there was a total of 117 anti-Xa and APTTr measurements recorded. There was a modest correlation between anti-Xa level and APTTr (r_(s) = 0.38, p-value 0.00003) (figure 1.). Anti-Xa level was ≥0.3units/ml on 34 occasions (29%). Of these 34 occasions, APTTr was <2.0 on 21 occasions (62%), such that the heparin dose was reduced when previously it would not have been. On 20 occasions APTTr was ≥2.0 (17%), and on 7 of these, the synchronous anti-Xa level was <0.3units/ml (35%), such that heparin dose was not reduced whilst it would have been when following our previous protocol. On 76 occasions anti-Xa level was <0.3units/ml and APTTr was <2.0 (65%). On 13 occasions anti-Xa level was ≥0.3units/ml and APTTr was ≥2.0 (11%).

Figure 1.

Correlation between anti-Xa level and APTTr.

Conclusions: We found that in patients undergoing CRRT with heparin there was a modest correlation between anti-Xa level and APTTr. On 18% of the occasions there was a heparin dose reduction due to elevated anti-Xa level, which would not have occurred under our previous protocol. On 6% of occasions there was no heparin dose reduction, when our previous protocol would have mandated this. Further research is required to ascertain whether or not this new protocol changes the impact on efficacy (circuit lifespan) and/or safety (bleeding events).

Hollow circles, anti-Xa level <0.3units/ml and APTTr <2.0; shaded circles, anti-Xa level ≥0.3units/ml and APTTr <2.0; hollow diamonds, anti-Xa level <0.3units/ml and APTTr ≥2.0; shaded diamonds, anti-Xa level ≥0.3units/ml and APTTr ≥2.0.

Reference

1. Coene KLM, Dekker MJE, Kerskes MCHM, Hengst M, Schonck MJM, Konings CJAM and Scharnhorst V. Practical Value of Anti-Xa Activity in the Evaluation of Extracorporeal Circuit Anticoagulation during Haemodialysis: Results of a Cross-Sectional Single-Centre Study. Nephron. 2017;137(3):205-211.

5536

A comparison of eGFR calculated by established formulas using creatinine and cystatin-C with 24 hour urine CrCl in critically ill patients

Grace Jackson

manchester university NHS foundation trust

Introduction: Renal impairment is common among critically ill patients with an estimated 50% experiencing AKI, many of which have a background of chronic kidney disease (CKD).¹ Ability to quantify renal function accurately is crucial in determining appropriate drug dosing. Current standard practice using established equations to estimate glomerular filtration rate (GFR) have known limitations and have limited evidence for use in acute kidney injury (AKI), critically ill patients, extremes of body weight, patients with significant muscle wastage, as well as patients experiencing augmented renal clearance.² There has been a recent trend of utilising cystatin C to estimate renal function. Cystatin C production is not affected by muscle mass therefore its use is thought to minimise the variability seen with using creatine based equations in extremes of body weight. However, obesity, hypothyroidism, cigarette smoking and use of steroids are associated with higher cystatin C values therefore potentially causing an underestimate of GFR.³ Evidence for use of cystatin-C in critically ill patients is very limited. Measurement of urine creatinine clearance (CrCl) with a 24 hour urine collection is considered a gold standard for estimating GFR however can be considered less practical and can take longer to obtain result.⁴

Objectives: The aim of the study is to compare 24 hour urine CrCl with estimated GFR (eGFR) calculated from using the commonly used formulas (CKD-EPI (creatinine) CKD-EPI (cystatin C) and Cockcroft+Gault) to identify which eGFR formula most closely correlates with the 24 urine CrCl. By identifying the most accurate formula we will be able to make dosing decisions more confidently in critically ill patients.

Methods: A range of patients were selected with varying bodyweights, degrees of muscle mass and renal function. A wide range of patient types were chosen to accurately reflect the patient demographic treated on our unit. Patients receiving any type of renal replacement therapy were excluded. 24 hour urine collections were collected to measure 24 hour urine creatinine levels which were used to calculate urine CrCl. These results were compared with eGFR calculated using CKD-EPI (creatinine) CKD-EPI (cystatin C) and Cockcroft+Gault, including results for adjusted and ideal body weights.

Results: 14 patients have been selected and 24-hour urine collections have been completed in 10 of those patients., Currently no correlation has been observed between the calculated eGFR and the 24-urine CrCl. We are endeavouring to collect more data in the coming weeks (patient sample size 50) in an attempt to elaborate on the data already gathered.

Graph 1 demonstrates the results obtained so far:

Conclusions: Evidence for use of formulas (CKD-EPI, Cockcroft+Gault) to quantify renal function in critically ill patients is limited. There is no validated approach or clear guidance on what is the most accurate method. With further sampling we hope to ascertain which formula, using creatine or cystatin C, is the most accurate in critically ill patients at MFT in order to inform more accurate decisions on drug dosing in the future.

References

1. Mohsenin V. Practical approach to detection and management of acute kidney injury in critically ill patient. Journal of Intensive Care. 2017 Sep16;5(1).

2. Bragadottir G, Redfors B, Ricksten S-E. Assessing glomerular filtration rate (GFR) in critically ill patients with acute kidney injury - true GFR versus urinary creatinine clearance and estimating equations. Critical Care. 2013 Jun15;17(3).

3. Toffaletti J. Clarifying the confusion of GFRs, creatinine, and cystatin C [Internet]. Clarifying the confusion of gfrs, creatinine, and cystatin C. 2018 [cited 2023 Feb25]. Available from: https://acutecaretesting.org/en/articles/clarifying-the-confusion-of-gfrs-creatinine-and-cystatin-c

4. Traynor J, Mactier R, Geddes CC, Fox JG. How to measure renal function in clinical practice. BMJ. 2006 Oct7;333(7571):733–7.

5547

Urinary [TIMP-2]*[IGFBP-7] and Major Adverse Kidney Events in Critically Ill Patients with Sepsis

Faraj K. Alenezi, Rahul Y. Mahida, David R. Thickett, Jaimin M. Patel, Dhruv Parekh

University of Birmingham

Introduction: Over the past decade, studies have explored the role of urinary tissue inhibitor of metalloprotease-2 [TIMP-2] and insulin-like growth factor-binding protein 7 [IGFBP-7], in predicting the risk of acute kidney injury (AKI) before serum creatinine. However, a limited number of studies have focused on using urinary [TIMP-2]*[IGFBP-7] to predict major adverse kidney events (MAKEs), a composite outcome used in critical care nephrology research. This study aims to assess the ability of urinary TIMP-2 and IGFBP-7 to predict MAKEs in sepsis patients with and without Acute Respiratory Distress Syndrome (ARDS) during intensive care unit (ICU) stay.

Methods: A single-centre retrospective study of invasively ventilated sepsis patients admitted to ICUs at the Queen Elizabeth Hospital Birmingham was undertaken from 2016 to 2019. Urine samples were collected within 48 hours, and development of AKI was assessed within 7 days of invasive ventilation initiation. All data were routinely collected on the hospital’s electronic patient records. The primary outcome was the development of MAKEs at 365 days (MAKE-365), consisting of the composite endpoint of renal replacement therapy (RRT) or decline in estimated glomerular filtration rate (eGFR) of < 75% of baseline, or all-cause mortality. The concentration of urinary TIMP-2 and IGFBP-7 was measured with the NephroCheck® test (Astute Medical).

Results: A total of 31 sepsis patients were enrolled, of which 16 had ARDS. The median age was 59.0 years [IQR, 47.0-67.5], and most patients were males (61.3%). Twenty patients (64.5%) developed AKI, of which 13 (65.0%) experienced MAKE-365. The individual causes of MAKE-365 among those patients was categorised by the reduction in eGFR (6, 46.2%), followed by the new initiation for RRT (5, 38.5%) and death (2, 15.4%). Urinary [TIMP-2] *[IGFBP7] values in patients with MAKE-365 were significantly higher than in patients without MAKEs (Median 1.52, IQR [0.650-2.40] vs 0.565 [0.245 -1.12], P= 0.036) (Figure 1). Patients with high urinary [TIMP-2] *[IGFBP7] had a higher risk of developing MAKE-365 (OR= 2.69, 95% CI: 1.15-7.67, P= 0.021). The Kaplan-Meier survival curve analysis indicated sepsis patients with MAKE-365 have reduced survival over time (Figure 2).

Figure 1.

Boxplots of urinary [TIMP-2] *[IGFBP7] in sepsis patients with and without MAKE-365.

Figure 2.

Kaplan-Meier curves of the Time to Event of survival among patients with and without MAKE-365.

Conclusion: Higher urinary [TIMP-2]*[IGFBP7] was significantly associated with MAKE-365 in sepsis patients with and without ARDS during their ICU stay. However, further studies with large sample sizes are required to validate our outcomes and establish an optimal time point for assessing these biomarkers.

5590

Successful implementation of a new CRRT system: A “hard switch” approach

Susana Lucena-Amaro¹, Peachi Subramanian², Christopher John Kirwan²

¹ Bart’s Health NHS

² Bart’s Health NHS Trust

Introduction: The Royal London Hospital (RLH Adult Critical Care Unit (ACCU) is a 44-bedded mixed level 2/3 unit with a nursing establishment of 210. In normal times, ~3,000 patients are admitted every year, with a varied case-mix of surgical, trauma and medical patients.

ACCU provides continuous renal replacement therapy (CRRT) for ~12% of all admissions; more than twice the national average. CRRT is a complex, expensive and labour-intensive therapy.¹ The safe and efficient delivery of CRRT relies in a specialised nursing workforce, who are responsible for the device set up and the ongoing monitoring and adjustment of multiple treatment options. Despite subtherapeutic dosing being associated with longer length of stay and greater costs,² safety and performance indicators for CRRT are yet to be clearly defined or routinely measured.³

The CRRT manufacturer and main therapy modality (CVVH to CVVHD) at RLH were changed in July 2019 from a third-generation machine to the fourth generation OMNI® system, which was new to the UK market. The safe implementation of the OMNI® required a carefully designed strategy focused on the timely delivery of training to a large workforce and the setup of robust quality assurance processes.

Objectives: Primary objective was to evaluate safety and effectiveness of the implementation of a new CRRT system.

Secondary objective was to identify key contributing factors in the safe rollout of a new CRRT system.

Methods: CRRT audits are routinely carried out to measure performance. Safety concerns are raised through the incident reporting system (Datix).

A retrospective review of safety related incidents and audit data for old and new CRRT systems was completed.

Results:

Implementation and switch

14 face-to-face core and advanced training sessions were delivered in the 4 weeks leading up to the implementation date and attended by 146 nurses (81% of nurses in post). Training continued during the implementation period supplemented with weekly drop-in sessions available for all staff.

A “hard switch” implementation occurred where the 5 patients receiving CRRT were sequentially moved to the “new” OMNI®. Clinical educators were continuously on site for the initial 48 hours and available 24/7 for 2 weeks thereafter. “In hours” presence and training sessions continued for 3 weeks after the go-live day.

Ensuring Safety and Quality

No safety concerns or incidents leading to patient harm were reported in the six months following implementation. The rate of incidents reported related to any CRRT issues was unchanged between systems in the six months pre and post implementation (1.5% v 0.87%, p=0.5).

Audit data indicated an improved efficiency profile with the new system, where set usage was reduced by 50% (231 v 117, p=0.018) for the same number of patients (52 v 54) and therapy days (3 (1-39) v 3 (1-26), p=0.24). Filter life also improved from a median of 27 to 47 hours censored for reasons other than clotting (p<0.007).

Conclusions: It is possible and safe to introduce a new CRRT system as a ‘hard switch’. Measures of CRRT quality need clarifying but we were encouraged by the findings of our internal audits.

References

1. Lau D, Pannu N, James MT, et al. Costs and consequences of acute kidney injury after cardiac surgery: a cohort study. J Thorac Cardiovasc Surg 2021;162:880–7. (in BMJ: Opgenorth D, et al. BMJ Open 2022;12: e054583).

2. Cerdá J, Baldwin I, Honore PM, Villa G, Kellum JA, Ronco C. & Acute Dialysis Quality Initiative (ADQI) Consensus Group. Role of technology for the management of AKI in critically ill patients: From adoptive technology to precision continuous renal replacement therapy. Blood Purification 2016;42(3):248–265.

3. Rewa OG, Tolwani A, Mottes T, et al. Quality of care and safety measures of acute renal replacement therapy: Workgroup statements from the 22nd acute disease quality initiative (ADQI) consensus conference. J Crit Care 2019;54:52–7.

5002

Acute Bronchospasm - When Conventional Methods Fail

Joseph Gavin¹, Bryan Donohue², Sandra Gelvez-Zapata²

¹ The Lister Hospital

² Lister Hospital

Introduction: Acute bronchospasm is a clinical presentation to the Emergency Department which has the potential to escalate into a life threatening emergency. In the event that the intensive care team are required, it is likely that first and second line therapy have been exhausted. Whilst theoretically drugs such as ketamine and volatile anaesthetic agents have bronchodilatory properties, there is only brief mention of them in the British Thoracic Society Guidelines.¹

Objectives: To present a case of successfully managed life threatening bronchospasm by non-conventional means.

Methods: A gentleman in his 60s presented to the Emergency Department with severe bronchospasm. On presentation he had a silent chest and severe type 2 respiratory failure. Despite initial therapy with nebulised bronchodilators, steroids and magnesium he became extremely hypoxaemic and obtunded. The patient was intubated using ketamine as an induction agent, and sevoflurane for sedation.

Results: Following an initial period of difficult ventilation, the hypoxaemia resolved & acidosis began to correct. The patients arterial blood gases improved significantly over the next 12 hours and was successfully extubated. The patient made a full recovery and was discharged from ICU after 24 hours.

Conclusions: The use of sevoflurane & ketamine may be usefully employed when conventional methods of treating bronchospasm have been exhausted.

Reference

1. British Thoracic Society [Internet]. Asthma | British Thoracic Society | Better lung health for all. [cited 2022 Dec22]. Available from: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/

5064

Xtubation- ascertain the uncertain

Janani Vaghani¹, Sumit Vaghani¹, Thomas Owen²

¹ Royal Preston hospital

² royal preston hospital

EXtubation is an integral part of airway management. The ASA Task Force on Management of the Difficult Airway states that an extubation strategy is a logical extension of the intubation process¹ Even with the success of a spontaneous breathing trial, the possibility of an extubation failure (that is, the need for re-intubation within 48 to72 hours) is 10% to 20%.² Any extubation must have a protocolised approach in terms of assessing the patient for extubation, a post-extubation plan and have clearly-defined endpoints.³ An algorithm/checklist that could facilitate extubation assessment would improve quality of care and help assessing patients on an everyday basis by the bedside- also reduce the ICU stay of patients and bring financial benefit. There are different guidelines/ tests predicting success of extubation- but are very complex and need training and expertise. Our aim is to create an easy checklist that would facilitate extubation with minimal chances of failure.

Our study is a retrospective analysis ranging over a period of 6 months from 1/3/22 to 1/9/22. our study showed that 302 patients had level 3 care in our unit during that period- 9% of them got re-intubated which is within the expected level of extubation failure as per national guidelines. These patients were assessed in terms of the primary diagnosis, cause of extubation failure, time to re-intubation, SBt trial before extubation, CXR, anti-agitation measures, outcome and average stay in ITU post re-intubation. Results proved that the reason for extubation failure was multifactorial with increased secretions, poor cough being the primary reason, followed by agitation. Spontaneous breathing trial, cause of extubation failure, re-intubation and post extubation plan was not documented anywhere. Also, pain management, agitation management and chest physiotherapy input were not mentioned.

Hence, we suggest implementation of an extubation checklist, education among medical staff, doing SBT trials and cuff down assessment, laryngeal training on a regular basis and see if it helps protocolising extubation. The way forward is to re-audit in 6 months’ time

References

1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118: 251–70.

2. Esteban A, Frutos-Vivar F, Ferguson N, Arabi Y, Apezteguia C,Gonzales M, Epstein S, Hill N, Nava S, Soares M-A, D’Empaire G,Alia I, Anzueto A: Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004, 350: 2452-2460.

3. Sturgess DJ, Greenland KB, Senthuran S, Ajvadi FA, van Zundert A, Irwin MG. Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review. Anaesthesia. 2017 Feb;72(2):248-261. doi: 10.1111/anae.13668. Epub 2016 Nov 2. PMID: 27804108.

5371

Extubation practices in the intensive care unit: time for change

Abdul Rahim Bakhsh¹, Sukesh Pelluri², J J Patil²

¹ HEE north west

² The Royal Oldham Hospital

Introduction: Extubation with liberation off mechanical ventilation is a major step forward in the care of the critically ill. Current evidence shows that inappropriate extubation trials are associated with significant morbidity & mortality, that in addition leads to an increase in the length of stay on ICU. Implementation of predictors of successful extubation trials, though established, is not robust. The Difficult Airway Society guidelines for ‘at-risk’ extubation recommend a stepwise approach with a key focus on optimising patient related factors prior to attempts at extubation.¹ Therefore, we initiated this QIP to identify potential reasons for failed extubation, more specific to our patient population if any, and introduce measures to mitigate them.

Aims & Objectives: We audited extubation criteria, reintubation rates, possible reasons for failed trials of extubation and impact on length of stay in ICU. The eventual aim is to standardise the process of extubation in ICU with the introduction of an “Extubation Checklist” and improve patient safety by reduction in the morbidity & mortality associated with extubation.

Methods: The project was carried out at the Royal Oldham Hospital Intensive Care Unit following registration with the local audit department. The ICU is a 22-bedded unit in a moderately large district general hospital. Extubations are carried out by trained nursing staff on assessment of fitness criteria. Data was collected over a period of 5 months from October 2022 to March 2023. We looked at both prospective and retrospective extubation trials. We evaluated the assessment criteria for fitness to extubate and patients’ clinical parameters prior to and following extubation.

Results: We assessed 34 patients who underwent extubation trials. There were 9 (26%) failed extubations identified that required re-intubation. 10 (30%) of 34 cases were extubated onto nasal high flow oxygen, 2 of these 10 (20%) cases required re-intubation. 6/9 (66%) failed extubation attempts required re-intubation within 4 hours and 5/9 (55%) required a tracheostomy to enable liberation off the ventilator. The rapid shallow breathing index was noted to have been evaluated in only 3 of the 34 (8%) trials of extubation. Hypoxic respiratory failure with increased work of breathing was the most common reason for failure (40%) followed by excessive secretions (20%) and hyperactive delirium (20%). Of note, 1 case of failed extubation suffered hypoxic cardiac arrest with successful resuscitation and another one had to be re-intubated due to drop in GCS due to non-convulsive seizures. Only 11/34 patients (32%) had documented assessment of neuromuscular strength and upper airway reflexes. Most patients (85%) were noted to have reversal of underlying pathology prior to the extubation trial. There was no mortality attributable directly to any of the extubation attempt.

Conclusions: Hypoxia is the most common reason for failure despite most patients needing minimal oxygen support prior to extubation. Majority of the patients with failed extubation needed a tracheostomy. The re-intubation rates noted on our unit are higher than that quoted in available evidence (10-20%).² Use of an “extubation checklist” may lead to a reduction in the incidence of failed extubation.

References

1. Das extubation guidelines [Internet]. DAS Extubation Guidelines | Difficult Airway Society. [cited 2023 Feb 18]. Available from: https://das.uk.com/content/das-extubation-guidelines

2. Torrini F, Gendreau S, Morel J, Carteaux G, Thille AW, Antonelli M, et al. Prediction of extubation outcome in critically ill patients: A systematic review and meta-analysis. Critical Care. 2021;25(1).

5450

Establishing the relationship between neuroprotection measures and the need for chest physiotherapy techniques following traumatic brain injury

Mark Price

Kings College Hospital NHS Foundation trust

Introduction: The priority in the management of patients admitted with severe Traumatic Brain Injury (TBI) is to achieve physiological homeostasis whilst avoiding secondary injury to the brain.¹ Standard neuroprotective measures employed to achieve this include deep sedation, mandatory ventilation, temperature control and reverse trendelenburg positioning to facilitate CSF drainage whilst establishing ICPs between 5-15mmHg.²

Prolonged periods of recumbence, immobility and sedation are however associated with reduced lung volumes and impaired secretion clearance with potential development of chest infection and respiratory failure, which may further impact intracranial dynamics.³

To date there is little literature that explores the association between patients placed on neuroprotective measures, the need for chest physiotherapy and subsequent development of chest sepsis and respiratory failure.

Objectives: To examine the relationship between patients receiving neuroprotective measures and the need for chest physiotherapy to aid secretion clearance

To examine the number of patients on neuroprotection measures developing respiratory failure.

To review the physiotherapy interventions used to aid secretion clearance in patients receiving neuroprotective measures.

Methods: Electronic clinical notes were reviewed for all patients admitted to an 18-bed neurosurgical critical care unit from May 2021 to November 2022.

Patients receiving standard neuroprotective measures following primary admission with a TBI were included in the review. Patients were excluded if they had a pre-existing lung condition.

The following baseline data were extracted for patients: gender, age, ICP on admission, sedation duration, admission FiO2, RASS score and need for paralysis (Table 1).

Table 1.

Patient demographics.

	Neuroprotection	Control
Gender	M 69% (N=22)	M 56% (N=18)
Age	47 (18-84)	61.5 (19-85)
Baseline FiO2 on admission	.33 (.21-.65)	35 (.21-.100)
Baseline ICPs on admission	14mmHg (8/25)	-
Paralysed	77% (N=17)	9% (N=3)
Sedation Duration	8 days (1-20)	8 days (1-23)
RASS Score	-5 (-3–5)	-4 (-3–5)
RIP	26% (N=8)	6% (N=3)

The same data set was collected for a comparison group not receiving neuroprotection on the same critical care unit during the same period (Table 1).

Requirement for chest physiotherapy was based on clinical reasoning of the treating physiotherapist.

Data was collected on need for chest physiotherapy, day intervention was required, type of intervention and whether the patient developed respiratory failure whilst ventilated.

Data was analysed using descriptive statistics, presented as median (range) and absolute numbers as appropriate.

Results: 32 patients were assigned to the neuroprotective group and 32 patients to the comparison group.

62% of patients (n=20) on neuroprotective measures required chest physiotherapy compared to 47% (n=15) in the comparison group.

Peaks were seen in physiotherapy requirement on admission and day 4 post intubation.

Respiratory failure developed in 65% (n=13) of patients receiving neuroprotective measures compared to 25% (N=7) of the comparison group.

Physiotherapy interventions were similar preference between groups. Favouring expiratory vibrations (41% neuroprotection, 36% comparison), followed by cough assist (35% neuroprotection, 29% comparison) and hyperinflation (12% neuroprotection, 21% comparison). All patients in the neuroprotective group received mucolytics to facilitate clearance.

Conclusions: Patients receiving neuroprotective measures following a TBI demonstrated an increased need for chest physiotherapy whilst sedated compared to non-neuroprotected patients. Peaks in need were seen at admission and 4 days of ventilation. Development of respiratory failure was higher in the neuroprotected group than the comparison group.

Physiotherapy treatments were employed with similar frequencies in both groups.

Expanding the existing data pool and comparing to other neurosurgical units would allow a larger data set to further examine these trends.

References

1. Grände P-O, Juul N. Guidelines for treatment of patients with severe traumatic brain injury. Management of Severe Traumatic Brain Injury. 2020; 395–401.

2. Mezidi M, Guérin C. Effects of patient positioning on respiratory mechanics in mechanically ventilated ICU patients. Annals of Translational Medicine. 2018;6(19):384–.

3. Vinje V, Ringstad G, Lindstrøm EK, Valnes LM, Rognes ME, Eide PK, et al. Respiratory influence on cerebrospinal fluid flow – a computational study based on long-term intracranial pressure measurements. Scientific Reports. 2019;9(1).

5568

Safety and benefit of early Fibreoptic Endoscopic Evaluation of Swallowing (FEES) in patients with a tracheostomy on Extra-Corporeal Membrane Oxygenation (ECMO)

Elicia Jones, Sarah Wallace

Manchester University NHS Foundation Trust

Introduction: The use of FEES for accurate swallowing assessment in ICU is well established (Hafner et al. 2008). However, it’s utility within the ECMO population has not been previously reported. ECMO is a specialised intervention for patients with very severe respiratory failure and increasingly, patients are safely undergoing tracheostomy during ECMO to facilitate weaning from sedation (Grewal et al. 2020). For many patients oral intake is a priority yet they frequently remain cuff inflated, ventilated and nil by mouth for weeks due to concerns regarding dysphagia, aspiration and laryngeal trauma (Wallace et al. 2021). Dysphagia and intubation-related laryngeal injury are common in ICU and FEES is the only accurate assessment tool when a tracheostomy cuff is inflated. The need to avoid complications such as aspiration pneumonia (Dallal-York et al. 2022), bleeding risks and medical instability also delay oral feeding. In our cardiothoracic ICU FEES is well established and in collaboration with the MDT, we piloted FEES in this population.

Objectives:

1. To explore the safety and benefits of FEES during ECMO

2. To report laryngeal injury, swallow function and feeding outcomes during and after ECMO.

Methods: A pilot retrospective observational study of consecutive FEES was carried out in our tertiary hospital cardiothoracic ICU (a designated ECMO centre). FEES was carried out by two trained and experienced SLTs using Xion EndoFlex digital nasendoscope equipment, using routine procedure with oral trials and validated rating scales. Saliva secretions, laryngeal injury, swallow function, aspiration risk, adverse effects and feeding outcomes were recorded. Timing of FEES was dependent on medical stability and included patients receiving ECMO and those recently decannulated, still ventilated. All were tracheotomised with cuff inflated.

Results: 7 patients (4 females, 3 males), age range 29-43 years (median 40 years) underwent FEES. Medical diagnoses included 2 lung transplant, 3 COVID pneumonitis and 2 severe asthma. 3 patients were receiving ECMO, and 4 patients were two to three weeks post ECMO decannulation. Time from commencing ECMO to FEES was 10-65 days.

No adverse effects occurred during or post FEES.

Laryngeal injury was seen in all 7 patients.

Laryngeal injury FEES findings	n = 7
Unilateral vocal cord palsy/paresis	4
Laryngeal oedema	4
Posterior glottic granulation	4
Erythema	6
Vocal cord atrophy	3
Laryngopharyngeal reflux signs	7

3/7 patients were silently aspirating secretions and were unsafe for oral trials. 2 patients had normal secretions and 2 had mild pooling. On oral trials, 2 patients had no laryngeal penetration or aspiration, 1 patient aspirated overtly and 2 had laryngeal penetration but no aspiration. Oral trials frequently resulted in pharyngeal residue due to swallow weakness and fatigue.

3/7 patients remained NBM following FEES due to high aspiration risk. 4 were safe to commence oral feeding: 4 on normal fluids, 3 on modified diet and 1 on normal diet. 2 were recommended therapeutic Above Cuff Vocalisation (ACV) and 4 instigated swallowing exercises. 2 patients commenced medication to reduce secretions and 1 increased reflux medication following MDT discussion.

Conclusion: This small pilot study indicates that early FEES in this cohort is safe and facilitates early identification of laryngeal injury, dysphagia and aspiration risk. Laryngeal injury has important implications for voice, swallowing, tracheostomy weaning and decannulation. Importantly, FEES enabled early safe oral feeding in patients who would have otherwise been kept NBM, benefitting quality of life. Uniquely, FEES allowed safe oral intake during ECMO.

Further research is needed. FEES in this population requires experienced SLT, embedded within the MDT ensuring optimal collaboration, safety and patient outcomes.

References

Hafner G, Neuhuber A, Hirtenfelder S et.al. Fiberoptic endoscopic evaluation of swallowing in intensive care unit patients. Eur Arch Otorhinolaryngol. 2008 Apr;265(4):441-6.

Grewal J, Sutt A-L, Cornmell G et. al. Safety and Putative Benefits of Tracheostomy Tube Placement in Patients on Extracorporeal Membrane Oxygenation: A Single-Center Experience. J Int Care Med 35 (2020): 1153-1161.

Wallace, S, McGrath B.A Laryngeal complications after tracheal intubation and tracheostomy: A MDT approach. (2021). Brit J Anaesth Educ

Dallal-York J, Segalewitz T, Croft K et.al. Incidence, risk factors, and sequelae of dysphagia mediated aspiration following lung transplantation. J Heart Lung Transplant. 2022 Aug;41(8):1095-1103.

McGowan SL, Gleeson M, Smith M. A pilot study of fibreoptic endoscopic evaluation of swallowing in patients with cuffed tracheostomies in neurological intensive care. Neurocrit care 2007; 6:90-93.

5001

Should we can the CAM? Screening for Delirium on a Neuro-Intensive Care Unit

Jeanie Worthington¹, Jonathan Smith¹, Gen Gomez²

¹ North Bristol NHS Trust

² Intensive care unit at North Bristol NHS trust

Introduction and Objectives: Delirium is highly prevalent in intensive care unit (ICU) patients, and is associated with increased mortality, prolonged ICU and hospital stay, and increased long-term cognitive impairment.¹ As such, Guidelines for The Provision of Intensive Care Services (GPICS) advise daily screening using an approved tool.² At North Bristol NHS Trust (NBT) ICU (a 48-bed unit), the Confusion Assessment Method for the ICU (CAM-ICU) is the designated screening tool for delirium. This study aims to determine whether the CAM-ICU screening in this unit complies with the GPICS standard, to explore how well CAM-ICU correlates with clinical judgement when assessing delirium and therefore explore how effective we are at detecting delirium. With the implementation of a delirium and sleep working group, including members of the multi-disciplinary team (clinical psychologists, senior nurses, ICU consultants and junior doctors), we aimed to improve the identification, screening, prevention and treatment of delirium and also identify factors that were affecting patients sleep using a validated sleep questionnaire.³

Methods: The first stage of the data collection looked at CAM-ICU screening entries recorded on our computerised notes system. These were retrospectively analysed for 46 inpatients over a 48-hour period. Subsequently, CAM-ICU screening was performed on eligible patients across NBT ICU on two separate days. The consultants and senior nurses responsible for these patients then provided their clinical judgement on which patients had delirium. Patients were also asked questions about their sleep using the Richards-Campbell sleep questionnaire (RCSQ).

Results: Regarding screening frequency, at least once daily CAM-ICU screening was recorded in only 6 patients, whilst 40 were not screened at all during the study period. For the second stage of the data collection, looking at CAM-ICU screening performed, there were 14/58 (24.1%) positive CAM-ICU scores: only 35.7% (5/14) of these cases were identified as delirium by ICU consultants and only 50% (7/14) identified by nurses in charge. Consultants identified 12/58 (20.7%) cases of delirium in total, of these only 41.7% (5/12) were CAM-ICU positive. According to the RCSQ, across all areas of sleep, the average score was 53 or below, indicating poor quality of sleep, frequent awakenings, difficulty returning to sleep and high noise levels.

Conclusions: In conclusion, at NBT ICU, CAM-ICU screening rarely meets the GPICS standard. Moreover, there is a poor correlation between CAM-ICU screening and clinical judgement. Sleep quality is poor for all ICU patients leading to a significant impact on levels of delirium. These findings will guide the department how best to screen for delirium. Based on the data collected, there will be continuing focus on this area by the Delirium and Sleep working group, with various strategies on screening to be implemented in the future months. Further preventative strategies to be considered include orientation tools, optimising patient circadian rhythms and discussion with the wider MDT to create a pragmatic and practical approach to the prevention, screening and treatment of delirium.

References

1. Reade M et al. Sedation and Delirium in the Intensive Care Unit. The New England Journal of Medicine. 2014;370:444-54.

2. The Faculty of Intensive Care Medicine/Intensive Care Society. Guidelines for the Provision of Intensive care Services. Version 2.1. July 2022.

3. Locihova et al. Sleep quality assessment in intensive care: Actigraphy vs. Richards-Campbell Sleep Questionnaire. Sleep Science. 2020.

5018

Inhaled sedation - Where do the cost savings come from?

Chloe Prager

East and North Hertfordshire NHS Trust

Introduction: NICE Medical Technology Guidance (MTG) 65 recommends the anaesthetic conserving device Sedaconda ACD-S as a cost-saving option for delivering inhaled sedation in an intensive care setting when inhaled sedation is indicated. NICE cost modelling is based on a 30 day model comparing it to the cost of sedation with IV propofol. They predict a cost saving of £3,833.76 per adult based on savings from reduced time on mechanical ventilation and reduced time in critical care. Despite uncertainties in the data used, NICE conclude that the threshold for the treatment to be cost saving is low. The aim of this case presentation is to use a real life case to demonstrate the actualised cost savings from additional factors not considered in the NICE MTG.

Objectives:

1. Outline the medical technologies guidance from NICE

2. Using a patient case study demonstrate how inhaled sedation can deliver cost savings in terms of

 a) Drug costs

 b) Use of ancillaries

 c) Nursing time

Methods:

Case study – Necrotising pancreatitis

36 year old male diagnosed with alcohol induced necrotising pancreatitis with AKI stage 3 and metabolic acidosis and portal vein thrombus requiring multi organ support

He had high sedation requirements for 10 days. Various combinations of sedatives and neuromuscular blockers were trialled to keep patient safely ventilated and sedated.

Inhaled sedation with isoflurane using the Sedaconda ACD-S was commenced and all other IV sedation apart from fentanyl for pain relief were tapered down over a short period of time as inhaled sedation became effective.

Results:

Pre-initiation of inhaled sedation - TOTAL DRUG COST £400

Drug	Dose	Number of syringes/24hrs
Propofol	100mg/hr	NA
Fentanyl	250mcg/hr	3
Midazolam	24mg/hr	12
Dexmedetomidine	147mcg/hr	8
Atracurium	80mg/hr	4
Noradrenaline	1.28mg/hr	3
	Total:	30

Post-initiation of inhaled sedation - TOTAL DRUG COST INCLUDING SEDACONDA KIT £116

Drug	Dose	Number of syringes/24hrs
Propofol	-
Fentanyl	250mcg/hr	3
Midazolam	-
Dexmedetomidine	-
Atracurium	-
Isoflurane	9ml/hr	6 (provided in kit)
Noradrenaline	0.38mg/hr	2
	Total:	11

Saving of £284/24hrs plus 1/3 of the syringe changes reducing valuable nursing time with drug preparation.

Conclusion: NICE states that using Sedaconda ACD-S for inhaled sedation is cost saving based on reduced time on mechanical ventilation and in critical care. This real-life case demonstrates significant additional daily cost saving based on factors not considered by NICE such as drug costs, use of ancillaries and nursing time.

Reference

Sedaconda ACD-S for sedation with volatile anaesthetics in intensive care NICE Medical technologies guidance [MTG65] Published: 27 January 2022.

5025

Daily sedation holds in critical care: a quality improvement project

Joanna Lau¹, Martin O’Connell¹, Esme Lewis¹, Thomas Wallbridge¹, Rebecca Rice¹, Jack Butler²

¹ Russells Hall Hospital

² -

Introduction: Sedation infusions are commonly used on the intensive care unit, principally to limit the stress response to mechanical ventilation. However, over-sedation has undesirable side effects of hypotension, pneumonia, prolonged ventilation, and prolonged ICU stay¹. Sedation holds are known to reduce ventilation time, length of ICU stay, and complications such as pneumonia and venous thromboembolism².

Objectives

1. Audit whether sedation holds are occurring appropriately in our district general hospital intensive care unit

2. Identify barriers to nursing staff performing sedation holds independently

3. Deliver targeted intervention via “tea trolley” teaching and re-audit

Methods: We analysed the digital records of patients present on area A of our intensive care unit between 20/10/22 and 26/10/22. All patients on this area have their data recorded on IntelliSpace Critical Care and Anaesthesia (ICCA), which allowed for consistency in information gathering.

A patient on a sedation infusion on one day of their stay was counted as one “period” of sedation. For each period, we looked in the medical ward round entry, nursing notes, neurological observations, and drug chart, for documentation of a sedation hold.

If no sedation hold was documented, we looked for contraindications as defined by our Trust guidance (neuromuscular blocking agents, possibility of raised ICP/head injury, or respiratory parameters suggesting difficulty in ventilation).

We asked our nursing staff to answer an anonymised survey to gauge confidence in sedation holds and perceived barriers to performing sedation holds independently. Based on these findings, we developed “tea trolley” teaching delivered by senior nursing staff.

Results: On our initial audit, 30 out of 39 periods of sedation were managed appropriately (sedation hold performed, or contraindicated). We identified 7 missed opportunities for a sedation hold. Sedation was stopped in the remaining 2 periods for end of life care.

When surveyed, nursing staff (n=18) cited a junior workforce, and lack of knowledge, as barriers to performing sedation holds independently.

Following education through “tea trolley” teaching, we re-audited and found a similar proportion received appropriate management (47 out of 67 sedation periods).

However, compared with our initial audit, we found that sedation holds were occurring earlier in the day (10/16 performed before 10am, compared to 1/15 on initial audit) and were better documented in the nursing notes (13/22 compared to 5/15) and neurological observations (11/22 compared to 4/15).

Conclusions: The majority of patients in area A of our district general hospital intensive care unit are on sedation infusions. Though we are performing better than we had expected (30 out of 39 patients receiving appropriate management), sedation holds are often performed after ward round instruction, later in the day. This has the potential to delay progress in care. We would like to re-instigate the culture of nurse-led sedation holds being performed early in the day.

Nursing staff cite a junior workforce and a lack of knowledge as reasons for the lack of nurse-led sedation holds performed. Education has improved the timing of early morning sedation holds, as well as nursing documentation, potentially expediting patient progress through their hospital journey.

References

1. Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114:541–548.

2. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471–1477.

5370

Re-Audit for Delirium in Cardiothoracic Intensive Care Unit

Ashutosh Meena, Smitangshu Mukherjee

Imperial College Healthcare NHS Trust

Introduction:

• In Previous Audit - Data was collected for potential causes of Delirium and how it was managed.

• Recommended to reinforce use of Delirium package tool and training for RASS and CAM-ICU assessment.

• In Re-Audit we compared the current practice with relevant Good Standard Practice and NICE Quality standards.

Aims & Objectives:

• In Re-Audit,we compared the current practice with,

Relevant NICE Quality Standards

• Assessing recent changes that may indicate Delirium.

• Interventions to prevent Delirium.

• Communication of Diagnosis to primary team

Relevant Good Standard Practice

• Daily Sedation Wean

• Daily Sedation Goal

• Use of Delirium package tool

Methodology

• Data was collected retrospectively for 1 month duration.

• All the patients who suffered from Delirium were identified (CAM-ICU used) and relevant data was collected from Electronic Documentation Platform and collated.

• Data colletion format:

Age	Sex	Type of Delirium	Surgical	Medical	Delirium Risk Factors	Delirium package tool used	Daily Delirium Assessment	Documentation of Daily sedation wean plan	Daily Sedation goal documentation	Duration of stay	Outcome	Delirium Diagnosis/ Event documentation	Documeted/Informed to primary team on discharge about Delirium diagnosis/event

Results:

• Key Findings

  • Median ICU Length of stay was 12 days and Median age was 73 yr.
  • 8 Surgical and 4 Medical patient.
  • Delirium incidence in the respective month was 20% (12 out of 60 patients).
  • Nursing Documentation of Delirium assessment and use of Delirium package tool (‘DREAMS’) had 100% compliance.
  • Medical Plan for Sedation goal and sedation wean was not documented regularly.
  • Patients who were at high risk of Delirium not identified at admission.
  • Handover to the primary team at discharge about the diagnosis of Delirium was not documented.

Strengths of this audit

• Each patient’s management compared against NICE Quality Standards.

• Over a 4-week period the audit managed to capture 12 patients with Delirium.

Limitations

• Large Dataset on electronic health records, possibility of some inaccuracies.

• No Hypoactive Delirium was diagnosed.

Conclusion:

Reflection on local practice

• Burden of Delirium remain high in the Unit.

• Hypoactive Delirium remain hard to diagnose.

Key strengths identified

• 100 percent Compliance of Nurses for Delirium assessment and use of Delirium package tool.

Key areas for improvement

• Delirium risk assessment for all ICU admitted patients.

• Needed awareness and training to detect Hypoactive Delirium.

• Medical team needs to comment on sedation plan and sedation goal on daily basis.

• Documentation of diagnosis/event of delirium in handover to the primary team at discharge.

Recommendations:

Ref.	Gap identified/Risk area	Recommendation	Management Comments (How will you know that actions are completed?)
1.	Medical team documentation for Sedation Goal and sedation Wean	Make aware the ICU department of the issue	Trial of Use of standard ICU Medical Notes Checklist (as checklist resulted in 100% compliance for nursing documentation)
2.	Delirium Risk assessment for all ICU admitted patients.	same	ICCA Nursing admission Checklist update
3.	Awareness and training to detect hypoactive Delirium	same	Education and training
4.	Documentation of the diagnosis of Delirium in handover to the primary team at discharge.	same	Development of discharge Documentation Checklist

References

https://www.nice.org.uk/guidance/qs63/chapter/List-of-quality-statements

https://www.imperial.nhs.uk/about-us/blog/easing-delirium-in-intensive-care

5504

Intravenous thiamine as a potential therapy for agitation and delirium in critically ill patients: a survey of clinician perspectives

Ashraf Mumin¹, Leanne Aitken², Daniel Hadfield³, Fraser Hanks⁴, Valerie Page⁵, Edwin van Dellen⁶, Arjen J C Slooter⁶, Bronagh Blackwood⁷, Daniel McAuley⁷, Peter E Spronk⁸, Mike P W Grocott⁹, Cathrine A McKenzie⁹

¹ Pharmacy, King’s College Hospital NHS Foundation Trust, London, United Kingdom

² School of health and psychological sciences, City, University of London, London, United Kingdom

³ Critical care, King’s College Hospital NHS Foundation Trust, London, United Kingdom

⁴ Pharmacy, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom

⁵ Intensive care, Watford General Hospital, Watford, United Kingdom

⁶ Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

⁷ Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom

⁸ Intensive care, Gelre ziekenhuizen Apeldoorn, Apeldoorn, Netherlands

⁹ Perioperative and Critical Care Theme, Southampton NIHR Biomedical Research Centre, University Hospital Southampton, Southampton, United Kingdom

Introduction: Delirium is common in critical illness,¹ a leading predictor of long-term cognitive impairment,² and distressing for patients and caregivers, who have ranked it within the top three priority areas for research in the Intensive Care Unit (ICU).³ Currently, there is no effective pharmacological therapy for delirium.⁴ Thiamine di-phosphate (TDP), the active form of thiamine, is an essential cofactor in glucose metabolism, glutamate transformation and acetylcholinesterase activity; all reported in delirium occurrence.⁵ We hypothesised that routine intravenous (IV) thiamine supplementation in ICU will reduce the number of days a patient spends in delirium. The aim of this survey was to explore ICU clinician perspectives for IV thiamine in agitation and delirium.

Objectives: The objectives of this survey were to: 1) establish clinical scenarios where clinicians considered that IV thiamine may be effective; 2) seek views on established therapy including antipsychotics and alpha-2-agonists; 3) establish the views on safety of IV thiamine and compare to established therapy; 4) describe interest in randomised clinical trial of IV thiamine or Pabrinex® for agitation and delirium in critical care.

Methods: An on-line survey was devised, assessed and piloted, then revised by UK delirium experts and disseminated to UK-based ICU clinicians, by a variety of methods including email and via professional networks and social media (https://www.surveymonkey.co.uk/r/WDNHVTJ). Reminders were sent every two weeks for eight weeks. Data were collated and analysed using Microsoft Excel.

Results: 189 respondents to the online survey included medical doctors (91, 48.1%), clinical pharmacists (85, 45.0%), nurses (10, 5.3%) and advanced critical care practitioners (3, 1.6%). With regard to treatment with IV thiamine in agitation and delirium (including refractory cases) in critical illness: a total of 35 (19.6%) reported they would review, recommend, prescribe or administer IV thiamine in the acute scenario (fig. 1), whereas 115 (64.2%) responded that they would not. In contrast, 80 (44.7%) reported daily to weekly prescribing of antipsychotics, and 88 (49.2%) reported daily to weekly prescribing of alpha-2-agonists in agitation and delirium (fig. 2). Regarding safety, 145 (81%) respondents considered thiamine safe, in contrast to antipsychotics and alpha-2 agonists, where only 8 (4.5%) and 11 (6.1%) respondents respectively described these therapies as safe. Finally, 117 (66.5%) expressed an interest in participating in a randomised controlled trial (RCT) of IV thiamine for agitation and delirium in critical illness.

Figure 2.

Reviewing, recommending, prescribing or administering other pharmacological therapy in agitation and/ or delirium in ICU.

Figure 3.

Relative attitudes towards safety/adverse event profiles of pharmacological therapies in ICU.

Conclusions: Relative equipoise existed among critical care clinicians with regard to IV thiamine use in agitation and delirium in the acute scenario. It was not surprising that more respondents opted for antipsychotics and/ or alpha-2-agonists, as this mimics the current clinical practice. More than 80% regarded IV thiamine as safe and it was deemed safer than antipsychotics or alpha-2-agonists. There was strong support among ICU clinicians for an RCT to explore IV thiamine as a therapy for agitation and delirium.

References

1. Slooter AJC, Otte WM, Devlin JW et al. Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Med. 2020 May;46(5):1020–2.

2. Pandharipande PP, Girard TD, Jackson JC et al. Long-Term Cognitive Impairment after Critical Illness. N Engl J Med. 2013 Oct 3;369(14):1306–16.

3. Reay H, Arulkumaran N, Brett SJ. Priorities for Future Intensive Care Research in the UK: Results of a James Lind Alliance Priority Setting Partnership. J Intensive Care Soc. 2014 Oct;15(4):288–96.

4. Burry L, Mehta S, Perreault MM et al. Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Dementia and Cognitive Improvement Group, editor. Cochrane Database Syst Rev [Internet]. 2018 Jun 18 [cited 2023 Feb 24];2018(6). Available from: http://doi.wiley.com/10.1002/14651858.CD005594.pub3

5. Marrs C, Lonsdale D. Hiding in Plain Sight: Modern Thiamine Deficiency. Cells. 2021 Sep 29;10(10):2595.

5907

Presence of fentanyl in urine following extubation is associated with delirium in adult intensive care patients

Tej Pandya¹, Christos Costa², Will Thomson¹, John Prowle¹, Zudin Puthucheary¹

¹ Adult Critical Care Unit, Royal London Hospital, William Harvey, Research Institute, Barts and The London School of Medicine and Dentistry

² Barts and The London School of Medicine and Dentistry, Queen Mary University of London

Introduction: Delirium affects more than half of patients in the intensive care unit (ICU) and is associated with poorer long-term outcomes including longer hospital stay, an increased risk of cognitive impairment, and higher ICU and in-hospital mortality.¹ The causes of delirium are associated with numerous risk factors, one of which is the use of opioids for pain management.² Fentanyl is the most common opioid used in adult intensive care for analgesia and sedation, given in up-to 78% of patients.³ The metabolism of fentanyl is significantly altered in critical illness due to inflammation, reduced hepatic blood flow and kidney dysfunction and this could lead to prolonged effects following cessation of infusion.⁴

Objectives: We sought to determine the presence of fentanyl in patients’ urine following cessation of infusion and its association with delirium.

Methods: 46 urine samples were taken from 37 patients 24-72 hours following cessation of fentanyl infusion. Samples were then tested for fentanyl using a competitive lateral flow immuno-assay (Nal van Minden Drug-Screen ® FYL 10 (Nal van Minden, Germany) with a cut-off sensitivity of 10ng/ml. Baseline characteristics and dosing information was collected for each patient with delirium assessed using the Confusion Method for ICU (CAM-ICU).

Results: Patients who were delirious (n=24) were significantly more likely (p<0.05) to have fentanyl in their urine then non-delirious patients (n=22). Amongst delirious patients, the total amount of fentanyl given after adjusting for weight and time was greater than in non-delirious patients. There were no significant differences in blood and physiological characteristics between the two groups of patients.

Conclusions: Prolonged fentanyl usage is associated with delirium in adult intensive care patients. Larger differentials in the preceding 24 hours prior to extubation may be contributing to delirium through withdrawal effects. Further work should target examining how altered pharmacokinetics of fentanyl contribute to delirium.

References

1. Fiest KM, Soo A, Hee Lee C, Niven DJ, Ely EW, Doig CJ, Stelfox HT. Long-term outcomes in ICU patients with delirium: a population-based cohort study. American Journal of Respiratory and Critical Care Medicine. 2021 Aug 15;204(4):412-20.

2. Zaal IJ, Devlin JW, Peelen LM, Slooter AJ. A systematic review of risk factors for delirium in the ICU. Critical care medicine. 2015 Jan 1;43(1):40-7.

3. Luz M, Brandão Barreto B, de Castro RE, Salluh J, Dal-Pizzol F, Araujo C, De Jong A,Chanques G, Myatra SN, Tobar E, Gimenez-Esparza Vich C. Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic. Annals of intensive care. 2022 Feb 4;12(1):9.

4. Andrew HW, Ling L, Lee A, Joynt GM. Altered pharmacokinetics in prolonged infusions of sedatives and analgesics among adult critically ill patients: a systematic review. Clinical therapeutics. 2018 Sep 1;40(9):1598-615.

5331

A multi-centre evaluation of the use of anakinra in the management of haemophagocytic lymphohistiocytosis secondary to COVID-19

Luke Flower¹, Nicholas Laundy², Maryam Khosravi³, Jim Buckley⁴, Aislinn Gale⁵, Oluwatomisin Otenigbagbe⁶, Inder Kumar⁷, Rachel Tattersal⁸, Jessica Manson⁹, Vanessa Quick⁸

¹ William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London

² Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

³ Kings College Hospital NHS Foundation Trust

⁴ Royal Free London NHS Foundation Trust

⁵ Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK

⁶ School of Medicine, University of Leeds

⁷ East Lancashire Hospitals NHS Trust

⁸ Luton and Dunstable University Hospital

⁹ University College London Hospitals NHS Trust

Background: A small sub-group of patients with COVID-19 develop secondary haemophagocytic lymphohistiocytosis (sHLH). Diagnosis of sHLH remains a challenge and there is limited evidence on management.^1,2 The interleukin-1 receptor antagonist anakinra has a good safety record in critically ill people and was a locally agreed treatment option in several UK hospitals in the pandemic.³

Objectives: Retrospective evaluation of anakinra in the management of people with COVID-19 associated sHLH (COV-HLH) assessing clinical trajectory, common dosing regimens and patient outcomes.

Methods: We collected data from people treated with anakinra for COV-HLH admitted to three NHS Hospital Trusts over a four-month period during the first wave of the pandemic. Data were collected on ten patients over a three-week period from treatment initiation. Final patient outcome was recorded at 14 weeks. The project was registered with the clinical governance departments at each participating hospital with individual case consent and two patients contributing to the analysis. Ethical approval was not required.

Results: All 10 patients were admitted to intensive care (ICU). Median age was 46 and 80% (8/10) were male. sHLH was defined by a combination of clinical trajectory, modified HScore and expert review. At treatment initiation all patients had a HScore of >143·5 and/or a serum ferritin of >10,000µg/L. Anakinra treatment regimens varied from 70mg IV BD to 200mg IV TDS. Four patients started on ≤200mg anakinra per day required rapid up-titration to 200mg IV BD. A median reduction in ferritin (9576µg/L to 3034µg/L), temperature (38.8-37.0°C, p=0·039), and HScore (164-84, p=0·004) was observed at 14 days after anakinra initiation (figure 1). Mortality was 40%.

Figure 1.

Line graphs of change in parameters over 21 dats of treatment for each patient.

Conclusion: The challenges associated with sHLH diagnosis became more apparent during the peak of the COVID-19 pandemic where key components of the HScore were difficult to obtain. An experienced multidisciplinary team approach was important for early recognition and treatment. Mortality in this small cohort was lower than previously reported for sHLH and for COVID-19 ICU admission. An improvement in both physiological and biochemical parameters following initiation of anakinra was seen. Optimal treatment for COV-HLH and sHLH are not supported by randomised controlled trials but this series adds to accumulating evidence for anakinra.

References

1. Flower L, Gale A, Elfar E, et al. Adult onset PIMS-TS with secondary haemophagocytic lymphistiocytosis: into the eye of the cytokine storm, Rheumatology Advances in Practice. 2021; 1: i1.

2. Flower L, Laundy N, Khosravi M, et al. Haemophagocytic lymphohistiocytosis secondary to COVID-19: a case series. Lancet Rheumatology. 2021;3: e744-e747.

3. Mehta P, Cron RQ, Hartwell J, et al. Silencing the cytokine storm: the use of intravenous anakinra in haemophagocytic lymphohistiocytosis or macrophage activation syndrome. Lancet Rheumatology. 2020;(6):e358-e367.

5623

A case of haemophagocytic lymphohistiocytosis precipitated by T-cell lymphoma

Virad Kisan, David Purchase, Tom Beach

Ysbyty Glan Clwyd

Background: Haemophagocytic lymphohistiocytosis (HLH) is a syndrome of immune dysregulation with excessive activation of cytotoxic T-lymphocytes, natural killer cells and macrophages.^1-3 This leads to tissue damage causing life-threatening multi-organ failure. HLH is usually triggered by both infective and non-infective inflammatory causes. HLH is more common in children but can also affect adults.¹ A greater proportion of adult cases are triggered by malignancy and have a poor prognosis.^3-4 There are genetic mutations associated with HLH, often involving elements of the cytotoxic granule pathways, however these are not always identified.²

Case Summary: Our case report concerns a fit and well female in her 60’s in a Welsh district general hospital (Figure 1).

Figure 1.

Case Summary.

She initially presented to A+E with pyrexia. She was admitted and treated for a suspected bacterial infection of unknown origin whilst extensive investigations were performed. Initial positive findings (including ANCA, EBV + CMV serology) confused the picture. Around 10 days into her admission T cell lymphoma was diagnosed, and a diagnosis of HLH followed shortly afterwards. Marked clinical deterioration occurred and she was transferred to ICU with multi-organ failure. Despite tertiary centre input regarding HLH management, and inpatient chemotherapy, treatment response was poor. The patient was eventually palliated and passed away shortly afterwards.

Discussion: HLH commonly presents as pyrexia of unknown origin (PUO) with organomegaly and organ dysfunction.^1,4 Many diagnostic features of HLH are non-specific. As seen in this case, patients are often initially managed as sepsis despite no clear infective source.³ HLH is usually considered as a differential relatively late in presentations, after treatment with broad spectrum antimicrobials fail, leading to inferior patient outcomes.

In our case, HLH was considered as a differential only after discussion with the Liverpool Infectious Diseases team. Local haematology services were consulted throughout the patient’s admission, especially from a HLH perspective. This patient however did not meet formal HLH-2004 diagnostic criteria or diagnostic H-Scores until relatively late in their presentation with raised triglycerides and a markedly raised ferritin.^4-5

Management of HLH involves immunosuppressive treatments to induce remission as outlined in the HLH-2004 protocol.⁴ The patient was discussed with the Newcastle Adult Histiocytosis Clinic which advised treating as HLH. The patient received Anakinra (IL-1 receptor antagonist) and methylprednisolone.

Simultaneous management of the underlying trigger of HLH is concurrently required; in this case high-grade T-Cell lymphoma.³ A decision was made to give R-CHOP and DOBCL chemotherapy to treat the underlying trigger. Adult presentation HLH driven by underlying malignancy carries an especially poor prognosis. This patient unfortunately did not tolerate treatment, developed multi-organ failure and died.

If HLH remission is induced, patients are considered for allogenic haematopoietic cell transplantation.

Learning points

• HLH should be considered as a differential in patients with PUO or sepsis not responding to antimicrobial treatment.³

• H-Score can be used to screen patients based on history and readily available investigations (Figure 2).⁵

• HLH-2004 diagnostic criteria involve testing conducted in relatively few centres with long turnaround times.⁴ It is however possible to meet HLH-2004 diagnostic criteria with readily available testing.

• histiouk.org provides useful contacts for specialist advice.

Figure 2.

HScore.

References

1. Risma K, Jordan MB. Hemophagocytic lymphohistiocytosis: updates and evolving concepts. Curr Opin Pediatr. 2012 Feb;24(1):9-15. doi: 10.1097/MOP.0b013e32834ec9c1. PMID: 22189397.

2. Pachlopnik Schmid J, Côte M, Ménager MM, Burgess A, Nehme N, Ménasché G, et al. Inherited defects in lymphocyte cytotoxic activity. Immunol Rev. 2010 May;235(1):10-23. doi: 10.1111/j.0105-2896.2010.00890.x. PMID: 20536552.

3. Strenger V, Merth G, Lackner H, Aberle SW, Kessler HH, Seidel MG, et al. Malignancy and chemotherapy induced haemophagocytic lymphohistiocytosis in children and adolescents - a single centre experience of 20 years. Ann Hematol. 2018 Jun;97(6):989-998. doi: 10.1007/s00277-018-3254-4. PMID: 29411124.

4. Henter JI, Horne A, Aricó M, Egeler RM, Filipovich AH, Imashuku S, et al. HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer. 2007 Feb;48(2): 124-31. doi: 10.1002/pbc.21039. PMID: 16937360.

5. Debaugnies F, Mahadeb B, Ferster A, Meuleman N, Rozen L, Demulder A, et al. Performances of the H-Score for Diagnosis of Hemophagocytic Lymphohistiocytosis in Adult and Pediatric Patients. Am J Clin Pathol. 2016 Jun;145(6):862-70. doi: 10.1093/ajcp/aqw076. PMID: 27298397.

5477

Procalcitonin-Guided Antibiotic Therapy: A QI Initiative to Improve Antimicrobial Stewardship in Critical Care

Sophie Thompson¹, Anandh Balu¹, Jonathan Collins¹, Phillip Harrington², James Baker¹, Luke Hawkins¹, Mohammed Arshad¹, Jaimin Patel¹

¹ University Hospitals Birmingham NHS Foundation Trust

² Worcestershire Acute Hospitals NHS Trust

Introduction: Sepsis is associated with significant morbidity and mortality. Early initiation of antibiotics in sepsis is vital in improving outcomes, however appropriate de-escalation is equally important and has also been shown to both improve outcomes and reduce antimicrobial resistance, a global health priority.^1,2 Serum procalcitonin (PCT) is a sensitive and specific biomarker of bacterial infection, which has been shown to reduce antibiotic duration in sepsis.^3,4 Algorithms for PCT-guided antibiotic therapy suggest a PCT value of <0.25 as the cut off for the discontinuation of antibiotics.⁴

Objectives: This QI project aims to implement a PCT-guided antibiotic therapy protocol in our ICU to facilitate early discontinuation of antibiotics, drive change in prescribing habits and promote antimicrobial stewardship.

Methods: This study was conducted at the Queen Elizabeth Hospital, Birmingham, a large tertiary centre with approximately 2500 ICU admissions annually. A PCT-guided algorithm was implemented to guide clinicians regarding antibiotic cessation based on serum PCT. It recommended that PCT be measured at the time of commencement of antibiotics, then every 48-hours thereafter. The clinician should consider stopping antibiotics if PCT is <0.25. Serial data was collected from all ICU admissions in monthly cycles, and multiple interventions were implemented to improve adherence to the protocol using plan-do-study-act QI methodology. These interventions included integration of PCT results into our electronic system for easy access to results, distribution of user-friendly posters and presentation at departmental educational meetings to improve awareness and understanding of the protocol. Data collected included admission details, antibiotics prescribed, whether PCT was sent at time of initiation, and when subsequent PCTs were sent. Primary outcomes included whether the protocol was followed as intended, whether the PCT result influenced the decision to stop antibiotics, and number of days of antibiotic exposure.

Results: Initial data was collected between October-December 2021. In the first month, 122 patients (56.7% of admissions) received treatment-intended antibiotics.PCT was sent in 10 patients (8.2%) and repeated appropriately in 80.0% to assess the trend. The protocol was followed in just 1 patient. Where PCT was sent, it altered prescribing habits in 70.0%. In 4 patients, PCT <0.25 influenced the decision to stop antibiotics; in 1 patient, PCT influenced the decision to start antibiotics; and in 2 patients, it aided the decision to continue antibiotics.

In the second month of data collection, with the introduction of our electronic results system, more PCT tests were requested (27.4%) in 179 patients who had treatment-intended antibiotics. Adherence to protocol improved, being followed in 58.1% of those where PCT was used. The use of PCT influenced prescribing in 80.6% where it was sent. In the third month, again more PCT tests were requested compared to baseline (20.7%) however adherence to protocol was poor (4.5%). Where it was sent, PCT influenced antibiotic decisions in 40.3%. PCT was most commonly used to influence the decision to continue antibiotics. In a smaller number, it was used to influence the decision to stop or start antibiotics. In one case, it was used to decide upon the safety of high-dose immunosuppression. Overall, with improved adherence to our protocol, we demonstrated a reduction in the mean duration of antibiotics per patient from 7.7 days to 6.8 days over a 3-month period.

Conclusion: The use of a PCT-guided approach to antibiotics in ICU may improve antimicrobial stewardship, reducing the number of antibiotic days per patient. Adherence to protocol was poor, however PCT was commonly used outside of protocol at the clinicians discretion, such as to continue antibiotics where PCT remained high. Further cycles of data collection are underway, 12-months following departmental education about the protocol. We plan to further refine the population that may benefit from a PCT-guided approach, in addition to cost-effectiveness analyses.

References

1. Schuetz, P and Mueller, B. Biomarker-guided de-escalation of empirical therapy is associated with lower risk for adverse outcomes. Intensive Care Med. 2014,40,141.

2. Jee, Y, et al Antimicrobial resistance: a threat to global health. Lancet Infect Dis.2018.18,939-40.

3. Wirz, Y, et al. Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials.Crit Care. 2018.22,191.

4. Meier, MA, et al. Procalcitonin-guided antibiotic treatment in patients with positive blood cultures: a patient-level meta-analysis of randomized trials.Clin Infect Dis. 2019,69,388-396.

5428

Why we should care about Red Cell Width Distribution in critical care: a single centre observational study

Zeynep Elcioglu¹, Matthew Bickerton², John Simpson³, Thomas Hellyer³, Anthony Rostron⁴

¹ RVI

² NHS

³ Newcastle University / Newcastle Hospitals

⁴ Newcastle University / South Tyneside and Sunderland NHS Foundation Trust

Introduction: Frailty is characterised by decreased physiological reserve, leading to vulnerability to stressors such as critical illness.¹ Frailty is a recognised risk factor for poor outcomes during and following critical illness.² Immune dysfunction that persists after a critical illness may be more likely in the frail cohort, predisposing patients to hospital-acquired infections (HAI).³ Routinely collected blood tests may identify immune dysfunction, including lymphopenia (persistence correlates with increased mortality) and raised red cell width distribution (RDW) (marker of bone marrow frailty).^4,5

Objectives: This study aimed to identify whether there was a relationship between admission frailty, risk of developing hospital-acquired infection, and immune dysfunction, as characterised by lymphocyte and RDW counts. We hypothesised that frailty would correlate with risk of hospital-acquired infections. The primary outcome was hospital-acquired infection.

Methods: Retrospective, single centre, cohort study of non-COVID related admissions to a general adult critical care unit over a 12-month period from April 2020 to April 2021was carried out. Patients with length of stay greater than 48 hours were included and followed up to day 14. Follow-up of patients continued following critical care discharge. In the event of multiple critical care admissions, only the initial ICU admission was considered. Demographic data included sex, age, Rockwood Clinical Frailty Score (CFS), length of stay in intensive care, and mortality data. Blood counts were collected including lymphocyte count and RDW. Electronic notes were also reviewed for evidence for treatment of HAI. This process included review of any microbiological samples, radiological images, and reports, as well as documentation by physicians and nursing staff.

Results: Total of 227 patients were included. Frail patients (CFS≥5) were older than patients without frailty (CFS≤4), (mean [SD] age 62.5 [14] vs. 58 [17] years). Frailty was not a statistically significant risk factor in HAI development (OR 0.642 p=0.436). Patients who developed HAI were more likely to die (critical care and hospital mortality) but this was not statistically significant (OR 1.45, p=0.241 and OR 1.05, p=0.903, respectively). Patients who developed HAI were on average 4.17 years older than those who did not, but this did not reach statistical significance (p=0.062). There was no significant association between development of persistent lymphopenia (i.e. lymphopenia measured on more than one occasion) and HAI (p=0.745). There was no significant difference between frail and non-frail patients in development of persistent lymphopenia (p=0.099). In contrast, an elevated RDW (≥13.3%) at any point during a patient’s admission was significantly associated with the development of HAI (p=0.005). Raised RDW was also associated with increased age (p= 0.009). Non-survivors were more likely to have a raised RDW, but this was not statistically significant (OR 2.36, p=0.175).

Conclusions: In conclusion, this retrospective study found that age and frailty did not significantly increase risk of HAI. Simple blood tests, such as an elevated RDW, may be useful biomarkers of critical illness related immune dysfunction. This study highlights the importance of future research into persistent immune dysfunction related to critical illness.

References

1. McDermid R, Stelfox HT, and Bagshaw SM. Frailty in the critically ill: a novel concept. Crit Care.2011;15(1): 301. doi: 10.1186/cc9297.

2. Muscedere J, Waters B, Varambally A, Bagshaw SM, Boyd JG, Maslove D, Sibley S, and Rockwood K. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med.2017;43(8):1105-1122. doi: 10.1007/s00134-017-4867-0.

3. Vincent JL. Nosocomial infections in adult intensive care units. 2003;(14) 361(9374):2068-77. doi: 10.1016/S0140-6736(03)13644-6.

4. Drewry AM, Samra N, Skrupky LP, Fuller BM, Compton SM, Hotchkiss RS. Persistent lymphopenia after diagnosis of sepsis predicts mortality. Shock. 2014;42(5):383-91. doi: 10.1097/SHK.0000000000000234.

5. Wang B, Lu H, Gong Y, Ying B, Cheng B. The Association between Red Blood Cell Distribution Width and Mortality in Critically Ill Patients with Acute Kidney Injury. Biomed Res Int. 2018;(24). doi: 10.1155/2018/9658216.

5481

Tracheostomy Care: An E-Learning Module

Mark Foale, Edward Scarth, Donna Salter, Kerrie Large

Torbay and South Devon NHS Foundation Trust

Background: Within the cohort of patients that pass through a district general hospital’s post anaesthesia recovery unit (PACU), patients with tracheostomies are seldom seen. PACU staff can easily become de-skilled and therefore under-confident when managing this patient group. This was reflected in a questionnaire answered by Torbay Hospital’s PACU staff and staff who work in the greater theatre complex. We received 72 responses, covering 13 questions from the National Tracheostomy Safety Project¹. Across all questions, for all staff members, the average score was 35%. These results demonstrated the issue and therefore our aim was to improve staff competence and skill level when managing this patient group, through an electronic teaching platform.

Objective: After identifying the issue, senior theatre and PACU staff members held a meeting, to organise a solution, to help train PACU staff in this area of care. It was agreed that this would take the form of an e-learning module within the hospital trust’s online training platform.

Method: A team of clinical staff wrote the script for the e-learning module and in conjunction with the hospital ‘Learning Technology’ team, filming and audio recordings were added. This was then edited together to combine pictorial, video and audio segments along with assessments at the beginning and at the end of the module to achieve certification.

Results: The module finished production and was then added to the e-learning database, ‘The Hive’ for all PACU and theatre staff to complete. A short list of multiple-choice questions were added to the module at the beginning and at the end, to gain an insight into the current levels of knowledge of the staff, but also to show the knowledge gained from completing the module. At the current time, 44 staff members have accessed the module, with 26 completing the pre-module quiz and 12, the post-module quiz. The average pre-module quiz result was 48.7% and the average post-module quiz result was 94.4%.

Conclusion: Overall the e-learning module has provided PACU staff with an online teaching platform to improve their understanding of tracheostomy care. Uptake has been moderate so far, but has shown a clear improvement to staffs’ knowledge and we therefore hope this translates to patient care going forward. We have also had the challenge of overcoming minor IT issues. This has included the compulsory completion of the pre & post-module quizzes. This will not only enable recipience of a completion certificate, but will yield more outcome date. We also hope to explore the possibility for this module to be used in other hospital trusts within the South-West region.

Reference

1. National Tracheostomy Safety Project [Internet]. http://www.tracheostomy.org.uk. [Accessed 11 April 2022].

5617

The impact of a dedicated Critical Care Speech and Language Therapy Service on multidisciplinary team management of patients with a tracheostomy

Pippa Day

University Hospital Coventry and Warwickshire

Introduction: The Guidelines for the Provision of Intensive Care Services (GPICS v2, 2022) recommends all patients with a tracheostomy are seen by a Speech and Language Therapist whilst the National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 2014) recommends Speech and Language therapy (SLT) forms part of the multidisciplinary team caring for patients with a tracheostomy. In April 2022 additional funding secured a dedicated SLT service on General and Cardiothoracic Critical Care units at University Hospital Coventry and Warwickshire (UHCW) which created an opportunity for SLT to become part of the multidisciplinary team (MDT) caring for those with a tracheostomy.

Objectives: For every patient referred into the SLT service from General or Cardiothoracic Critical care, a specific set of data is collected so the impact of having a dedicated service can be measured. This data, along with data collected by the Critical Care unit has been analysed to identify the following:

• Timing of referral to SLT for tracheostomy management

• Time between tracheostomy placement and cuff deflation

• Time between tracheostomy placement and PMV use

• Time to decannulation

Method: The inclusion criteria for this study was:

• Patients who have had a tracheostomy

• Patients who have survived their stay on Critical Care

• Patients of all levels of consciousness

The data was analysed so the key objectives above could be better understood.

Results: Evaluation of this data has shown that there appears to be more consistency with time from insertion to decannulation following input from SLT as part of the MDT managing tracheostomies on Critical care, as well as an overall reduction in time with a tracheostomy (Figure 1). There were some limiting factors in November and December as the SLT caseload demands increased meaning there was often a delay in intervention.

Figure 1.

Length of time from insertion to decannulation in 2019 and 2022.

Further analysis of this data and the pathway of tracheostomy weaning has shown that timing of referral to SLT can influence the timing of cuff deflation and Pass Muir Valve (PMV) use (figure 2). This data does highlight that there is an increase in time to decannulation, however there are many variable factors which influence whether decannulation is appropriate. Earlier cuff deflation and PMV use often leads to earlier return to verbal communication and oral intake, both of which have been identified as priorities by patients in Critical Care (McGrath, Wallace & Lynch et al 2020).

Figure 2.

Tracheostomy weaning pathway according to point of referral to SLT.

Conclusion: A dedicated SLT service has created an opportunity for a profession to put a focus on, and lead on, earlier laryngeal weaning and create a change in process which in turn can influence the time to decannulation. This also supports patients in returning to oral intake, verbal communication as well as identifying laryngeal abnormalities; however, it seems timeliness in referral to SLT influences the tracheostomy weaning pathway even further with a particular improvement in the laryngeal wean.

References

The Guidelines for the Provision of Intensive Care Services (GPICS) v2.1 (2022) The Faculty of Intensive Care Medicine / Intensive Care Society.

National Confidential Enquiry into Patient Outcome and Death: On the Right Trach? (NCEPOD, 2014).

McGrath BA, Wallace S, Lynch J, Bonvento B, Coe B, Owen A, Firn M, Brenner MJ, Edwards E, Finch TL, Cameron T, Narula A, Roberson DW (2020) Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. British Journal of Anaesthesia 125(1) ppE119-E129.

5624

Creating a toolkit: a secondary analysis of intervention implementation from the Improving Tracheostomy Care Quality Program

Mark Brown, Brendan McGrath, Malachy Columb, James Lynch, Ruth Coleman

Manchester University NHS Foundation Trust

Introduction: The Improving Tracheostomy Care Quality Improvement (QI) Program demonstrated significant improvement in the quality and safety of care by implementing 18 interventions across 20 hospitals within the United Kingdom.¹ However, non-uniform implementation across sites made distinguishing the perceived impact of each individual intervention difficult. Many QI programs are “one size fits all.”

Objectives: This secondary analysis aimed to rank interventions based on their impact and ease of implementation, in order to make bespoke recommendations tailored to diverse hospitals.

Methods: Hospitals were restricted to adult populations. Interventions were grouped thematically: organisational efficiency, safety, and patient-centred quality of care. A single outcome metric for each thematic group was decided a priori (hospital length-of-stay, incident severity score, Hospital Consumer Assessment of Healthcare Providers and Systems scores respectively). For each intervention, a segmented linear mixed effects model produced an ‘impact score’.² A further ‘ease score’ was produced by measuring the time to implement an intervention over the course of the study, pooled across participating hospitals. Scores were then standardised across intervention themes producing a single ease-impact matrix. Principle component analysis and partitioning by k-means clustering described outcomes with similar characteristics from which recommendations were made.

Results: Eighteen hospitals were eligible for analysis, representing 2,339 hospital admissions with a tracheostomy. Impact and ease scores were produced for each intervention and model assumptions were tested graphically. From these metrics, mapping of the impact and ease scores produced a graphical ‘ease-impact matrix’ (figure). Four clusters of interventions with similar characteristics were found after the exclusion of an outlier. Clusters were ranked based on their impact and ease of implementation to produce recommendations.

Figure.

The ease-impact matrix for interventions implemented within the tracheostomy care and quality improvement program. Interventions were grouped thematically by organisational efficiency (O), safety (S) and patient centred quality of care (Q).

Conclusion: Our analysis described the associated impact and ease of implementation for individual interventions from a national multi-interventional audit. Our approach allowed us to produce a series of recommendations that could enable a clinician to choose interventions based on their ease of implementation and potential impact which may support tailored QI programs in diverse hospitals in the future.

References

1. McGrath BA, Wallace S, Lynch J, Bonvento B, Coe B, Owen A, Firn M, Brenner MJ, Edwards E, Finch TL, Cameron T. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. British journal of anaesthesia. 2020 Jul 1;125(1):e119-29.

2. Saeed S, Moodie EE, Strumpf EC, Klein MB. Segmented generalized mixed effect models to evaluate health outcomes. International journal of public health. 2018 May;63:547-51.

5639

Review of patients with aneurysmal SAH requring tracheostomy

Joshua Halyckyj-Smith¹, Sandeep Gudibande²

¹ University of Manchester

² Royal Preston Hospital

Aims: To review patients with aneurysmal subarachnoid haemorrhage (aSAH) requiring tracheostomy. Specifically, to determine the association between patient factors and the requirement for tracheostomy and the outcomes in this cohort. Patient factors include: sex, age group, Charlson comorbidity index, WFNS grade of aSAH, and their outcomes.

Methods: One hundred and eighty-six consecutive patients from the Lancashire and South Cumbria region, who presented to RPH with SAH between January 2019 and April 2021, were available for our data collection. Of this cohort, ninety-four patients required mechanical ventilation, of which twenty patients required tracheostomy. The sample was obtained from a prospective database maintained by the neurovascular team. Descriptive analysis has been utilised to assess the association between patient features, the requirement for tracheostomy, and outcomes.

Results: See appendix for the graphical display of the results. 15% of patients that required a tracheostomy died, and only 20% of patients had good outcomes (GOS > 3). There is a slight predilection for those in their fifth decade, while there are no significant sex differences in the requirement of tracheostomy. Charlson comorbidity seems to have little impact on the requirement for tracheostomy, with exception to those with a score of 6. WFNS grades of 2 and 4 have the highest rates of tracheostomy.

Conclusion: While there is no association evident between sex and the requirement of tracheostomy, other patient factors may illuminate valuable associations. However, despite what these results demonstrate, it is essential to note that this is a very small sample, so further research needs to be completed on a larger scale to validate any associations portrayed. It appears that those who unfortunately experience an aSAH in their fifth decade are most likely to require a tracheostomy. Associations with Charlson comorbidity index may demonstrate that the intervention may have diminishing returns after a certain level of comorbidity. Severity of aSAH, as defined by WFNS grade, demonstrates that those most likely to receive tracheostomy are those with grades of 2 and 4, suggesting those are the patients who are deemed to benefit most from the intervention. We have been able to illuminate that patients receive tracheostomy across a broad spectrum of timings after admission. Outcomes for patients requiring tracheostomy are poor. Further research is required on a larger scale to identify the optimal timing of tracheostomy, thus optimising outcomes in these patients.

5377

Information technology can streamline the production and improve the quality of transfer documentation: a triple-cycle, single centre audit

Tim Nye¹, Mae Bethell², Nicola Jones²

¹ West Suffolk Hospital NHS Foundation Trust

² Royal Papworth Hospital NHS Foundation Trust

Introduction: Transfers between intensive care units (ICUs) are common as patients move to or from specialist ICUs, or are transferred for capacity reasons, and have further increased during the Covid-19 pandemic. Reliable handover information about these complex patients is essential and is stipulated in Intensive Care Society / Faculty of Intensive Care Medicine guidelines¹.

Objectives: To improve handover documentation for patients transferred from our cardiothoracic ICU, either to local secondary centre ICUs or to other tertiary centres for ongoing specialist care.

Methods: Three audit cycles were undertaken in 2021-2022. All patients transferred from our unit to ICU-level care in another hospital were included. We used the Trust’s MetaVision ICU electronic patient record (EPR) to access their transfer letters retrospectively, and audit against our unit’s transfer checklist of twelve categories (Figure 1). Our target was that over 75% of the data in each category should be included across all letters. Steps were taken between audit cycles to improve standards.

Figure 1.

Transfer checklist.

Results:

Round 1

27 letters for transfers from March to May 2021 were analysed. Working diagnosis (85%) was the only checklist category that met the 75% target. Notable categories where information was incomplete were past medical history (67%), renal status (22%) and microbiology (53%).

First intervention and round 2

We collaborated with the Trust’s digital team to populate information readily available in the EPR automatically into the final transfer document. Subsequently, 24 letters for transfers from September to December 2021 were reviewed. 5 of the 12 categories now included the target 75% of data, including microbiology (53% to 95%), imaging reports (74% to 88%) and past medical history (67% to 91%).

Second intervention and round 3

Due to limitations of the EPR, not all required information could be included automatically in transfer summaries, so our second intervention publicised the data requiring manual entry. A ‘how-to’ guide for transfer letters was included in the EPR, and a QR code in the doctors’ offices enabled access to a phone-sized version (Figure 2), giving a walkthrough of what to include. Following this, 24 letters were analysed for patients transferred between April and July 2022. 8 of 12 categories now had the target 75% completion rate. Notable improvements included documenting the patient’s neurological (63% in round 2 to 92%), respiratory (60% to 79%), and cardiovascular status (68% to 76%). Figure 3 shows the progression of handover completeness across the three rounds.

Figure 2.

a sample page from the phone-sized transfer letter guide.

Figure 3.

Completeness of information in inter-ICU transfers by category.

Conclusions: This triple-cycle audit demonstrated the use of information technology to streamline the creation of transfer information and led to quality improvement, aiding the continuity of care between ICUs. Firstly, EPR systems can automatically compile relevant transfer information, reducing time-consuming manual gathering of data. Secondly, where manual input is required, walkthrough guides clearly specify the key details needed, simplifying the process for doctors who may be new to ICU. Both these initiatives resulted in more comprehensive handovers between organisations, essential for ensuring ongoing high quality care. Further work should focus on those categories still inadequately completed, particularly around the important area of escalation plans.

Reference

1. Guidance On: The Transfer Of The Critically Ill Adult [Internet]. Faculty of Intensive Care Medicine. 2019 [cited 2023Feb]. Available from: https://ficm.ac.uk/sites/ficm/files/documents/2021-10/Transfer_of_Critically_Ill_Adult.pdf

5566

Muscle wasting and health-related-quality of life in critically ill patients with tetanus and other central nervous system infections in Vietnam

Duy Nguyen Trong¹, Nhat Phung Tran Huy², Khiem Dong Phu³, Hao Nguyen Van¹, Thach Pham Ngoc³, Thao Nguyen Thi Phuong⁴, Phuong Le Thanh⁴, Phu Vu Dinh³, Phong Nguyen Thanh¹, Thomas Rollinson⁵, Alberto Gomez⁶, Yen Lam Minh⁴, Linda Denehy⁵, Louise Thwaites⁷

¹ Hospital for Tropical Diseases, Ho Chi Minh city, Vietnam

² Oxford University Clinical Research Unit, Ho Chi Minh city, Vietnam; School of Biomedical Engineering Imaging Sciences, King’s College London, UK

³ National Hospital for Tropical Diseases, Hanoi, Vietnam

⁴Oxford University Clinical Research Unit, Ho Chi Minh city, Vietnam, ⁵University of Melbourne, Melbourne, Australia

⁶ School of Biomedical Engineering Imaging Sciences, King’s

⁷ Oxford University Clinical Research Unit, Ho Chi Minh city, Vietnam; Centre for Tropical Medicine GlobalHealth, University of Oxford, Oxford, UK.

Introduction: Survivorship of critically ill patients in low- and middle-income countries is improving, however these are often different populations with different diseases, and little is known about their long-term prognosis.¹ In Vietnam, neurological diseases including tetanus are common reasons for intensive care unit (ICU) admission, and preliminary data from patients with tetanus suggests significant muscle wasting with severe disease.² While muscle wasting and poor functional outcome are commonly observed in critically ill patients in affluent regions, there are few data regarding such potentially modifiable outcomes in under-resourced areas. Such data are vital in planning future interventions or rehabilitation services.

Objective: To evaluate muscle wasting and long-term outcome amongst adults with severe tetanus and other central nervous system (CNS) infections.

Methods: A prospective study was conducted at the Hospital for Tropical Diseases (HTD) in Ho Chi Minh City and the National of Tropical Diseases (NHTD) in Hanoi. We recruited adult patients within 72 hours of ICU admission (expected to stay at least 5 days) with severe (Ablett Grade 3 or 4) tetanus or other CNS infections (meningitis or encephalitis). Muscle wasting was measured using serial rectus femoris cross-sectional-area (RF-CSA) ultrasound measurements at enrolment, 7 days, and ICU/ hospital discharge using standard point-of-care ultrasound (Venue-Go, GE Healthcare) or handheld devices (Lumify, Phillips).³ Long-term outcome was evaluated by EuroQol’s five-dimensional 5-level utility score (EQ-5D-5L), at hospital discharge and telephone follow up six months after discharge. A sample size of 160 patients was calculated based on approximately 80 patients in CNS and tetanus groups. EQ-5D-5L index scores were calculated using Vietnamese population data.⁴ The study was approved by the HTD and OxTREC Ethics committees. All patients/representatives gave written informed consent.

Results: 113 patients were enrolled between June and February 2022. Recruitment was stopped early due to the pandemic. 87 patients had 6-month data available (Figure 1).

Figure 1.

Consort diagram: Observational study.

Demographic and clinical data are given in Table 1. Ultrasound evaluation was possible in all patients using standard or hand-held devices.

Overall, 6-month outcomes were good: 63/87 patients (72%) had no problem in any EQ-5D-5L domain (48 with tetanus and 15 with CNS infection). EQ-5D-5L scores improved in over 89% of tetanus and 92% of CNS infection patients after 6 months. Median EQ-5D-5L index was 0.66 at discharge increasing to 0.93 at 6 months for CNS infection and 0.58 and 1.00 respectively for tetanus patients (Figure 2). Median reduction in RF-CSA between admission and discharge was 23% (IQR 13 - 34%) in tetanus and 11% (IQR 4 - 16%) in CNS infection patients. No relationship was observed between percentage RF-CSA (admission to discharge) although most patients with lower EQ-5D-5L index at 6 months had discharge muscle measurements in lower 2 quartiles (Figure 3).

Figure 2.

Tetanus and CNS EQ-5D-5L score improvement on discharge and follow up.

Figure 3a.

Muscle wasting effect on 6-month follow-up Quality of life score.

Conclusions: We observed significant muscle wasting in patients with tetanus, finding that low-cost ultrasound devices were feasible to measure RF-CSA. Overall long-term outcomes were good, however the number of those with CNS infections was less than planned and our study was underpowered to perform subgroup analyses in those with poorest outcomes.

Figure 3b.

Muscle size on discharge and Quality of life score at 6-month follow-up.

References

1. Phua J, Lim CM, Faruq MO, Nafees KMK, Du B, Gomersall CD, et al. The story of critical care in Asia: a narrative review. J Intensive Care. 2021;9(1):60.

2. Trung TN, Duoc NVT, Nhat LTH, Yen LM, Hao NV, Truong NT, et al. Functional outcome and muscle wasting in adults with tetanus. Trans R Soc Trop Med Hyg. 2019;113(11):706-13.

3. Puthucheary ZA, McNelly AS, Rawal J, Connolly B, Sidhu PS, Rowlerson A, et al. Rectus Femoris Cross-Sectional Area and Muscle Layer Thickness: Comparative Markers of Muscle Wasting and Weakness. Am J Respir Crit Care Med. 2017;195(1): 136-8.

4. Mai VQ, Sun S, Minh HV, Luo N, Giang KB, Lindholm L, et al. An EQ-5D-5L Value Set for Vietnam. Qual Life Res. 2020;29(7):1923-33.

5101

‘Breathing easy’ - a multidisciplinary approach to improve the care of patients suffering blunt chest wall trauma

Harry Goss¹, Lianne Stevenson², Alaw Huws², Stephan Clements²

¹ Poole Hospital

² Betsi Cadwaladr university health board

Introduction: Rib fractures are a common complication of chest wall trauma and account for a significant number of acute hospital admissions. A key component of their management is effective analgesia to facilitate physiotherapy, deep inspiration and secretion clearance - therefore reducing the risk of complications such as pneumonia, atelectasis and respiratory failure.¹

Objectives: We sought to improve the care of patients with rib fractures admitted to our remote and rural acute hospital though the implementation of a multidisciplinary cross specialty guideline with patient centred, individualised interventions based on injury patterns and risk of complications.

Methods: We encouraged early risk stratification and implemented care bundles and multimodal analgesic regimes based on the patient’s STUMBL severity score.² This included the introduction of a novel technique to our emergency department (ED) - the serratus anterior plane block.^3,4 We delivered teaching sessions, led by consultant anaesthetists, covering the delivery of this technique following a survey of ED staff which identified lack of training as a barrier to ED delivered regional anaesthesia. We also produced a ‘how to’ guide to serve as an aide-memoire, as well as a serratus anterior procedural checklist to support completion of safety critical steps.

Patients with the highest risk scores were referred to our anaesthetic team for consideration of a continuous catheter regional technique such as thoracic epidural or erector spinae plane catheter. We reinforced the importance of early referral for respiratory physiotherapy. Patient education was also a priority, with patients being given an information leaflet outlining the importance of deep breathing and coughing exercises.

In order to assess the impact of these interventions we retrospectively reviewed the records (both electronic and paper) for one month’s worth of acute admissions with chest wall trauma and compared patient management before and after the guideline was implemented. The initial audit period covered all patients admitted in April 2021 (N=22), with the repeat audit looking at all patients admitted in April 2022 (N=15).

Results: Following implementation of the guideline:

• 42% of patients had a severity score documented on admission (vs 32% prior).

• 100% of very high risk patients were referred directly to intensive care (vs 66% prior).

• 89% of patients were referred for chest physiotherapy (vs 45% prior).

• 67% of high risk patients received regional anaesthesia during admission (vs 55% prior).

• 1 serratus anterior block was delivered by the Emergency Department during the reaudit period (versus none prior).

Conclusions: The implementation of this ambitious guideline required a collaborative multidisciplinary approach from ED, ICU, general surgery, orthopaedics, physiotherapy and the acute pain team. There were cross speciality practical teaching sessions provided by consultant anaesthetists to their ED colleagues to support delivery of serratus anterior blocks, along with a variety of other formal and informal learning sessions. Whilst scope for further improvement certainly remains, we feel that our approach, championing education and engagement, has led to significant improvements in meeting national standards of care for patients with blunt chest wall trauma in our hospital.

References

1. May L, Hillerman C, Patil S. Rib fracture management. BJA education. 2015;16(1): 26-32.

2. Battle C, Hutchings HA, Driscoll T, et al. A multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL Trial. BMJ Open 2019;9(7):e029187.

3. Blanco R, Parras T, McDonnell JG, et al. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68(11): 1107-1113.

4. RCEM Learning. Ultrasound Guided Serratus Anterior Plane Block. https://www.rcemlearning.co.uk/reference/ultrasound-guided-serratus-anterior-plane-block. [accessed 11.4.22.].

5440

Alcohol dependency and rib fracture outcomes: a systematic review and meta-analysis

Fiona Field¹, Jenny Olsson², Anna Hurley³

¹ Queen Mary University London

² King’s College Hospital London

³ Hull University Teaching Hospitals

Introduction: Chronic alcohol use has been associated with poor outcomes following trauma with evidence that impaired immunological and neurological function may be responsible¹. Rib fractures are a particularly common injury in this demographic and carry a high risk of pulmonary complications due to the effects of direct lung injury. This risk may be heightened in alcohol dependent patients who already have a significantly increased susceptibility to pneumonia². Despite the high prevalence of rib fractures and known physiological effects of chronic alcoholism, no systematic review has previously been conducted to examine clinical outcomes in this patient group. Identification of high risk subgroups can aid clinical decision making regarding intensive care admission and early interventions. Hence, the aim of this review is to collate the best available evidence to determine the effect of alcohol dependence on rib fracture outcomes.

Objectives: The primary aim is to examine the risk of in-hospital mortality following rib fractures in patients with alcohol dependence compared to patients without.

The secondary aim is to explore the risk of in-hospital complications (including pneumonia and intensive care length of stay) between the two groups.

Methods: The systematic review was conducted in line with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. The Embase, Pubmed and Web of Science databases were searched for studies examining adult patients with rib fractures with and without a history of alcohol dependency. Study selection was performed independently and in duplicate by two reviewers, with disagreements settled by use of a third reviewer. The primary outcome of interest was in-hospital mortality. Secondary outcomes included pulmonary complications, intensive care length of stay, ventilator days and hospital length of stay. A meta-analysis was performed to combine the data and compare results.

Results: Three studies^3-5 met met the criteria for inclusion in the review and all studies were observational in design. Published dates of included studies ranged from 2019 to 2021 with a total of 41638 participants. Pooled results associate alcohol dependency with increased mortality (OR: 1.44 [95% CI: 1.33-1.56]), pneumonia (OR 2.14 [2.02-2.27]) and ARDS (OR 1.71[1.48-1.98]) as well as longer stays in hospital and intensive care (p<0.05). No difference was found in ventilator days between the two groups. The effect estimate for pneumonia was the strongest and all studies were individually able to demonstrate a significant association with alcohol dependence.

Figure 1.

PRISMA flow diagram outlining study selection process.

Table 1.

Results for mortality in alcohol and non-alcohol dependent patients.

Study	Alcohol dependent (%)	Non-alcohol dependent (%)	Odd’s Ratio	p-value [95% CI]
Vartanyan 2019	7.8	5.5	1.46	<0.001 [1.30-1.63]
Vartan 2020	8.0	5.7	1.44	<0.001 [1.29-1.61]
Gongola 2021	3.9	3.8	1.03	0.942 [0.49-2.18]

Conclusion: The results of this review support previous literature associating alcohol dependence with poor outcomes following rib fractures. Specifically, these patients have an increased risk of mortality, ARDS and pneumonia as well as longer intensive care and hospital stays. Early intensive care review should be considered to manage and minimize these complications. Furthermore, modification of rib fracture scoring systems could help to highlight this demographic and promote early intervention. However, these results should be interpreted with caution owing to the low number and poor quality of primary studies. Further research is needed to fully understand the correlation between alcohol dependency and rib fracture outcomes.

References

1. Hadjizacharia P. et al. 2011. Alcohol exposure and outcomes in trauma patients. European Journal of Trauma and Emergency Surgery. 37; 169-175. Available from: https://doi.org/10.1007/s00068-010-0038-5

2. Samokhvalov A. et al. 2010. Alcohol consumption as a risk factor for pneumonia: a systematic review and meta-analysis. Epidemiology and Infection. 138(12); 1789-1795. Available from: DOI: 10.1017/S0950268810000774.

3. Vartanyan P. et al. 2019. Chronic Alcoholism Is Bad for Broken Ribs: A Nationwide Analysis of 20,120 Patients with Rib Fractures. Journal of the American College of Surgeons. 229(4,1); s289-s290. Available from: https://doi.org/10.1016/j.jamcollsurg.2019.08.634

4. Gongola et al. 2021. Retrospective study on rib fractures: smoking and alcohol matter for mortality and complications. Trauma Surgery and Acute Care Open. 6(1); e000732. Available from: doi:10.1136/tsaco-2021-000732.

5. Vartan P. et al. 2020. Alcohol Use Disorder Is Bad for Broken Ribs: A Nationwide Analysis of 19,638 Patients With Rib Fractures. Journal of Surgical Research. 255; 556-564. Available from: https://doi.org/10.1016/j.jss.2020.05.053

5471

Initial Glasgow Coma Scale score as an independent risk factor for intensive care admission and death in trauma patients with an Injury Severity Score >9

Catherine Parker

University Hospitals Sussex

Introduction and objectives: Reduced Glasgow Coma Scale (GCS) score in trauma patients is known to be associated with increased mortality. However, association between GCS on presentation and likelihood of admission to intensive care units (ICU) remains unclear. This study aimed to investigate the association between GCS and ICU admission in trauma patients.

Method: This retrospective cohort study in a single tertiary centre hospital analysed data from the Trauma Audit and Research Network (TARN) database for patients aged 16 years or older presenting with an Injury Severity Score (ISS) greater than 9 between January 2017 and July 2021. The primary outcome was ICU admission according to GCS category on admission with secondary outcomes of mortality and ICU length of stay. Data was analysed for normality of distribution. Statistical analysis was performed using Chi-squared or Mood’s median testing where appropriate and risk ratios (RR) were subsequently calculated.

Results: Among 2949 trauma patients ICU admission occurred in 589 (20%) and death in 169 (5.7%). GCS scores of 9-13 were associated with at least a 2 fold (Risk Ratio(RR)2.3 to 4) increased risk of ICU admission across all age groups and over 4 fold (RR 4.5 to 68.5) increased risk of death in all age groups. A GCS score between 3-8 on presentation was associated with a RR of 3.2 to 5.2 for ICU admission and a RR of 11 to 374 for death when compared to a GCS of 14-15. Patients aged under 40 with a GCS of 15 on presentation had 0% mortality despite the highest ISS scores in the cohort occurring in this age group.

Lower GCS score on admission was associated with a statistically significant (p<0.05) increased length of ICU stay in those with a GCS 3-8 compared with GCS 14-15. Whereas there was no significant difference (p>0.05) between length of stay in those with GCS 9-13 compared with GCS 14-15.

The overall requirement for ongoing care in this cohort was high with 1135 (38.5%) discharged to rehabilitation or care homes.

Conclusions: The results from this study show that GCS score on admission in patients with an ISS>9 is an independent risk factor for ICU admission and mortality. The results show that a patient aged >65 presenting with a GCS 9-13 is more than twice as likely to require ICU admission than a patient with a GCS of 15. Patients aged >65 were least likely to be admitted to ICU but had the highest mortality and those aged 16-39 had higher ICU admission rates but with 0% mortality when presenting with a GCS of 14 and above demonstrating that age is a protective factor in trauma.

In this trauma population 20% of all patients required admission to intensive care, this represents a significant burden on resources. Given this the results of the study demonstrate that reduced GCS should act as a trigger for close observation and early ICU referral may be warranted. Once at-risk patients are identified as earlier intervention can be initiated to try and prevent deterioration where possible.

References

1. Leitgeb J, Mauritz W, Brazinova A, Majdan M, Janciak I, Wilbacher I et al. Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury. Eur J Trauma Emerg Surg. 2013 Jun;39(3):285-92. doi: 10.1007/s00068-013-0269-3.

2. Demetriades D, Kuncir E, Velmahos GC, Rhee P, Alo K, Chan LS. Outcome and Prognostic Factors in Head Injuries With an Admission Glasgow Coma Scale Score of 3. Arch Surg. 2004;139(10):1066–1068. doi:10.1001/archsurg.139.10.1066.

3. Cudworth, M., Fulle, A., Ramos, J.P. et al. GCS as a predictor of mortality in patients with traumatic inferior vena cava injuries: a retrospective review of 16 cases. World J Emerg Surg 8, 59 (2013). doi: 10.1186/1749-7922-8-59.

5582

Temperature management in severe burns

Niamh Keohane¹, Jennifer Driver², Tomasz Torlinski³, Randeep Mullhi³, Barbara Torlinska¹, Elizabeth Chipp³

¹ University of Birmingham

² Yeovil district hospital NHS FT

³ University Hospitals Birmingham NHS FT

Introduction: Local guidance for major burns patients advocates for a core-peripheral temperature gap of <2°C and avoidance of hypothermia during the first 48 hours after admission. An increased core-peripheral temperature gap is associated with increased mortality in patients with septic shock¹ however, there is no research into its relevance in critically ill burn patients.

Objectives: Our study aims to explore the timing, magnitude and prognostic factors of the core-peripheral temperature gap in patients with severe burns, as well as hypothermia in the initial resuscitation period.

Methods: A retrospective study of temperature management in patients with severe burns was carried out. Patients included were admitted to the Intensive Care Unit (ICU) within 48 hours of a severe burn covering >15% of total body surface area (TBSA). Patients admitted for palliation or without core and peripheral temperature readings were excluded.

Temperatures during the first 48 hours of admission to ICU were recorded, Hypothermia was defined as <36°C core temperature or peripheral temperature if the core temperature was unavailable. Analysis of core temperatures and core-peripheral temperature gaps was conducted using linear regression and mixed-effects multilevel linear regression when analysed longitudinally.

Results and discussion: A total of 32 patients were included in the study. Both the core and peripheral temperatures increased over the initial period of 18h and then stabilised (Figures 1 and 2). The temperature gap was highly variable during the first 18h with notably reduced variability thereafter (Figure 3). The gap decreased with a mean rate of 0.11°C every 12h (95%CI: -0.17 – -0.051). This reduction in the temperature gap may be attributed to interventions such as using forced air patient warming and control of ambient temperature.

Figure 1.

Exploratory core temperature over time.

Figure 2.

Exploratory peripheral temperature over time.

Figure 3.

Exploratory temperature gap over time.

A TBSA of >50% was associated with a significant difference in core temperature at baseline (-1.3°C, 95%CI: -2.1 – -0.46; P=0.003), and over the initial 48 hours (-0.76°C, -1.2 – -0.29; P=0.002). A revised Baux score of >100, was associated with a baseline core temperature (-1.1°C, 95%CI:-1.9 – -0.31; P=0.008) but not during the initial 48h. There was no association of TSBA or Baux score with the temperature gap either at baseline or during 48h.

Hypothermic patients had a significantly lower core temperature, on average -2.2°C (95%CI:-2.8 – -1.6; P<0.0001) than normothermic. The difference continued over the first 24h on average (-1.4°C, 95%CI:-1.6 – -1.2; P<0.0001). Core temperatures of <36°C were observed beyond baseline (Figure 1). The temperature gap was smaller in hypothermic patients during the 48h (-0.66°C; 95%CI: -0.95 – -0.37, P<0.0001) but not at baseline.

Conclusion: Both core and peripheral temperatures followed a similar trend over the initial hours following a burn, plateauing at around 18 hours post-admission. This trend was also supported in the longitudinal gap data which became significantly less variable after 18 hours. Higher TBSA and revised Baux scores are associated with lower core temperatures at baseline. Further studies are required to establish possible links between differences in core temperature and patient outcomes.

Reference

1. Amson H, Vacheron CH, Thiolliere F, Piriou V, Magnin M, Allaouchiche. Core-to-skin temperature gradient measured by thermography predicts day-8 mortality in septic shock: A prospective observational study. J Crit Care. 2020 Dec:60:294-299.

4951

SWICM: Severn Women in Intensive Care, ‘Its Swell-being in SWICM’

Inthu Kangesan¹, Jeanie Worthington²

¹ UHBW

² North Bristol NHS Trust

Introduction: Inspired by the established group, WICM (Women in Intensive care), we aimed to create a network for female intensive care trainees in the Severn deanery. Intensive Care Medicine (ICM) nationally has a disproportionately low representation of female consultants (20%) compared to the proportion graduating from medical school (55%) according to a recent survey.¹ This trend is borne out in our region, where only 22% of the regional consultant body in ICM are female and 27% of female ICM trainees, compared to the national level of 39%. Across other hospital specialties in the UK, 37% of consultants are female in Medical specialties and 14% in Surgery, whilst the proportion in General Practice is 54%.

Several national and international Intensive care organisations such as the European Society of Intensive Care Medicine (ESCIM) have highlighted that a diverse workforce results in more positive outcomes for patients,² and major initiatives have been launched to address the lack of diversity within our workforce.

Objectives and Methods: What can we do locally?

We aim to forge a strong local community of women in ICM at all stages of training and including consultant colleagues, to support women through their training, improved trainee experience, wellbeing, and therefore retention within the specialty.

We intend to achieve this through a number of initiatives focused around six main areas:

• Mentoring

• Networking Events

• Wellbeing and Social support

• Educational events

• Direct engagement with Regional and Local ICU leads, and Training Programme advisors.

• Promotion of the specialty to trainees in the early stages of their career.

Results: We promoted a career in ICM at our local Foundation programme careers evening. As part of a junior doctor teaching program aimed at ACCS doctors, we asked them to participate in a survey to identify factors which attract trainees into a career in Intensive care medicine.

Of those that participated in the survey, 70% were female, 70% are considering a career in ICM. Factors attracting doctors into this specialty were the acuity of work, breadth of clinical knowledge and developing practice skills. The main reason listed against choosing ICM was working pattern/lifestyle. The majority intended to pursue a single CCT in ICM, followed by a dual CCT with Emergency Medicine or Anaesthetics.

Conclusion: Primarily as a wellbeing initiative targeting female doctors throughout training and beyond, but with the added aim of inspiring intensivists of the future, we have pioneered SWICM in the Severn deanery. We hope to inspire others to continue with this model of creating a mentoring, educational and morale boosting support network.

References

1. GMC. The state of medical education and practice in the UK: the workforce report. General medical Council, 2019. Available: https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/the-state-of-medical-education-and-practice-in-the-uk/workforcereport-2019

2. https://www.esicm.org/the-esicm/diversity/

5122

The core conditions to thrive: doctors in training and SAS doctors in Intensive Care

Ella Mayberry¹, Julie Highfield², Stuart Edwardson³, Catriona Felderhof⁴, Emma Jackson⁵, Kenneth McGrattan⁴

¹ NHS Wales

² University Hospital Wales, Intensive Care Society

³ Association of Anaesthetists

⁴ Faculty of Intensive Care Medicine

⁵ Intensive Care Society

Introduction: COVID-19 brought a focus to the importance of critical care staff wellbeing.¹ However, it is clear that issues existed pre-pandemic.² We often hear the term wellbeing, though it is a nebulous term, is often subjective and is difficult to define.³

There is often a focus on individuals to self-manage their wellbeing without addressing the systemic problems.² Frequently, wellbeing interventions feel tokenistic and do not address root causes.² Throughout the literature, wellbeing is pathologised or equated to the absence of distress and burnout, with little attention paid to the ability of trainees to thrive.^1,4 Primary prevention is important to maintain trainee wellbeing, however there is not a great deal of evidential research in this area as relates to critical care.

When trainee and SAS doctors’ wellbeing is prioritised, doctors thrive in their workplace - which ultimately improves patient outcomes, including patient mortality.⁵ Conversely, burnout is known to be associated with medical errors, poor quality of patient care and low patient satisfaction.⁵ We wanted to understand what factors doctors felt were most important for their wellbeing.

Objectives: This study aims to learn about the conditions needed for critical care trainees and SAS doctors to thrive in their workplace and therefore experience good wellbeing.

Methods: We worked with a team of trainees and SAS doctors to understand their particular workplace wellbeing needs. Using thematic analysis, we pulled their thoughts into themes, which were then grouped and put into survey format using Office Forms. The survey was shared via the Intensive Care Society mailing list and social media.

Doctors were presented with 42 statements regarding factors that may impact their experience of the workplace. The statements were divided into six sections: Job Design, Supervisor Support, Practicalities of the work setting, Rota & Pay, Education & Exams and Relationships.

They were asked to attribute a rating from 1 - 7 for the impact of each factor (1 - “not at all important”, 7 - “of extreme importance”).

Results: Of our provisional results, 110 responses were received. The respondents were as follows (to one decimal place):

• Dual with anaesthesia: 33.6%

• SAS and Specialist Doctors: 33.6%

• Single ICM: 15.4%

• Dual with medical specialties: 7.7%

• Dual with EM: 1.9%

• Other: 8.7%

Rota & Pay was the theme receiving the highest average rating.

The individual statements that doctors in training and SAS doctors rated the most highly were:

1. I have access to trust electronic systems such as intranet, electronic patient records

2. I have a badge that works and allows access to all required areas of the hospital

3. Paid the right amount, and nodal increase, and tax is correct

The most highly rated statements did not vary between trainees and SAS doctors.

Conclusion: Our findings indicate that doctors feel ensuring that basic and required services are functional is of the most value. Therefore, our findings suggest focusing on systemic change (i.e. primary prevention) rather than secondary and tertiary interventions, would be the best focus to improve wellbeing and enable trainees and SAS doctors to thrive.

References

1. Greenberg N, Weston D, Hall C, Caulfield T, Williamson V, Fong K. Mental health of staff working in intensive care during Covid-19. Occupational Medicine. 2021;71(2):62-7.

2. Kinman G, Teoh K. What could make a difference to the mental health of UK doctors? A review of the research evidence. Society of Occupational Medicine; 2018 2018-10-08.

3. Simons G, Baldwin DS. A critical review of the definition of ‘wellbeing’ for doctors and their patients in a post Covid-19 era. International Journal of Social Psychiatry. 2021;67(8):984-91.

4. Vincent L, Brindley PG, Highfield J, Innes R, Greig P, Suntharalingam G. Burnout Syndrome in UK Intensive Care Unit staff: Data from all three Burnout Syndrome domains and across professional groups, genders and ages. Journal of the Intensive Care Society. 2019;20(4):363-9.

5. West M, Coia D. Caring for Doctors Caring for Patients. [Internet]. 2019 [cited 2023 Jan 11]. Available from: https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf

5160

Self-Rostering as a Workforce Wellbeing Tool for Junior Doctors on the Intensive Care Unit (ICU) – A Quality Improvement Exercise

Rabiu Momoh¹, Rukhiya Syed¹, Ruth Tighe², Camille De Oliveira³

¹ William Harvey Hospital, Ashford, Kent, UK

² William Harvey Hospital, Kent, UK

³ -

Introduction: Reducing burnout and promoting junior doctors’ wellbeing, work satisfaction and retention on the intensive care unit in the post-COVID era is a task that should be ensured by all involved with critical care delivery.

Objectives: To demonstrate whether self-rostering could be a means for an improved work experience among junior doctors working on the intensive care unit.

Methods: An evaluation of the satisfaction of junior doctors with the rostering system at a district general hospital’s (DGH) intensive care unit was done pre- and post-intervention. The intervention introduced was the trial of an existing online self-rostering application to which the junior doctors were required to create an account to and book shifts to total expected hours for a six-month period as against manual rostering of personnel by administrative staff members for the unit.¹

Results: The benefits demonstrated a jump from a less than 50% satisfaction with the rostering system among the junior doctors sampled pre-intervention to a 100% satisfaction post-intervention. The outcome of the rota intervention was presented at the Local Intensive Care Medicine Faculty Group Meeting at the William Harvey Hospital, Ashford, Kent in November 2022. Other qualitative benefits described included flexibility of work hours, lesser swaps between staff members, better leave-booking experience, less burnout, better experience for less-than-full-time trainees, transparency in terms of number of hours worked/remaining, and better control of compliance with rest hours.

Conclusions: We have been able to demonstrate the impact of self-rostering on junior doctors’ wellbeing in a quality improvement exercise undertaken at a DGH’s ICU. More work to further explore the benefits of self-rostering for wider groups of critical care staffing for a satisfied ICU work experience will need to be done.

Reference

1. Galloway R, Onyiriuka O, Brown A, et al. HealthRota: An evaluation of a digital rostering platform for managing hospital doctors’ rotas and leave. doi:10.7861/fhj.2022-0022. PMID: 35928190.

5345

Supporting staff in the workplace, embedding the role of the Professional Nurse Advocate in critical care - a national approach

Karen Wilson

Cheshire and Mersey Critical Care Network / CC3N Critical Care Network National Nurse Leads Group

Critical care national network nurses leads group (CC3N0 have been pivotal in the roll out of Professional Nurse Advocate training for 436 Critical Care nurses, liaising with NHSEI, HEIs and Critical Care units to ensure there is a PNA on every critical care unit in England.

​Pre-Covid data showed that a third of Critical Care Nurses experienced severe burnout, with 86% experiencing one of the three classic symptoms of exhaustion, depersonalisation and reduced personal accomplishment. (Moss et al. 2016).

In response to wave 1 of the COVID 19 pandemic, Ruth May (Chief Nursing Officer for England) announced in March 2021 the immediate role out of the Professional Nurse Advocate Programme in England starting with 400 critical care nurses meaning that there are two PNAs in every critical care unit in England. Since April 2021, the programme has been rolled out to more than 1,000 nurses from adult acute mental health, community, adult learning disabilities and children and young people. The aim is to have 5000 PNAs, across all specialties in England by April 2022.

The Professional Nurse Advocate (PNA) is a qualified practising nurse who has undertaken a Level 7 PNA accredited Programme that has been developed around the A-EQUIP model (Advocating for Education and Quality Improvement) initially introduced into Midwifery in 2017. The A-EQUIP model includes Restorative Clinical Supervision (RCS), which research shows has a direct impact on recruitment, retention, staff engagement, compassion fatigue and reducing sickness. The model also has an emphasis on Education and Development and Quality Improvement. All of which will have a positive impact on patient safety and experience.

Benefits of the PNA are:

• strengthens professional resilience

• Supports provision of high quality care

• Identifies areas for improvement

• Improves sickness and absence rates

• Improve staff well being

• Decreases stress and reduce burnout

• Increases job satisfaction

• Increases retention of staff and makes them feel valued

• Improves working relationships and team dynamics

• Assists with work life balance

Despite the roll out of the PNA role and training - the role is still not fully embedded into all critical care units. CC3N (2022) conducted a national adult critical care nursing workforce survey . 3145 registered nurses completed the survey across England, A specific question in relation to PNA was asked as part of the survey. PNA’s often do not time allocated to undertake the role and often undertake the role in their own time despite this being a role vital for supporting staff in critical care.

Results: 49% of respondent’s didn’t know who there PNA was for their critical care unit and what they did 14% knew who they PNA was but the PNA did not have time to undertake RCS sessions.

As a call for action for the embedding the PNA role as part of critical care unit practice, CC3N created the Professional Nurse Advocates in Critical Care: Standard Operating Procedure in 2022 and it recommends that each PNA in critical care gets the minimum of 15 hours per month in order to undertake the role within their own critical care unit and that each member of nursing staff should also be given the time to access the PNA within their own unit when it is required.

CC3N have also facilitate a national community of Practice for critical care PNA’s to support them in practice and to enable them to share practice with other PNA’s. We are collaborating with the national critical care national groups such as the BACCN to produce national PNA webinars to publicise the key benefits of the role in support of our critical care staff when it is needed the most.

References

Moss et al (2016) an official critical care societies collaborative statement : Burnout Syndrome in Critical care Healthcare Professionals : a call for Action Critical Care Medicine July 2016.

May (2021) ‘Roll out of Professional Nurse Advocate Programme ‘, Nursing Times 5th March 2021.

NHSEI (2021) ‘The professional nurse advocate A-EQUIP model: A model of clinical supervision for nurses, NHSEI 2021.

CC3N (2022) National Adult Critical Care Nursing workforce survey, CC3N 2022.

CC3N (2022) Professional Nurse Advocates in Critical Care: Standard Operating Procedure, CC3N 2022.

5484

Evaluating the utility of a Professional Tree of Life intervention to enhance team cohesion and wellbeing for nursing staff working within Intensive Care

Bridie Bradshaw, Caitlin Gillespie, Martin Parsons

King’s College Hospital (KCH) NHS Foundation Trust

Introduction: Staff burnout within the NHS has reached critical levels due to staff shortages, lack of resources and funding, and the lasting impact of the Covid-19 pandemic.¹ Levels of burnout are particularly problematic in intensive care units (ICUs), high acuity environments where staff are frequently exposed to challenging ethical situations, high patient mortality and excessive daily workloads.² Given that higher levels of burnout are associated with poorer individual wellbeing and lower quality of patient care, improving the wellbeing of staff who work in ICU is crucial. Team-building exercises within healthcare settings have been shown to be an effective buffer against stress, enhancing team cohesion and promoting wellbeing and resilience³. One potential intervention to facilitate this is the Professional Tree of Life (PToL). Originating from narrative therapy, the ‘Tree of Life’ (ToL) is a strengths-based exercise which supports people to recognise the skills, expertise and resources they already possess to create a more enabling narrative in tackling challenges, through telling the story of their life with the metaphor of a tree. The ‘ToL’ has since been adapted and applied for use with teams in professional contexts,^4,5 but there is limited evidence for its utility and no evidence of its use with staff in ICU settings.

Objectives: The aim of this project is to evaluate the potential utility of the PToL exercise to strengthen team cohesion and improve staff wellbeing within critical care at King’s College Hospital (KCH), a tertiary London hospital employing around 14,000 staff.

Methods: A single 90-minute adapted PToL session was developed by the KCH Staff Psychology Service and delivered during team away days, where two teams from different ICUs attend for a variety of training and updates annually. The facilitators began with an introduction to the exercise, followed by each team creating their shared ToL and presenting this to the other team. A mixed-methods approach was used to evaluate the intervention, in which staff were invited to complete anonymous feedback containing both 5-point likert-style and open-ended questions immediately after the session. Demographic information was also collected. Descriptive data was analysed and a thematic analysis was conducted on the qualitative data.

Results: Across eight months (July 2022 – Feb 2023), fourteen PToL sessions were delivered to 260 participants (78.6% female; 21.4% male) who were predominantly nurses (95.6%). Overall, the intervention was positively received, with 97.3% of participants agreeing that they felt more connected to their colleagues and 98.1% reporting that they felt confident in the team’s ability to manage challenges following the session (Figure 1). Analysis of qualitative feedback revealed four overarching themes: (1) Appraisal of PToL session; (2) Strengthening of Team Bond; (3) Space for Reflection; and (4) Enrichment of Team Narrative (Figure 2).

Figure 1.

PToL Quantitative Feedback.

Figure 2.

PToL Qualitative Thematic Map.

Conclusions: Overall, the PToL session was found to be an accessible intervention for NHS ICU staff, and easily adaptable from the original ToL model. Experienced as interactive and enjoyable by participants, a shared ToL enhanced team cohesion and connection, and provided a safe space to explore upcoming challenges and shared values.

Figure 3.

Example PToL.

References

1. Deakin M. NHS workforce shortages and staff burnout are taking a toll. BMJ 2022; 11; 377.

2. Ramírez-Elvira S, Romero-Béjar JL, Suleiman-Martos, N, et al. Prevalence, risk factors and burnout levels in intensive care unit nurses: A systematic review and meta-analysis. International journal of environmental research and public health2021; 18(21), 11432.

3. Clark PR. Teamwork: building healthier workplaces and providing safer patient care. Critical care nursing quarterly 2009; 32(3); 221-231.

4. Fraser J and Matias L. Using the Professional Tree of Life for Staff Wellbeing and Supervision. In: Conniff H (eds) Psychological Staff Support in Healthcare: Thinking & Practice. 1^st UK: Sequoia Books, 2022, pp.224-246.

5. Wonders S and Lee, C. Exploring roots and fruit: Using the ‘Tree of Life’ to help teams manage change. Clinical Psychology Forum 2019; 22-26.

5517

An audit to assess extent of junior doctor wellbeing and methods of improvement in a critical care unit at UHCW

Georgia Hinchliffe, Lulu Lyons

UHCW

Background: As evidence of junior doctor dissatisfaction permeates the news through strike action and resignations, we have devised an audit to quantify junior doctor wellbeing and usage of available support in a critical care unit at University Hospital Coventry and Warwickshire (UHCW). We are identifying two aspects of wellbeing – the availability of adequate resources and the usage and awareness of these by junior doctors. Sustaining and promoting wellbeing in junior doctors is essential for good quality care, but since the start of the pandemic junior doctors have suffered with an increasing extent of burnout and mental ill health.^1,2 Whilst the NHS is attempting to recover following this period, it is important that we promote and safeguard wellbeing.

Methods: Using the standardised BMA wellbeing checklist, we will audit the understanding of the available resources by junior doctors and their merit if used. This is a standardised checklist that can be replicated and used in further audits and other trusts. The questionnaire will cover four main themes: organisational structure, self-actualisation, feedback and workload.^3,4 The audit is for all junior trainees rotating through critical care, but with the aim of using it on a trust level for all specialties in the future. The audit will identify junior doctor’s awareness of what UHCW offers to support their wellbeing and highlight key areas for improvement of the resources themselves or access to them.

Results and conclusions: Audit currently in progress with results expected during Spring 2023. We plan to use the information gained during the audit to work with the relevant departmental managers to plan interventions to improve wellbeing, promote usage of available resources and hope that productive conversations can be facilitated between junior doctors and their employers.

References

1. BMA (2023) NHS medical staffing data analysis. Available at https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/workforce/nhs-medical-staffing-data-analysis (Accessed: 9 February 2023).

2. Simmons G, A critical review of the definition of ‘wellbeing’ for doctors and their patients in a post Covid-19 era. International Journal of Psychiatry 2021, Vol. 67(8) 984–991.

3. Rimmer A, What organisations around the world are doing to help improve doctors’ wellbeing. The BMJ, 2020; 369:m1541.

4. BMA (2023) Junior doctor wellbeing checklist. Available at https://www.bma.org.uk/media/4103/bma-junior-doctor-wellbeing-checklist-may-2021 (Accessed 9 February 2023).

5525

Differential outcomes in critical care survivors experiencing unscheduled hospital readmissions

Nicholas Plummer¹, Nazir Lone²

¹ East Midlands School of Anaesthesia

² University of Edinburgh

Introduction: Critical care survivors have excess health needs over other patients discharged from hospital, including frequent emergency readmissions.¹ However, preventing “avoidable” readmissions relies on understanding varying drivers for this over time in a heterogeneous patient population.

Objectives: To understand differences in outcomes for patients experiencing different forms of readmission.

Methods: National, regional, and local data from NHS Lothian over an eight-year period was linked. An iterative data-driven classification system² was applied to hospital readmissions after discharge following a critical care stay. Patients were followed up for twelve months, or until readmission to critical care. The study received ethical approval from the University of Edinburgh.

Results: 47% of survivors experienced at least one readmission. Potentially preventable readmissions occurred earliest (median 25 days, IQR 5 to 98). Anticipated but unpredictable readmissions – based on patient features prior to critical care – also occurred early during follow up (42, IQR 13 to 114). Readmissions related to the index critical care admission occurred earlier (50 days, IQR 14 to 141) than unrelated readmissions (65 days, IQR 18 to 167). Patients with potentially preventable readmissions spent a greater proportion of their follow up out of hospital (98%, IQR 95-100) and experienced fewer total readmissions (1, IQR 1-2) than anticipated but unpredictable readmissions (98%, IQR 93-100, p<0.001, and 2, IQR 1-3, p<0.001) and those experiencing a related admission (99%, IQR 95-100, p=0.001, and 1, IQR 1-2, p=0.037). Patients with unrelated admissions spent a smaller proportion of their follow up time out of hospital than related admissions (98%, IQR 93-100, p<0.001) and had a greater number of total admissions (2, IQR 1-3, p<0.001).

Significantly more patients in the anticipated but unpredictable readmission group were readmitted to critical care (38%) than the potentially preventable (29%), related (26%), and unrelated (15%) groups, and all groups showed a significantly difference in critical care readmissions when adjusted for mortality as a competing risk (table).

Overall mortality was higher in the broadly related readmissions cohort (20%) than in the potentially preventable (15%), anticipated but unpredictable (16%), and unrelated (14%) groups.

Conclusions: Distinct classes of hospital readmissions following critical care can be recognised as associated with differing patterns of hospital use and long-term outcomes. Understanding risk factors specific to these will allow more focussed, patient-centred interventions to be applied during critical care follow up to avoid unnecessary readmissions and minimise morbidity.

References

1. McPeake J, Bateson M, Christie F, et al. Hospital re-admission after critical care survival: a systematic review and meta-analysis. Anaesthesia 2022; 77: 475–85.

2. Blunt I, Bardsley M, Grove A, Clarke A. Classifying emergency 30-day readmissions in England using routine hospital data 2004-2010: what is the scope for reduction? Emerg Med J 2015; 32: 44–50.

Readmission class	Critical care readmission	Death before critical care	Death including critical care
Potentially preventable	2.22 (2.02 to 2.44) p < 0.001	1.05 (0.92 to 1.21) p = 0.470	1.07 (0.93 to 1.23) p = 0.330
Anticipated but unpredictable	2.99 (2.74 to 3.27) p < 0.001	1.07 (0.93 to 1.23) p = 0.370	1.08 (0.94 to 1.24) p = 0.290
Broadly related	1.92 (1.76 to 2.10) p < 0.001	1.49 (1.33 to 1.67) p < 0.001	1.50 (1.33 to 1.68) p < 0.001

Hazard ratio (95% CI) and p-value relative to unrelated readmission group (assumed to represent background risk).

5496

Embedding Allied Health Professionals in research roles

Ema Swingwood¹, Eleanor Daniel², Katie Sweet², Alex Barrow², Jeremy Bewley²

¹ University Hospitals Bristol and Weston NHS Foundation Trust/University of the West of England

² University Hospitals Bristol and Weston NHS FT

Introduction: Healthcare research and innovation is key to ensuring safe, evidenced based practice as well as, improving patient care and outcomes.¹ Despite these benefits, only a limited number of allied health professionals (AHPs) have access to research exposure and specific positions that encompass research.

Recently, Health Education England developed a research and innovation strategy for AHPs² which outlines the need for research opportunities to be available for all AHPs.

Objective: To increase research opportunities for AHP’s within an acute Teaching Trust (UHBW).

Methods: A number of simultaneous strategies were instigated:

Local capacity and capability funding was obtained for an AHP secondment into the intensive care nurse research team at the Bristol Royal Infirmary for a six month period. This post was supported by the lead research consultant and ICU research Matron. The UHBW competency framework was utilised to support development of the physiotherapist’s research knowledge, skills and attributes.

UHBW and local HEI collaborated to develop a ‘clinical academic placement’ for undergraduate physiotherapy. Students were exposed to clinical hours on an intensive care unit, alongside involvement in an ongoing PhD feasibility study. An integrated training programme ran alongside the placement which included GCP training, critical appraisal skills, journal clubs and peer support.

A series of research themed workshops were developed and hosted by UHBW for nurses and AHP’s from UHBW and the wider BNSSG network. Topics covered included Writing for publication; Introduction to Statistics; Academic Writing; Literature searches and critical appraisal skills.

Results: The secondment demonstrated that AHPs can work effectively within an ICU research team. AHPs have the skills, learning and experience for research roles traditionally advertised for registered nurses. Such a post provides multiple learning opportunities for clinicians.

Exposure to research at undergraduate level beyond the classroom is important and also a feasible placement opportunity. Feedback from students was positive and so continuation of such placements is of importance.

Conclusions: Consideration of embedding research experience and learning back into clinical practice post secondment is an important next step to promoting a research culture amongst AHPs. Ongoing challenges remain regarding navigating an AHP research career within a medical research infrastructure which include recurrent funding and research post opportunities.

References

1. Matus J, Wenke R, Hughes I and Mickan S. Evaluation of the research capacity and culture of allied health professionals in a large regional public health service. Journal of Mulitdisciplinary Healthcare. 2022 Dec 22; 12:83-96.

2. Health Education England. Allied Health Professions’ Research and Innovation Strategy for England. [Internet]. 2022. Available from: Allied Health Professions’ Research and Innovation Strategy for England | Health Education England (hee.nhs.uk).

5311

Management of spinal vascular malformation as a rare cause of acute quadriplegia in a young adult in neuro-intensive care – a multidisciplinary approach

Lubaina Bahar¹, Shakya Majumder²

¹ Royal Brompton Hospital

² Imperial College Healthcare NHS Trust

Introduction: Spinal Vascular malformations consist of an abnormal connection between normal arterial and venous systems and predispose the individual to ischaemia and haemorrhage if not diagnosed and treated emergently¹. The current guidelines suggest utilization of appropriate diagnostic imaging with or without neurovascular interventional procedures like embolization or neurosurgical intervention to achieve cure. Below we report a case of a young adult male with sudden, acute neurological deterioration due to haemorrhage around a glomus type cervical spinal cord vascular malformation. The neurocritical care of patients with AVM who present with quadriplegia with a spinal level, is mainly supportive with the involvement of the wider multi-professional team. Due to long rehabilitation time with slow recovery of neurological function, need for vasopressors due to neuroprotective targets and prolonged ventilatory support complicated by slow respiratory weaning, these patients produce a significant strain on intensive care resources and may remain neurologically dysfunctional in the long term. The case highlights the importance of appropriate radiological techniques for early recognition of life-threatening injury to the spinal cord resulting from ruptured AVMs. It also underpins the significant contribution by the nursing staff, physiotherapists and psychologists and the rest of the multi-professional team in improving the general quality of life for these remarkably young and healthy patients suddenly incapacitated by a rare medical occurrence.

Case Report: A young adult male was transferred to our neurocritical unit from a local hospital after being diagnosed with a spinal vascular malformation presenting with acute onset of quadriplegia. He underwent emergent MRI of his spine to confirm the diagnosis of a ruptured, glomus type arteriovenous malformation in the cervical area. He subsequently had a Digital Subtraction Angiography Scan followed by embolization of the culprit feeding vessels in quick succession. Between the procedures, he received supportive care by the multi-disciplinary team comprising intensivists, physiotherapists, dieticians, pharmacologists, microbiologists, psychologists and other allied health professionals. During his stay, he was intubated multiple times for procedures and eventually tracheostomised to manage secretions and facilitate ventilation and rehabilitation. The patient was found to be incidentally COVID-19 positive and had to be isolated. He was administered high dose dexamethasone to reduce cord oedema and was started on vasopressor support with metaraminol infusion for blood pressure augmentation as part of neuroprotective interventions. His supportive management in neurocritical care unit involved physiotherapy guided cough-assist for secretion clearance, frequent re-positioning for prevention of pressure sores, screening for common micro-organisms under surveillance, meticulous pain control, nutritional support, frequent family visitations and psychological support. The patient achieved significant recovery of his neurological function and was repatriated to his local hospital for further rehabilitation.

Conclusion: A focussed and holistic clinical management with routine involvement of the multidisciplinary team improves clinical outcomes in young critically ill patients suffering from neurological catastrophe.

References

1. A Gonzalez, G. (n.d.). Arteriovenous Malformations and Fistulas (AVM/AVF) of the Spinal Cord. [online] emedicine.medscape.com. Available at: https://emedicine.medscape.com/article/248456-overview [Accessed 16 Jan. 2023].

2. Peckham ME, Hutchins TA. Imaging of vascular disorders of the spine. Radiol Clin North Am. 2019 Mar. 57 (2):307-18.

3. Naito K. [Key of classification and diagnosis of spinal arteriovenous malformation]. No Shinkei Geka. 2021 Nov. 49 (6):1346-52.

4. Endo T, Tominaga T. [Surgical treatment for spinal arteriovenous malformation]. No Shinkei Geka. 2021 May. 49 (3):665-76.

5. Fugate JE, Lanzino G, Rabinstein AA. Clinical presentation and prognostic factors of spinal dural arteriovenous fistulas: an overview. Neurosurg Focus. 2012 May. 32 (5):E17.

5320

Speaking the ICU code

Jessica Annett

Swansea Bay University Health Board

Introduction: At the time I started my first ICU job I felt I had started to establish my professional identity. I had a framework of communication I used with other staff and patients, I felt comfortable in organising relevant and appropriate investigations and treatments and I was developing my own formulary of my common drugs. I knew my role and what was expected of me.

My confidence in my professional decisions changed when I started my first ICU job, in the sense that I had to learn a new “normal”. I learnt that someone’s “balance” wasn’t an indicator of falls risk, “light” didn’t refer to body weight and “appropriate” didn’t refer to their social interactions. The observations chart was gone, and was replaced with different coloured squiggly lines on a flashing screen. I struggled to learn where my role fit in.

Main body: In ICU there is a whole new language to learn, which is thankfully learnable with time. It includes a variety of unfamiliar drugs, but also interventions such as Vasc Cath, ICPm and PiCCO. This language is really hard to learn when you have no ICU experience, and it can feel really daunting to lack understanding when everyone else seems to speak this ICU “code”. It only gets worse when colloquialisms get used, like “trac” infusion and “dexdor”.

As critical care clinicians, we must always remember how little we knew about critical care before we stepped foot into it. This is mainly for the benefit of professionals joining ICU in the early part of their career who aren’t familiar with the variety of interventions we use. Introducing new team members to the language and treatments used at an early stage incorporates them into the team, enabling them to feel confident discussing patient care but also promoting safe handover between clinicians.

When starting as a doctor in ICU, I initially struggled to know where my role fit in and what was expected of me. I used to dread being ask to “watch” a patient - “watch them do what? Breathe?” (yes, sometimes). Different units have different expectations of their clinicians. This can be due to the organisation of the unit (including staffing), the competencies of non-rotational ICU staff and the sub-specialty of the ICU itself. Outlining the roles and responsibilities of new clinicians when they start on ICU helps to establish that sense of professional identity, and understand the part they play in the wider ICU team.

Conclusion: ICU is a more daunting environment than most. Many people are expecting to feel consciously incompetent and overwhelmed. Introducing new starters to their expected roles and duties in ICU, and teaching them the ICU “code” can help them to feel empowered and involved. When you next find yourself using ICU-specific language to a new starter, I encourage you to stop yourself and take a moment to explain - and remember how overwhelming it felt in the beginning.

5324

Perhaps the record quick wean of a morbidly obese patient thanks to Tracheostomy MDT?

Ruth Tighe¹, Brenna Fossey², Rebecca Hetherington², Anu Ludhia Kunjumon³

¹ Ekhuft

² William Harvey Hospital - Ashford, Kent

³ Intensive Care Unit, William Harvey Hospital

Introduction: In January 2021, we set up a hospital wide tracheostomy MDT (T-MDT) in response to increasing work from the National Tracheostomy Safety Project and the seminal service improvement drive by McGrath et al.¹ This case demonstrates how we’ve evolved our tracheostomy weaning utilising lessons learnt in COVID, T-MDT and inspirational speakers at SOA 2022 like Dr Anna Liisa Sutt,² leading to a hugely accelerated wean journey for a very high risk patient.

Main body: Day 0 - A 49yr male, 160kg, BMI 52 presented to A&E with chest pain and quickly developed T2RF failure with low GCS. His background was IHD (DNAed appointments for PCI), COPD, OSA (home BiPAP 20:8 but didn’t use it), T2DM and depression. His functional history was walking between sofa and kitchen with heavy ETOH intake. Of note, his ECHO in April 2022 was essentially normal.

He was intubated and ventilated in A&E and brought to ICU with the diagnosis of IECOPD (with normal inflammatory markers but COVID +ve).

Day 2 - hard to ventilate - on maximum oxygen, proning, APRV, 100% FiO2.

Day 7 - Improved, breathing spontaneously on APRV. Sedation holds unsuccessful as he was too agitated.

Unfortunately, he self extubated that day, leading to hypoxic peri-arrest due to de-recruitment and inadequate respiratory drive. He was re-intubated needing high settings on APRV to re-recruit.

As an MDT, we agreed aiming for direct extubation would be unlikely to succeed (given his BMI and length of sedation/ventilation). However, if we waited to convert to traditional ventilation settings to provide generally acceptable conditions for percutaneous tracheostomy insertion, it would add another 7-14 ventilator days before tracheostomy leading to a weaker patient and a longer wean after insertion. Ideally, our patient would have a quick safe surgical tracheostomy (trachea was 5 cm deep on US) on APRV, to allow his own strengthened negative pressure breathing (off sedation) to become predominant again.

Day 10 - Anaesthetist, Intensivist, ENT consultant performed safe surgical tracheostomy. Patient needed re-recruitment after lying flat and paralysis with APRV.

Day 11 - Propofol off - kept low dose fentanyl, clonidine and labetalol (for haemodaynamic stability) to permit smooth sedation wean.

APRV weaned to P high 18, Thigh 8 and FiO2 30%. At T-MDT that afternoon, he was mouthing words, keen to communicate. With our team, we decided to be bold and trial In-line Speaking valve on APRV. It worked extremely well - the patient spoke, coughed, swallowed and managed his secretions. He managed this for the rest of the day – we switched to Pressure Support to reduce discomfort from high pharyngeal airflow.

Day 14 – Ongoing cuff down on trachy mask 28% humidified oxygen. Delayed decannulation deliberately to form tract in such a difficult surgical tracheostomy.

Day 17 – Decannulated, but with normal laryngeal function (voice and drinking from day 11).

Conclusions: Using new techniques applied and developed by our MDT, we achieved a high quality and expedited tracheostomy wean for a BMI 52 co-morbid.

References

1. McGrath BA, Wallace S, Lynch J, Bonvento B, Coe B, Owen A, Firn M, Brenner MJ, Edwards E, Finch TL, Cameron T, Narula A, Roberson DW. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. Br J Anaesth. 2020 Jul;125(1): e119-e129. doi: 10.1016/j.bja.2020.04.064. Epub 2020 May 31. PMID: 32493580.

2. A.L. Sutt et al. The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients. Crit Care (2015).

5344

Retention, Retention, Retention !!! - helping fix the leaking bucket - a review of CC3N national ACC nursing workforce retention survey

Karen Wilson

Cheshire and Mersey Critical Care Network / CC3N Critical Care Network National Nurse Leads Group

Introduction: The first National Adult Critical Care (ACC) Nursing Retention Survey was facilitated by CC3N - Critical care National Network Nurse Leads Group in Summer 2022. The survey was developed as a method of gathering both qualitative and quantitative self-reported data from registered nurses currently working on adult critical care units. All survey data collected was anonymous. The aim of the survey was to help gain better understand how nurses feel about their roles, focusing on factors that may affect their wellbeing and any intentions they may have to leave.

Main Body: 3145 nurses responded to the survey from 195 units across England. 48% of all responses were from Band 5 nurses.

Report findings include:

Following the Covid-19 Pandemic 43.4% of ACC Registered Nurses have stated the pandemic made them less likely to stay in their current post. 42.4 % stated it made no difference.

1 in 2 of the survey respondents are expecting to leave their current critical care units in the next 3 years and 26% of those expecting to leave state they are going to leave the NHS completely.

The top five reasons respondents stated as the reasons why they were intending to leave out of a pick list of 18 factors were:

• Lack of recognition through pay awards

• Being asked to work on other wards or departments

• Lack of recognition from management

• Stressful and traumatic experiences they have encountered

• High workload

The top three factors that survey respondents gave as being important to them as Registered nurses working in critical are

• Being valued and respected

• Positive impact on patient care

• Positive relationships with colleagues

Whilst they do feel they are making a positive impact with patient care, have professional autonomy and have positive relationships with colleagues – they state are not receiving salary recognition for their skills and knowledge they have as critical care nurses, opportunities for career progression are lacking and they do not feel valued or respected as a nursing speciality.

6 out of 10 respondents feel they have a high level of stress because of their work and out of a picklist of 15 options – the top five causes of stress for survey respondents are:

• Staff shortages

• Being asked to move to other wards and departments

• Stressful and traumatic work experiences

• Workload

• Work life balance

Since the critical care nursing was the first to receive the Professional Nurse Advocate (PNA) role in March 2021 to provide Restorative Clinical Supervision (RCS) for Registered Nurses. Survey data shows it is still not fully embedded or resourced in many critical care units in England yet- 49 % of respondents did not know who their PNA was or what they did. Whilst 36% did know who their PNA was and they were available for them for RCS, there was still 14% of respondents who stated their PNA had not got the time to undertake restorative clinical supervision sessions.

68% of respondents stated they would recommend Critical Care as a place to work and there are six clear recommendations which help the retention of ACC registered nurses in the future.

Conclusion/recommendations: The overview report was published in Jan 23 and gave clear recommendations on how to help retain registered critical care nursing staff in critical care units in the UK

• Minimising and thorough risk assessment of critical care nursing staff moves to other wards and departments.

• Need for a National Critical Care Nurse Staffing Establishment and clearly defined National Critical Care Nurse Ratios

• Recognition of Critical Care Nursing as a speciality and remuneration/pay in accordance with skills, knowledge, and experience of critical care nurses with a defined career pathway.

• Need for Flexible staffing arrangements / rotas.

• Staff Mental Health and Wellbeing must be made a priority

• Units should have a comprehensive plan to provide a working environment and core conditions which meet National ACC Workforce Wellbeing Best Practice Frameworks, policies.

References

CC3N (2023) National Adult Critical Care Nursing Workforce Retention Survey Overview report, CC3N 2023.

CC3N (2022) Best Practice Principles to Apply When Considering Moving Critical Care Nursing Staff to a Different Clinical Area. Version 2.

CC3N (2023) Adult Critical Care Nursing Career Pathway, CC3N 2023.

CC3N (2021) Professional Nurse Advocates in Critical Care: Standard Operating Procedure, CC3N 2021.

5368

Implementing and embedding the Professional Nurse Advocate role in Critical Care – a service evaluation of the first five months

Ruby Shaikh

Guy’s and St. Thomas’ NHS Trust

Introduction: The Professional Nurse Advocate (PNA) programme was commenced in England in March 2021, towards the end of the third wave of the Covid-19 pandemic. The intention of the programme was to equip nurses with the skills to listen to and understand the challenges faced by colleagues, and to deliver quality improvement initiatives in response¹.

The PNA role has the principle of restorative clinical supervision (RCS) at its core. Clinical supervision is a process of professional support, reflection and learning that contributes to individual development². Benefits include reduced stress and burnout, improved quality of care, reduced sickness and staff turnover^1,3.

The author was responsible for establishing a PNA service in Critical Care. There was no prior PNA service in the trust. The author led a team of PNAs who are critical care nurses, providing a sessional PNA service to critical care nurses. Guidance from NHSEI¹ and CC3N⁴ was used to guide development of a local model for PNA service provision.

Main Body: A service evaluation was undertaken to determine effectiveness of the PNA role by examining two outcomes during the first five months of the service:

• Reasons for accessing the service

• Perceived benefits of the role by service users

To evaluate reasons for accessing the service, PNAs kept an anonymous log of session content and themes – these were broadly categorised into:

• RCS – clinical

• RCS - communication

• Quality improvement

• Career development

• Wellbeing/general support

To evaluate perceived benefits, service users were asked to complete an anonymous feedback form via a QR code given to them at the end of each session. The feedback form comprised 4 Likert scale questions, 4 multiple choice questions and 1 free-text question.

A Plan, Do, Study, Act (PDSA) cycle was used to guide the service evaluation, as recommended by NHSEI⁵- shown in Figure 1.

Figure 1.

Figure 2 shows the number and type of PNA sessions provided.

Figure 2.

Figure 3 shows a breakdown of themes of sessions.

Figure 3.

Figures 4 to 9 show the results of the feedback survey. Response rate for the survey was 45% (33 respondents).

Figure 4.

Figure 9.

Conclusion: This service evaluation shows that, in the 5 months since implementation, the PNA service is being used and is well-evaluated by service-users. The evidence from the service evaluation suggests that the PNA role is embedded in the author’s place of work, with 8 trained PNAs and one in training. NHSEI recommends a minimum ratio of 1 PNA per 20 registered nurses¹ – with 450 nurses working in Critical Care in the author’s place of work a ratio of 1 PNA per 50 nurses is achieved.

There are challenges around funding the PNA role across NHS England, with no funds ring-fenced for provision of the service. Based on the outcome of this initial service evaluation, the author’s recommendations are to train a further 13 PNAs and ring-fence funding for provision of a protected sessional PNA service. Further work is required to measure the impact of the PNA role on staff satisfaction, sickness rates and staff retention.

Figure 5.

Figure 6.

Figure 7.

Figure 8.

References

1. NHS England and NHS Improvement. Professional Nurse Advocate A-EQUIP model: a model of clinical supervision for nurses [Internet]. 2021 [cited 2023 Feb 24]. Available from:https://www.england.nhs.uk/wp-content/uploads/2021/12/B0799-national-professional-nurse-advocate-implementation-guide-with-links.pdf

2. Butterworth, T. What is clinical supervision and how can it be delivered in practice? Nurs. Times. 2022 Feb 04; 118(2):20-22.

3. Bifarin, O. and Stonehouse. Clinical supervision: an important part of every nurse’s practice. Br. J. Nurs. 2017 March 26; 26(6):331-335.

4. Critical Care Networks – National Nurse Leads. Professional Nurse Advocates in critical care: Standard Operating Procedure [Internet]. 2022 [cited 2023 Feb 24]. Available from: https://www.cc3n.org.uk/uploads/9/8/4/2/98425184/cc3n_pna_sop_final_version_02.22.pdf

5. NHS England and NHS Improvement. Plan, Do, Study, Act (PDSA) cycles and the model for improvement [Internet]. 2022 [cited 2023 Feb 24]. Available from: https://www.england.nhs.uk/wp-content/uploads/2022/01/qsir-pdsa-cycles-model-for-improvement.pdf

5375

Getting together: The secret to a good day

Philip Whelan¹, Rebecca Quinn²

¹ Salford Care Organisation

² -

Introduction: Salford Critical Care is made up of 40 beds, split into 5 ‘PODs’ of which there are 8 beds per POD.

The Salford Critical Care medical and nursing teams have always enjoyed an excellent working relationship. The Covid pandemic was incredibly challenging for both teams however the experience only enhanced and solidified the cooperative working relationship. That being said, there was no formal structure in place that provided a clear set of goals and a plan for the day. In particular due to the large volume of staff, approaches varied incredibly. As such we developed, based upon the approach used in theatre, a structured team ‘huddle’ or ‘brief’ in the morning attended by both the medical and nursing teams on each POD.

Safety Huddle: In May 2022 we introduced our first ‘Safety Huddle’ board – a static board on each ‘POD’ which the nursing and medical team gathered around at 8:15am to go through the plan of the day including introductions, level of experience, safety concerns, plans and goals for the day. For the medical team, there was now clear visibility of which nurses were caring for the patients they may be reviewing. Additionally, they could see where breaks were planned in and which other nurse would be ‘covering’ the patient. This allowed for no interruption of care and provided continued safety for the patients. For the nursing team it allowed clear plans and goals to be set and the opportunity for the team to ask questions and/or solve problems right at the start of the shift.

In addition to the team huddle there was a section added for a specific ‘Nursing Huddle’ – this was something that already took place but now it was clear, concise and happened every day consistently. This released more time to care.

Perhaps one of the best received changes was the introduction of a weekly ‘Safety Topic’ – this is a rotating series of topics to be discussed amongst the team each morning – this not only provided an opportunity to refresh important topics but also allow new members of the team to listen and ask questions. The topics currently rotating include sedation, antibiotics, medication safety and emergency equipment.

Whilst the board was initially introduced in May 2022 – it has gone through at least 5 version to finish at the board we currently use. Each time feedback was sought and changes were made as part of a small QI group.

The final version has now been in place for at least 3 months and has naturally formed part of the day to day operation of the unit. In addition, our sister site at Fairfield General Hospital has introduced it to their Critical Care unit which has also proved a success.

Conclusion: The working relationship previously mentioned worked together to create our Safety Huddle system and it is now fully embedded into practice at Salford Critical Care. There has been a noticeable reduction in errors associated with ‘high risk medications’ specifically because these are all discussed in Safety Huddle. The feedback continues to be positive and the introduction of a brief discussion each day around a specific topic has aided learning across all grades.

5391

Acute Disseminated Encephalomyelitis causing refractory seizure: A case report

Naomi Brown, Stephanie Pelia, Saibal Ganguly

The Royal Wolverhampton

Introduction: Acute Disseminated Encephalomyelitis (ADEM) is an autoimmune inflammatory condition of the central nervous system.¹ Its aetiology is thought to be immune-mediated as it usually follows an antecedent infection.¹ Our case report discusses a man with an acute history of rapidly progressive neurologic deficits who required an extended Intensive Care stay due to prolonged seizure episodes and was ultimately diagnosed with ADEM.

Case presentation: A 56-year-old fit and well man presented at the Emergency Department (ED) following a few days of lethargy, behavioural changes, and a possible seizure at home. He has a history of Trigeminal Neuralgia which was treated with carbamazepine before switching to lamotrigine two days before the ED presentation. The patient was not a known epileptic.

Whilst in the ED, he had another witnessed generalised tonic-clonic seizure which was terminated by intravenous lorazepam. This led to a drop in his consciousness level from GCS 11 (E4V2M5) to 6 (E1M4V1), leading to an ICU referral for airway support and management of status epilepticus.

In ICU following sedation holds, the patient continued having generalised tonic-clonic seizures. He was treated with pulsed IV methylprednisolone with a weaning steroid regime and five cycles of plasma exchange. EEGs were indicative of status epilepticus. CT head and CT carotid angiogram scans were unremarkable. A lumbar puncture showed increased opening pressure (25 mmH2O) with marginally raised protein (19.1 g/L) and elevated lactate (4.4 mmol/L). Routine blood tests were within normal parameters, while the viral serology, tuberculosis screen, and paraneoplastic serology were all negative. An MRI of the brain demonstrated diffuse white matter signal changes in both hemispheres, suggestive of demyelinating disease with inflammatory activity compatible with ADEM.

The treatment for the seizures initially involved the administration of intravenous levetiracetam along with midazolam, alfentanyl and propofol infusions. Because of the refractory nature of the seizures, he was commenced on sodium valproate, lacosamide, and phenytoin in increments. EEGs demonstrated persistent status epilepticus. Neurology advised holding all opioids and increasing propofol doses for burst suppression. On their advice, sodium valproate was discontinued, and perampanel was commenced. Twenty-four hours following perampanel administration, there was no visible seizure activity, and EEGs showed no evidence of status epilepticus with gradual improvement of his GCS.

Conclusion: ADEM is rare in adults, more typically seen in paediatric patients, and its incidence is unknown. Our case demonstrates difficulties in distinguishing ADEM from other neurological disorders.² Rapid progression of encephalopathy and neurological clinical signs, elevated cerebral spinal fluid protein, a preceding infection, and demyelinating lesions with grey matter involvement on MRI scans suggest ADEM but not specific ADEM.^2-4 Despite being in refractory status epilepticus for 22 days, our patient made an excellent recovery. This case shows that opioids, including alfentanyl can lower the seizure threshold and should be used with caution for seizing patients. Intensivists need to be knowledgeable of ADEM’s clinical features and presentations due to its challenges with diagnostic uncertainty. Neurology input, in this case, was invaluable, highlighting the importance of MDT involvement.

References

1. Granerod, J, H Ambrose, N Davies, J Clewley, A Walsh, D Morgan, R Cunningham, M Zuckerman, K Mutton, T Solomon, K Ward, M Lunn, S Irani, A Vincent, D Brown, N Crowcroft. “Causes of encephalitis and differences in their clinical presentations in England: a multicentre, population-based prospective study”. The Lancet Infectious Diseases. Volume 10, Issue 12 (2010).

2. Russell, D. “Acute Disseminated Encephalomyelitis”. Seminars in Pediatric Infectious Diseases. Volume 14, Issue 2 (2003).

3. Schwarz, S, A Mohr, M Knauth, B Wildemann, B Storch-Hagenlocher. “Acute disseminated encephalomyelitis: a follow-up study of 40 adult patients”. Neurology. Volume 56, Issue 10 (2001).

4. Sonneville, R, S Demeret, I Klein, L Bouadma, B Mourvillier, J Audibert, S Legriel, F Bolgert, B Regnier, M Wolff. “Acute disseminated encephalomyelitis in the intensive care unit: clinical features and outcome of 20 adults”. Intensive Care Medicine. Volume 34, Issue 3 (2008).

5392

Electrolyte replacement in Intensive Care - are we doing well enough?

Syed Abid, Damhnaic Mcdonald

University Hospitals Birmingham

Introduction: Patients admitted to ICU tend to be in a hypermetabolic state, with electrolyte abnormalities likely to be most pronounced in the first few days. Electrolyte disorders have been widely recognised to increase morbidity and mortality in this patient population.¹ Determining an optimal physiological range for electrolytes such as potassium, magnesium and phosphate remains a contentious topic. There is no consensus on when and how to replace electrolytes, with various guidelines recommending different targets and replacement regimens. In keeping with this uncertainty, clinicians may also subject electrolyte values to their own interpretation of true electrolyte deficiency, further influencing decisions to replace.² We carried out an audit at a local DGH ICU, evaluating whether electrolyte deficiency was being managed in accordance with local trust guidelines.

Methods: Retrospective review of prescription charts and patient notes to analyse electrolyte replacement practices against daily laboratory-measured serum potassium, magnesium and phosphate levels. Data was taken for all ICU inpatients each Monday over a 7-week period. There were a total of 101 patient episodes.

Results: Daily bloods were not available for two patients and so they were excluded from analysis. Of the remaining 99 patient episodes, 15/99 patients had a serum potassium value <4.0mmol/L, thus requiring replacement according to the trust guidelines. 5 patients received replacement, in the form of enteral potassium tablets or intravenous potassium chloride. 84/99 patients had a serum magnesium level <1.00mmol/L and thus deficient according to trust guidelines. 19 patients received intravenous magnesium sulphate as replacement. 19/99 patients had serum phosphate levels <0.8mmol/L - requiring replacement according to trust guidelines. 9 patients received phosphate replacement either enterally or as an intravenous phosphate polyfusor.

Discussion: Our results showed significant heterogeneity in replacement practices for the 3 included electrolytes. Magnesium was the most frequently deranged electrolyte (deficient in 85%) yet was the least replaced electrolyte, with only 23% of patients receiving replacement. Replacement for potassium and phosphate deficiency was slightly better at 33% and 47% respectively. Adjusting for patient renal function and other possible contra-indications did not significantly change results. The reasons for heterogeneity are many, not least the clinical context of the patient at that moment, which the data collection may have failed to capture. Indeed, identifying the reasons for the observed variability and short-comings in electrolyte replacement is beyond the scope of this project. We believe that there is scope for improved guideline compliance through simple education; raising awareness, particularly amongst rotating junior doctors, of the importance of optimum electrolyte levels in critically-ill patients. Additionally, given there are trust protocols providing clear guidance on replacement therapy, it may be prudent to objectively replace all deficient electrolytes. As a result of this audit, we have discussed the possibility of implementing a novel pre-prescribed protocol that would apply to all ICU admissions in our unit. This would allow all electrolyte deficiencies to be systematically replaced by nurses, as guided by our trust guidelines, and ensure uniformity in replacement practices.

References

1. Kraft, Michael & Btaiche, Imad & Sacks, Gordon & Kudsk, Kenneth. (2005). Treatment of electrolyte disorders in adult patients in the intensive care unit. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 62. 1663-82. DOI: 10.2146/ajhp040300.

2. Djulbegovic B, van den Ende J, Hamm RM, et al. When is rational to order a diagnostic test, or prescribe treatment: the threshold model as an explanation of practice variation. European Journal of Clinical Investigation. 2015 May;45(5):485-493. DOI: 10.1111/eci.12421. PMID: 25675907.

5409

Multidisciplinary Fire Safety Project in the Intensive Care Unit

David Harding¹, Sarah Marsh²

¹ Bradford Teaching Hospitals NHS Foundation Trust

² Harrogate and District Foundation Trust

Introduction: At least three major fires have occurred in UK Critical Care Units over the past 10 years, all of which required a full-scale emergency evacuation of patients, staff and relatives.¹ Whilst Fire safety training is mandatory in all trusts, it does not address the complex processes and procedures required to evacuate an intensive care unit. Reflections and reviews of such fires on the ICU have highlighted the need to adequately prepare for such an incident with regular multidisciplinary staff training in fire safety, a bespoke accessible evacuation policy to use during an emergency and timely staff debriefing after the incident. Following a refurbishment of our unit, a review of fire safety was undertaken and a multipronged project launched to achieve national recommendations.²

Main Body: The project was multifaceted. Firstly a survey was distributed to all nursing, medical and allied health professionals involved in the care of patients on ICU to ascertain their knowledge of fire safety and evacuation procedures on our ICU. A bespoke fire and evacuation plan was produced in conjunction with the fire safety department and the Estates team from the trust. Best practice solutions from the recommendations were followed including creating prominently placed and easily accessible summary action cards giving stepwise instructions to staff in the event of an evacuation. A fire and evacuation safety video was created moving methodically through the ICU outlining important locations such as the area service valve units, fire alarm call points and fire extinguishers. This was then uploaded to the trust intranet and to the mandatory training platform for all staff working on ICU to complete annually. A multidisciplinary simulation was created and delivered to give staff a real time experience of evacuating the ICU. The same survey was then re-distributed to the multi-disciplinary team.

Our initial survey demonstrated a poor knowledge of the fire and evacuation plan for the ICU amongst all staff members. Only 5% of respondents knew how many fire alarm call points there were on ICU. No respondents knew how many fire extinguishers there were. 72% did not know how to turn off piped gases to the unit and 42% did not know where patients would be evacuated to in an emergency. Furthermore, many staff fed back that they had not considered the issues they would be faced with should the need for evacuation arise.

Our multi-pronged and multidisciplinary approach resulted in vastly improved survey scores and anecdotal feedback from staff that they felt much more ‘confident’ in managing an evacuation of the ICU.

Conclusion: Despite mandatory fire training for all Trust staff, an ICU evacuation presents unique challenges that many staff have never faced or considered. Moving critically unwell patients quickly requires detailed planning in terms of logistics and manpower. The recommendations from the Association of Anaesthetists and GPICSv2 provide a framework by which to create a bespoke evacuation plan for an ICU.^1,2 A combination of simulation, mandatory training and evacuation action cards can hugely improve staff knowledge and understanding of an evacuation from ICU.

References

1. Kelly FE, Bailey CR, Aldridge P et al. Fire safety and emergency evacuation guidelines for intensive care units and operating theatres: for use in the event of fire, flood, power cut, oxygen supply failure, noxious gas, structural collapse or other critical incidents. Anaesthesia 2021; 76 (10): 1377-1391.

2. Guidelines for the provision of intensive care services. Edition 2. https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/gpics-v2.pdf (2019, accessed 13 January 2023).

5413

Professional socialisation in Intensive Care Medicine: welcoming the non-airway trained doctors to ICU

Zwesty Rimba

North West Anglia NHS FT

Introduction: Professional socialisation theory in medical education examines the process of how a person ‘becomes’ their professional identity or ‘identifies’ with the professional group they are with¹. Socialisation in ICU for rotating doctors begins with an identifier ‘are you airway trained?’ Just like in Hogwarts, they will be sorted into specific tasks, expectations, and social groups based on the answer to this question. As airway skill is gained outside of ICU placement, this label is quickly internalised. The non-airway trained ICU doctors might feel different to the rest of the team and their professional role models (ICU registrars and consultants), who are airway trained.

Launched in 2019, Internal Medicine Training (IMT) stipulates a mandatory rotation in ICU which means there has been an increase in non-airway trained doctors rotating to ICU (including trust grade doctors needing ICU experience to get the equivalent competencies). We were core anaesthetics trainees that had done 3 months of ICU in our current hospital but needed another 3 months of ICU placement due to the recent change in the anaesthetics curriculum. Together with the other trainees and a consultant, we did a few informal things to welcome the new rotating doctors to our ICU in August – October 2022.

Main Body: The highlights of the activities are as follows. (1) A new Whatsapp group for ICU junior doctors specific to this rotation was set up to facilitate communication. (2) We hosted a Halloween house party near the hospital and crafted pumpkins together. (3) We had a bowling night, followed by a dinner in a restaurant at the end of three months. (4) In several day shifts, we organised between ourselves to get coffee from a local coffee shop using the free vouchers that were available at that time for ICU staff to use. (5) We invited everybody to share their thoughts and feedback about ICU quite early in the placement through casual chats with the consultants; as we might benefit from ‘fresh eyes’ to expedite change. Subsequently, a formal survey was disseminated by the department.

In reflection, we could have made this a well-being project: send a ‘before’ and ‘after’ questionnaire, use the Likert scale, and demonstrate some improvement. However, authentic relationships are intangible, and not meant to be measured quantitatively. Instead of demonstrating ‘success’, we wish to highlight an important thing: friendship is a powerful force and has a place in professional life.² We welcomed the non-airway trained doctors in ICU by extending our camaraderie and friendship to them. This is as opposed to enforcing speciality tribalism, which creates a strong in-group relationship by diminishing the out-group identity of these doctors³.

Conclusion: Professional socialisation is a critical phase in junior doctors’ training that shapes their workplace engagement and career trajectory. Cultivating friendships in the workplace is beneficial and powerful. Further research using a qualitative interview might be useful to gain narratives and a deeper understanding of the professional socialisation of non-airway trained doctors in ICU rotation.

References

1. Haruta J, Ozone S, Hamano J. Doctors’ professional identity and socialisation from medical students to staff doctors in Japan: narrative analysis in qualitative research from a family physician perspective. BMJ Open. 2020;10(7):e035300.

2. Roberts D. Friendship fosters learning: The importance of friendships in clinical practice. Nurse Education in Practice. 2009;9(6):367-71.

3. Braithwaite J, Clay-Williams R, Vecellio E, Marks D, Hooper T, Westbrook M, et al. The basis of clinical tribalism, hierarchy and stereotyping: a laboratory-controlled teamwork experiment. BMJ Open. 2016; 6(7):e012467.

5430

A retrospective analysis of the relationship between patient body weight and ICU mortality

Will Ashley-Fenn¹, Will Ashley-Fenn², Lauren Achiam², Patrick Morgan²

¹ Surrey & Sussex Healthcare NHS Trust

² Surrey & Sussex Hospital NHS Trust

Introduction: Extremes of weight are associated with different challenges in critical illness. Low body weight, particularly in cachexia, may mean poor physiological reserves and muscle strength which prevent clearance of respiratory secretions and may be associated with a weaker immune system, while higher body weights and high adipose contents are associated with a systemic inflammatory state, challenges around intubation and cardiovascular compromise. Previous studies, including one meta-analysis involving over 7000 patients, have suggested that overweight or obese body mass index is associated with reduced mortality from sepsis in adults admitted to ICU.^1,2 We were interested to see how body weight itself has correlated with mortality on our adult intensive care unit. We predicted that there would be a U shaped relationship between absolute body weight and mortality.

Method: We conducted a retrospective study using audit trail data for our unit dating back to 1993, involving a total number of patients of 16,477. We divided the data set according to patient’s weight on admission, searching in categories of 10kg from 31-50kg up to 141-150 kg, and thereafter 151-400kg, and plotted them against unit mortality rates (%), and adjusted mortality rates (adjusted for age or APACHEII score).

Results: We found a U shaped relationship between body weight on admission (kg) and mortality, which persisted when controlling for age and APACEII score. The body weight class 111-120kg had the lowest adjusted mortality score, while the 31-40 category had a mortality rate twice that of the 110-120kg group, and similarly the 150-400kg class had an adjusted mortality 1.7 times greater that of the 111-120kg group.

Conclusion: When controlled for age and disease severity, ICU morality varied in a U shaped fashion with absolute unit admission weight, with the lightest and heaviest body weights having the highest mortality; the lowest adjusted mortality rates were found between 91kg to 130kg.

References

1. Pepper DJ, Sun J, Welsh J, Cui X, Suffredini AF, Eichacker PQ. Increased body mass index and adjusted mortality in ICU patients with sepsis or septic shock: a systematic review and meta-analysis. Crit Care Lond Engl. 2016 Jun 15;20(1):181.

2. Sakr Y, Alhussami I, Nanchal R, Wunderink RG, Pellis T, Wittebole X, et al. Being Overweight Is Associated With Greater Survival in ICU Patients: Results From the Intensive Care Over Nations Audit. Crit Care Med. 2015 Dec;43(12):2623–32.

5443

Multi-disciplinary management of bridge to lung transplant with Protek Duo VV -ECMO and successful management of associated complications

Harjot Singh, Diana Desa, Samuel Denham

The UHB NHS Foundation Trust

Introduction: We present a multi-speciality case of bilateral sequential lung transplant in a patient with Obliterative Bronchiolitis, who was bridged to transplant with Protek Duo (CardiacAssist Inc.) extracorporeal life support (ECLS). The maintenance of candidacy to transplant was complicated by prolonged wait for organ availability, ensuing complication of heparin induced thrombocytopenia (HIT) and conduct of lung transplant with alternative anticoagulation, upgraded ECLS support with Veno-Arterial extra corporeal membrane oxygenation (VA -ECMO) and successful management of further complications with multi-disciplinary input from physicians in intensive care, transplant, haematology, cardiac anaesthesia and surgery, perfusion, vascular surgery, nursing and physiotherapy teams at our hospital.

Main Body: A 33 year young female with positive cyclic citrullinated peptide antibodies obliterative bronchiolitis, on the lung transplant waiting list, suffered rapid progressive decline and hypercapnic respiratory failure necessitating a bridge to lung transplant while the organ becomes available.

The experience with suitable size Protek Duo (a dual channel cannula) as a modality of ECLS and bridge to lung transplant is limited to case series¹ in the world literature and involves expertise in percutaneous insertion through internal jugular vein in the neck and placing the return tip in pulmonary artery under imaging surveillance. This allowed maintenance of oxygenation, adequate ventilation, progress to extubation, mobilisation and prevention of deconditioning.

Despite being on super urgent list, a suitable organ was not available for more than a month. The prolong wait reduces the chances of successful outcomes due to patient and ECLS related complications.² In this case, a serious complication of HIT developed on day 13, This was managed with appropriate blood component therapy, anticoagulation with Argatroban and multiple circuit changes to heparin free circuits.

A multi-disciplinary meeting ruled out a therapeutic plasmapheresis for HIT and a change of anticoagulation to Bivalirudin to maintain ECLS and its further use during the operation (on ECMO or cardiopulmonary bypass) was recommended.

After 35 days, a bilateral sequential lung transplant was successfully conducted. Primary graft and right ventricular dysfunction required further VA -ECMO support. A vascular intervention was required on post-op day one to treat leg ischaemia, changing back to further VV-ECMO.

Patient was successfully weaned off the ECLS and discharged, with management of on-going post-transplant immunosuppression and anticoagulant therapy to cover HIT duration.

Conclusion: On reflective learning, we would consider using Bivalirudin to maintain ECLS, in first place (to avoid dreaded complication of HIT) and transition from Argatroban to Bivalirudin can be avoided too. We also learnt that sustained pressure can avoid decannulation of Protek Duo related complications such as haematoma, in wake of systemic anticoagulation.

It is vital to work as a multi-disciplinary team, as demonstrated, with shared knowledge and skills in such a resource intensive case for optimal outcome.

References

1. Sinha N, Goodarzi A, Akku R, Balayla G. ProtekDuo as a bridge to lung transplant and heart-lung transplant. Clin Transplant 2021;35: e14273.

2. Patterson CM, Shah A, Rabin J, Dichiacchio L, Cypel M, Hoetzenecker K et al. Extracoporeal life support as a bridge to lung transplantation: Where are we now? J Heart Lung Transplant 2022;41:1547-1555.

5489

Early cuff deflation and Passy Muir Valve use with a fully ventilated and tracheotomised spinal cord injury patient- A case presentation

Elizabeth Montgomery¹, Claire Randall²

¹ St George’s University Hospital NHS Foundation Trust

² St George’s University Hospital NHS Trust

Introduction: The aim of this case presentation is to highlight the benefits of a collaborative multi-disciplinary team (MDT) approach to facilitate use of early cuff deflation and Passy Muir valve application with a tracheostomised and ventilated spinal cord injury patient.

Main Body: 67 year old female admitted to St George’s Hospital after falling down the stairs and sustaining an ASIA A C3-4 spinal cord injury. She had C3-4 laminectomies and fixation with lateral screws and a percutaneous tracheostomy was inserted on day 4 of her admission due to her high spinal cord injury. Due to the level of her injury, she was unable to wean from the ventilator to a support mode as she was not triggering breaths.

The patient was first seen by a Speech and Language Therapist (SLT) on day 7 of her admission to support with communication whilst the tracheostomy cuff was inflated. She was becoming frustrated as she was unable to use her voice to communicate. The patient also wanted to be able to drink.

The patient was ventilating on a pressure control mode and Physiotherapists (PT) supported chest clearance via cough assist and manual assisted cough.

An initial cuff deflation and Passy Muir Valve (PMV) trial was carried out in line with the ventilator, jointly by SLT and PT, on day 9. The trial was successful and facilitated a functional voice and began the process of rehabilitating the upper airway. Progression of tracheostomy weaning was initially limited due to episodes of bradycardia and hypotension, however this quickly improved and trials were re started again. A FEES (firbreoptic endoscopic evaluation of swallowing) was carried out on day 15 which showed adequate management of oro-pharyngeal secretions and recommended progression of cuff deflation and PMV use. A repeat FEES was carried out on day 25, with no evidence of pharyngeal dysphagia and recommended for the patient to start on full oral intake. By day 30 of the admission, the patient had returned to full oral intake and was tolerating cuff deflation and PMV use all day whilst remaining ventilator dependent, thus, achieving her goals around communication and swallowing.

Conclusions: The importance of collaborative MDT working in critical is highlighted in many research and guidelines surrounding tracheostomy weaning (NCEPOD 2014, Bonvento et al 2017, Barrow 2020). By having regular patient discussions and weekly goal setting we were able to achieve a coordinated approach to care which resulted in positive outcomes for this patient. Laryngeal weaning (cuff deflation and PMV use) was started early in the patient’s journey, aiming to facilitate verbal communication and promoting laryngeal function (Sutt et al 2016). The use of multiple FEES assessments were also vital to assess early use of cuff deflation/PMV use, supporting feeding decisions and management of dysphagia.

References

Barrow, C. (2020). Can a multidisciplinary trach team improve swallowing in patients with a tracheostomy? Dysphagia Café, retrieved from https://dysphagiacafe.com/2020/07/25/can-a-multidisciplinary-trach-team-improve-swallowing-in-patients-with-a-tracheostomy

Bonvento, B., Wallace, S., Lynch, J., Coe, B., & McGrath, B. A. (2017). Role of the multidisciplinary team in the care of the tracheostomy patient. Journal of Multidisciplinary Healthcare, 10, 391–398. https://doi.org/10.2147/JMDH.S118419

NCEPOD (2014) On the Right Trache? A review of the care received by patients who underwent a tracheostomy.

Sutt AL, Caruana LR, Dunster KR, Cornwell PL, Anstey CM, Fraser JF. (2016) Speaking valves in tracheostomised ICU patients weaning off mechanical ventilation–do they facilitate lung recruitment? Crit Care. 2016 Apr 1;20:91. doi: 10.1186/s13054-016-1249-x. PMID: 27038617; PMCID: PMC4818462.

5505

Caring for our carers

Andrew Bates¹, Hannah Golding¹, Sophie Rushbrook², Natalie Pattison³, David Baldwin⁴, Grocott Mike⁵, Cusack Rebecca¹

¹ University Hospital Southampton

² Dorset University Healthcare NHSFT

³ University of Hertfordshire/East & North Herts NHS Trust

⁴ Southern Health NHS Foundation Trust

⁵ NIHR Southampton Biomedical Research Council

Introduction: Prior to the SARS-CoV-2 pandemic, ICUs were facing a crisis of burnout, recruitment, and retention.¹ Current evidence suggests increasing psychological distress,² but the longer-term mental health trajectory of our staff remains uncertain.³ It is also unclear which strategies may help to mitigate these effects.

Our objectives were to quantify the post-pandemic mental health of ICU staff; to determine which supportive strategies have been accessed by staff and their perceived benefit.

Main body: We emailed a cross-sectional questionnaire to all staff at a General ICU of a large teaching hospital in the United Kingdom. Baseline survey was distributed in April 2020, repeated at 6-months and 2-years. We collected 1) sociodemographics; 2) post-traumatic stress disorder (PCL-C); 3) Anxiety (GAD-7); 4) Psychological support services accessed; 5) perceived usefulness of available supportive strategies. Responses were anonymous. Institutional ethics approval granted.

We received 313 responses from a circulation of 518 (60%) across the surveys. 68% of respondents were nurses; 32% non-nurses (Doctors and allied health professionals); 78% female; 55% had less than five years ICU experience. Nurses were substantially more likely to score above cut off for clinically significant anxiety (≥10 on GAD-7) at baseline (OR 6.8 (95% CI, 1.4–31.9). 38% scored ≥10 at baseline, falling to 35% and 31% at 6-months and 2-years respectively. 18% of nurses had a baseline PCL-5 score suggestive of provisional PTSD diagnosis (≥31/80), increasing to 35% at 6-months, then falling, after 2-years, to 26%. Anxiety increased within the doctor/AHP group, from 10-20% and PTSD increased from 8-13% from baseline to 2-years.

Staff perceived adequate PPE, proper rest facilities, and regular breaks as the most useful among the suggested supportive interventions at baseline. Formal psychological support was perceived the least useful and had been accessed by 3% of responders. After 2-years, staff most frequently accessed, and perceived benefit, from attending peer-to-peer support (51%); availability of PPE hoods (47%); feel good treats (46%); improved education (46%); acceptable working patterns (35%); high-quality food (35%). 24% of staff accessed and benefitted from clinical psychology within ICU, and a further 20% outside of ICU.

Conclusions: Among frontline ICU staff, nurses were disproportionately affected by psychological distress, reaching a peak in October 2020, with partial resolution towards the elevated baseline by April 2022. The incidence of mental ill-health remains high and needs to be addressed, however, these results should be considered in light of poor mental health prior to the pandemic⁴. Partial resolution may reflect an initial acute stress response, rather than mental health deterioration.

ICU staff consistently rated peer-to-peer support, improved education, adequate personal protection, food, and improved working patterns as most beneficial. Such supportive strategies are readily achievable through organisational changes. Without a healthy organisational culture and reasonable working conditions, person directed interventions alone are unlikely to reduce turnover intention.⁵ However, our survey suggests that clinical psychology should be available for those requiring specialist, trauma-focussed interventions.

While acknowledging methodological limitations, our data suggest that researchers and managers should explore organisational changes, to improve the ergonomics of working in ICU, alongside provision of formal psychological support for individuals experiencing persistent work-related distress.

References

1. Kleinpell R, Moss M, Good VS, Gozal D, Sessler CN. The Critical Nature of Addressing Burnout Prevention: Results From the Critical Care Societies Collaborative’s National Summit and Survey on Prevention and Management of Burnout in the ICU. Crit Care Med. 2020 Feb;48(2):249-253. doi: 10.1097/CCM.0000000000003964

2. Kisely S, Warren N, McMahon L et al (2020) Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ.

3. Allan SM et al. The prevalence of common and stress-related mental health disorders in healthcare workers based in pandemic-affected hospitals: a rapid systematic review and meta-analysis. Eur J Psychotraumatology 2020;11:18109023.

4. Carrieri D, Briscoe S, Jackson M, et al ‘Care Under Pressure’: a realist review of interventions to tackle doctors’ mental ill-health and its impacts on the clinical workforce and patient care BMJ Open 2018;8: doi: 10.1136/bmjopen-2017-021273

5. Ramos, S., et al. (2020). “Intervening on Burnout in Complex Organizations – The Incomplete Process of an Action Research in the Hospital.” Frontiers in Psychology 11.

5542

Multidisciplinary team reflections on cough and swallow function with respect to readiness to decannulation

Ruth Shrimpton

Bart’s Health NHS Trust

Introduction: Tracheostomies aid ventilatory weaning, provide airway protection and allow tracheal suctioning. In the UK approximately 14,000 are inserted annually across a range of specialties. Tracheostomy is a foreign body and has associated risks, however, there are no universally agreed criteria for tracheostomy decannulation. Tracheostomies may be short term or permanent. There is wide variation in team members making decisions about readiness for decannulation. Teams have different levels of experience and outcomes. Some literature refers to importance of cough and swallow function for decannulation, but there is wide variation in practice of measurement and no consensus of function necessary for decannulation.

A service evaluation was carried out in 2020 in a population with respiratory failure requiring ventilation and tracheostomy. A simple 3 point tool was devised to categorise function of cough, swallow and voice for team discussions. The tool was similar but not identical to PICUP. Cough, swallow and voice function was measured on initial cuff deflation and at decannulation. Noticeable change was seen in cough and swallow function by decannulation, supporting literature that suggests cough and swallow function as requirements for successful decannulation. Slight change was seen in voice.

Method: Different teams use different terms for cough and swallow with little or no consensus of function. This was addressed in an engagement group in semi-structured interviews on teams and included; Speech and Language Therapists and physiotherapists from Critical care, neurology, neuro-oncology & neurosurgery; Previous patient with permanent tracheostomy was also present. Medics were invited. A recording was taken and the data analysed for patterns.

Aim was to explore terminology used to describe cough and swallow function and discuss level of function considered necessary for decannulation. Summary of literature findings share, cough and swallow for decannulation. Each member of the engagement group was invited to:

• Share their understanding of cough and swallow function for tracheostomy decannulation, explain how it is measured

• Share terms used for cough and swallow

• Raise potential barriers and empowerers for decannulation.

Data was reviewed, and patterns extrapolated.

Results: Patterns identified in the data were.

1. “Effective cough” – There was consensus for demonstrating how effective cough was in clearing secretions and foods into the mouth. This needed to be considered alongside true suctioning needs for the individual. No single instrumental measurement was thought optimal.

2. “Effective swallow” – There was consensus around ability to manage secretions. with or without adjunct treatments (e.g. drying agents). Also, individuals’ tolerance of aspiration. Note thresholds for safety are patient specific.

3. Effect of fatigue on function should also be considered.

Conclusion: Cough and swallow function are important criteria for decannulation readiness and outcome. Agreement in function for effective cough and effective swallow was reached with the engagement group. Also agreement this could be measured through observation and discussion

Every patient is unique and decannulation readiness should be considered on an individual basis.

5549

Dwindling confidence in the management of tracheostomy emergencies amongst rotating junior doctors - how can we get back on trach?

Roshni Bahri¹, Damhnaic McDonald², Daniel Park¹

¹ University Hospitals Birmingham

² university hospitals birmingham

Introduction: The Intensive Care Society (ICS), along with the National Tracheostomy Safety Project (NTSP) has established that first responders in tracheostomy emergencies should be able to “detect airway problems, assess tracheostomy patency and provide basic emergency oxygenation”.¹ The primary responders in such situations are often Junior Doctors, many of whom are non-airway trained Doctors on rotation. Published data suggest that most Junior Doctors across all specialities feel apprehensive and ill-equipped to deal with tracheostomy emergencies.² We undertook a survey to assess confidence and knowledge amongst non airway-trained rotating Junior Doctors within a busy 24-bed District General Intensive Care Unit (ICU). The aim was to develop local strategies for plugging the perceived training gap.

Main Body: We undertook a survey using Google Forms (Google Inc.) to capture all non airway-trained Doctors rotating through the ICU between August and December 2022. Nine questions assessed trainee grade, previous teaching, experience and confidence in initiating emergency management, and some questions to measure awareness and knowledge of the NTSP management algorithms. The survey was repeated in the next cohort of rotating Doctors following the inclusion of an induction lecture on tracheostomy emergencies and dissemination of the NTSP algorithms.

There were 15 respondents to the initial survey and 8 to the second. Of the 15 initial respondents, 12 were non-airway trained Junior Doctors, all holding Resuscitation Council UK (RCUK) Advanced Life Support (ALS) qualification. Of these, 4 (33.3%) had previously received some form of teaching and 5 (41.7%) had experience as a primary responder. Average confidence was 2.42 (on a scale of one to 5, where one is no confidence and five is very confident). Four (33.3%) respondents were aware of the NTSP algorithms with correct responses on management ranging from 41% to 75%. When the survey was repeated following lecture teaching, 4 (50%) were aware of NTSP guidelines and average confidence was 2.38. Correct responses ranged between 12.5% and 75%. Five (62.5%) had received teaching previously and 3 (37.5%) had been involved in tracheostomy emergencies.

Conclusion: Our survey results come as no surprise; most respondents had received no teaching in the management of tracheostomy emergencies and were not aware of the NTSP algorithms. This is concerning and goes against ICS and NTSP recommendations. Despite lacking basic knowledge and self-reporting low confidence, half had managed tracheostomy emergencies. It is noteworthy that tracheostomies do not form a part of ALS training, usually the only formal ‘certification’ required of Junior Doctors. After inclusion of a lecture covering tracheotomy basics and the NTSP algorithms, the next cohort of rotating Junior Doctors felt no more confident and even scored worse when questioned on initial assessment and oxygenation. It is perhaps not surprising that the passivity of traditional lectures doesn’t lend itself to the teaching of clinical skills. Other methods could be trialled; hands-on tracheostomy teaching followed by simulated scenarios to consolidate learning. Ultimately, perhaps it is time that basic-early management of tracheostomy emergencies should be included in the ALS programme?

References

1. Intensive Care Society (2014). Standards for the care of adults patients with a temporary tracheostomy; standards & guidelines. https://www.wyccn.org/uploads/6/5/1/9/65199375/ics_tracheostomy_standards__2014_.pdf

2. Findlay, Georgina, and Yasmin Abbas. “Management of tracheostomy-related emergencies: An audit of junior doctors’ knowledge and skills.” Journal of Cardiothoracic Surgery. Vol. 10. No. 1. BioMedCentral, 2015.

5561

Patient Profile Form - I Am Your Patient But Do You Know Me?

Helen Whiting

West Suffolk NHS Foundation Trust

Introduction: In healthcare we always strive to provide compassionate and patient-centred care. Using the Patient Profile Form (PPF) we can know more about our patient individually along with their clinical details, which will probably go a long way in delivering that care. This is even more necessary in a Critical Care Unit (CCU), where a patient may be left sedated for several days. There is a chance that a patient in CCU can be considered only as a person with a particular disease and not as an individual. The PPF is a simple paper document that the patient/family/carer voluntarily completes. It consists of oval sections each with headings which provides quick viewing at the bedside.

Main Body: As a health care provider (HCP) it would be nice to know about our patients hobbies; what time they prefer to go to sleep; whether they’re frightened of hospitals, and so much more. Many patients aren’t in a position to give us this information themselves, but being cared for by HCP armed with this knowledge could transform their hospital experience. The PPF in Critical Care at West Suffolk NSH Foundation Trust (WSHFT) has helped patients and their loved ones feel that we care for them as an individual and value their needs and beliefs. The form has improved palliative care, management of delirium, communication and rehabilitation in particular.

The beginning of COVID 19 no families could visit. A nurse liaison completed the form on the telephone with the next-of-kin and the form was then put by the patient’s bedside. Monitoring completed forms by the hospital digital information centre during two years for the onset of COVID 19 showed that from March 2020 - March 2022 the completed forms was 455. The PPF is expanding in WSHFT digitally.

The PPF fulfils the Intensive Care Society (ICS), Guidelines for the Provision of Intensive Care Services, Version 2.1. July 2022. In section 3.8 The Patient and Relative Perspective. ‘a this is me type board or equivalent should be used. Understanding the individual who has become critically ill is important to help their treatment and recovery.’

Conclusion: Patient centred care is much more difficult than we think, especially in a busy clinical area with stretched resources. Innovative ideas, to provide empathic and individual focused care does not need to be resource consuming or expensive. We firmly believe and have shown that the PPF has made a difference in how we can deliver individual patient centred care in CCU, which can also be dissipated to other clinical ward settings. It is a great way of empowering patients and helps normalise thing in a highly pressured and invasive environment.

5564

A multi-disciplinary Human Factors approach to medicines safety threats in Oxford Critical Care

Cherry Lumley¹, Elizabeth James¹, Daniele Giudici², Lily Shaw¹, Laura Vincent³

¹ Oxford University Hospitals NHS Foundation Trust

² Oxford Univesity Hospitals NHS Foundation Trust

³ Oxford University NHS Foundation Trust

Introduction: The introduction of the Patient Safety Incident Response Framework in 2022 demonstrates a significant cultural shift in the NHS acceptance of a systems approach to managing patient safety.¹

In recent years, an increase in near-miss medication-related incidents was observed within Oxford Critical Care (OCC) with potential catastrophic outcomes. This coincided with a surge in recruitment of new staff, dilution of senior nursing support due to resignation and high sickness levels. Recognising the compromise to patient and staff safety, a Human Factors (HF), systems analysis of medication incidents was initiated, to understand how the domains of the work system interact and to identify a strategy for improvement through a systematic and scientific methodology.²

Objectives: Use HF methods and maximise on the skills and knowledge of representatives from the MDT, to analyse medication management within OCC and generate recommendations to optimise patient safety, staff well-being and overall system performance.³

Main Body: Human Factors methods used by the project team of nursing, pharmacy, and medical representatives, led by the lead Clinical Governance nurse, to understand medication management within OCC:

1. Thematic Analysis of medication-related incidents on OCC.

2. Implementation of Systems Engineering Initiative for Patient Safety (SEIPS) protocol to study the interaction of the entire system.²

3. High-level Hierarchical Task Analysis (HTA), a structured approach to understanding the steps a user must complete to achieve a task.⁴

4. A comparison of how work is imagined vs work as done through review of policies and link analysis.

5. Actor Map analysis (Swimlane diagram) to identify communication gaps within the work system.

Using the Hierarchy of Control, recommendations were generated and implemented using a multi-pronged systems-focused approach.

The SEIPS analysis identified performance influencing factors that could lead to medication-related incidents.² The acuity within OCC, workload of staff, availability of tools and usability of technology, regulatory board and Trust policies, skill mix, and environmental layout were found to contribute to system performance and staff well-being.

Comparison of work as imagined vs work as done, evaluated the effectiveness of mitigations/controls such as policies and procedures that the unit has in place.

The Actor Map analysis of communication within OCC identified gaps in communication and informed areas for improvement, emphasising the role of communication across the MDT and system hierarchy. The novel introduction of Situational Awareness Meetings to the working day highlighted the value of risk identification and communication at the bedside.⁵

Through evidence-based Human Factors methods, the MDT project group provided recommendations that are sustainable and replicable. In collaboration with the education team, the project group have implemented 20 actions points, to mitigate risks in medication management.

Conclusion: The systems methodologies employed by the multi-disciplinary medication safety project group to tackle medication management within OCC has demonstrated how our department can learn from the interaction of the whole work system (NHS England, 2022). An MDT, HF grounded approach to medication safety can yield far reaching improvements not only to patient safety but to the wellbeing of patients and staff.

References

1. NHS England (2022). Patient Safety Incident Response Framework [online]. https://www.england.nhs.uk/publication/patient-safety-incident-response-framework-and-supporting-guidance/ (Accessed 18 October 2022).

2. Carayon, P., Xie, A., Kianfar, S. (2013). Human factors and ergonomics as a patient safety practice [online]. https://qualitysafety.bmj.com/content/qhc/23/3/196.full.pdf (Accessed 21 November 2022).

3. International Ergonomics Association (2023). What is ergonomics? [online]. https://iea.cc/what-is-ergonomics/. (Accessed 15 February 2023).

4. Hornsby, P. (2022). Hierarchical Task Analysis [online]. https://www.uxmatters.com/mt/archives/2010/02/hierarchical-task-analysis.php (Accessed 22 March 2022).

5. Lumley, C. (2022). Situational Awareness Meeting: A systems approach to safety huddle. Oxford Critical Care, Oxford University Hospitals NHS FT.

5626

Promoting multidisciplinary team management of emergencies in Intensive Care using in-situ simulation

Marie-louise (Lulu) Lyons

University hospital Coventry and Warwickshire

Introduction: In-situ simulations aim to create a realistic experience of clinical situations in a chosen learning environment.^1,2 In our intensive care unit (ICU), we have regularly rotating junior doctors. These junior doctors all have varied Intensive care medicine (ICM) experience, particularly that of emergencies. Our ICU also has many new ICM nurses, who are supported by the senior nurses, as well as health care assistances (HCA) who may be new to working in the ICM environment. During one simulation of a tracheostomy emergency varied members of the junior multidisciplinary team (MDT) were asked to review the patient. The simulation highlighted the importance of human factors in healthcare in a junior team managing a critically unwell patient, particularly understanding the team’s role and knowledge base in an ICM emergency.

Main body: The (MDT) responded to a critically unwell simulated patient during an in-situ simulation on the ICU. The exercise involved health care assistances, junior ICM nurses, simulation team members, two junior doctors, and later a senior nurse and the nurse in charge to attend. The primary measure outcomes were to assess participants initial management of the critically unwell patient, integration of teamwork skills in a time-pressured environment and identify threats and system issues that consequently could lead to poor patient outcomes. The simulation was observed by an ICM consultant, trainee and simulation team who collected information during the fifteen-minute simulation and led a debrief.

There was a standardised debrief for all those involved in the simulation. Every team member was asked how they believed it went. There was a particular focus on how supported they felt by the team leader (foundation two junior doctor) and whether everyone understood their roles. The most notable finding was that all the HCA and junior nurses had never experienced a tracheostomy emergency before. However, the junior nurses were comfortable and confident at managing tracheostomies. When this question was asked to the junior doctors involved, neither had managed a tracheostomy emergency before nor had much if any experience in managing tracheostomies. The most experienced MDT member with tracheostomies in the scenario was the senior nurse and nurse in charge. This came as a surprise to the HCA and junior nurses, their view being ‘when the doctor arrives, they know everything’. This in situ-simulation highlighted this is not the case, a guideline was followed by the doctors but ultimately senior support was needed.

Conclusion: Understanding the skills and experience of colleagues during an emergency is vital to ensure optimal patient outcomes and appropriate escalation to senior assistance. Embedding regular in-situ simulation as a routine practice in ICU at the time of junior doctor rotations will allow the MDT to appreciate the experience of colleagues and appropriately escalate. Particularly with regard to doctors, many junior members of the team do not have extensive experience in managing airway or other emergencies. In-situ simulation will aid further understanding of the skills of colleagues and promote cohesive management of emergencies in a multidisciplinary fashion, promoting patient safety and optimal outcomes.

References

1. Patterson M, Geis G, Falcone R, LeMaster T, Wears R, In situ simulation: detection of safety threats and teamwork training in a high risk emergency department, BMJ Quality & Safety, Volume 2, Issue 6, Available from https://qualitysafety.bmj.com/content/22/6/468 Accessed 25/02/23

2. Patterson M, Blike G, Nadkarni V, In Situ Simulation: Challenges and Results, Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools), Available here https://www.ncbi.nlm.nih.gov/books/NBK43682/ Accessed 25/02/23

5425

Elucidating determinants of recovery from intensive care acquired weakness in a human modelmodel

Ashley Thomas¹, Paul Kemp², Julie Sanders³, Mark Griffiths⁴

¹ Barts Heart Centre

² Imperial College

³ QMUL

⁴ BartsHealth

Introduction: Understanding the recovery phase of ICU acquired weakness (ICUAW) is crucial because patients with disease related sarcopenia often present with the established condition for which there are no disease-modifying treatments. Herein, we adapted a well characterised human model¹ to study mechanisms of recovery. We have previously shown that approximately half of patients one week after elective aortic valve surgery suffered at least 10% rectus femoris (RF) wasting (range 0 to 40%) using metabolomics to identify associated pathways and potential biomarkers.^2,3 The plasma metabolome by LC-MS suggested that pre-existing mitochondrial dysfunction was associated with the loss of muscle mass and function, which is consistent with observations in ICUAW patients in whom loss of ATP was a critical component of muscle loss and that this preferentially occurred in patients with pre-existing chronic disease.⁴ Molecular mechanisms discovered in this model have been found by our group to play a role in ICUAW and sarcopenia associated with chronic disease and vice versa.

Objectives: To profile the recovery of muscle bulk and strength after aortic surgery and to correlate both with potential modulators of muscle wasting and recovery, and health related quality of life (HRQoL).

Methods: Adult patients undergoing elective aortic valve surgery at Barts Heart Centre without an established neuromuscular disorder were included in the study (IRAS 18/LO/1618). Rectus femoris cross-sectional area (RF_csa) was measured using ultrasound as an index of muscle mass. Muscle strength was measured as knee extension, hand grip, lying:standing forced vital capacity. Measurements were assessed pre-operatively, at post-op day 7, and 6 weeks after surgery. Potential mediators and biomarkers of sarcopenia, identified in previous studies were quantified by metabolomics and ELISA.

Results: Thirty-one patients were recruited: 22 patients attended follow-up. As expected, patients lost (day 7) and recovered strength at follow-up according to all measured parameters. However, despite the uncomplicated surgery, evidenced by an ICU stay of 2.1 (1.3 days, median and IQR), the trend was for muscle loss at day 7 to continue until follow-up (Fig 1). Hence, 48% patients lost >10% RFcsa between pre-op and day 7, and 54% between pre-op and follow-up. The proportion of muscle lost between day 7 and follow-up correlated with HRQoL at follow-up (Pearson r=0.54, p=0.01, n=22). Finally, we confirmed that circulating carnitines (markers of mitochondrial function) were associated with loss of muscle mass (RFcsa). Furthermore, these data showed that multiple circulating carnitines from day 3 post-op plasma samples associated with muscle loss over the course of this experiment.

Conclusion: In a cardiac surgery model of ICUAW, patients’ strength recovered to baseline but loss of muscle bulk continued until follow-up and correlated with HRQoL. Plasma concentrations of carnitines peaking at day 3 post-op predicted subsequent muscle loss compatible with a central role of mitochondrial dysfunction in this process.

References

1. Bloch SA, Lee JY, Wort SJ, Polkey MI, Kemp PR, Griffiths MJ. Sustained elevation of circulating growth and differentiation factor-15 and a dynamic imbalance in mediators of muscle homeostasis are associated with the development of acute muscle wasting following cardiac surgery. Crit Care Med 2013;41(4): 982-9. DOI: 10.1097/CCM.0b013e318274671b.

2. Kemp PR, Paul R, Hinken AC, Neil D, Russell A, Griffiths MJ. Metabolic profiling shows pre-existing mitochondrial dysfunction contributes to muscle loss in a model of ICU-acquired weakness. J Cachexia Sarcopenia Muscle 2020;11(5):1321-1335. DOI: 10.1002/jcsm.12597.

3. Paul R, Lee J, Donaldson AV, et al. miR-422a suppresses SMAD4 protein expression and promotes resistance to muscle loss. J Cachexia Sarcopenia Muscle 2018;9(1):119-128. DOI: 10.1002/jcsm.12236.

4. Puthucheary ZA, Astin R, McPhail MJW, et al. Metabolic phenotype of skeletal muscle in early critical illness. Thorax 2018;73(10):926-935. DOI: 10.1136/thoraxjnl-2017-211073.

5451

Analgosedation in extracorporeal membrane oxygenation

Christopher Remmington¹, Cathrine McKenzie², Luigi Camporota¹, Fraser Hanks¹, Mike Barker¹, Barnaby Sanderson¹, Louise Rose³

¹ Guy’s and St Thomas’ NHS Foundation Trust

² University Hospital Southampton

³ King’s College London

Introduction: Intravenous analgosedation is commonly administered to patients receiving extracorporeal membrane oxygenation (ECMO).¹ However, there is limited data on factors associated with drug dosing.

Objectives: Our objective was to explore factors associated with analgosedation administered during ECMO.

Methods: We conducted a single-centre retrospective (January 2016 to July 2021) cohort study including patients aged 16 years and older with severe cardio-respiratory failure, receiving continuous intravenous analgosedation during ECMO. We documented demographics, analgosedation doses for intravenous and enteral opioids and sedatives (benzodiazepine and propofol), ECMO parameters, and 90-days survival. Opioids were converted into fentanyl-equivalent dose; benzodiazepines into midazolam-equivalent dose. To calculate the average drug dose/kg/day we divided the total fentanyl-equivalents, midazolam-equivalents and propofol doses by the number of ECMO-days and adjusted using actual body weight on admission to the ECMO unit. We documented the doses on ECMO initiation of intravenous fentanyl, midazolam and propofol as well as, minimum and maximum hourly doses. We assessed associations of drug dose (dependent variable) with demographic and clinical factors selected a priori based on expert opinion and existing evidence using multi-variable linear regression models.

Results: We included 546 ECMO patients with median (IQR) age of 46 (35, 53) years; weight of 83 (71, 100) kg. Most patients were male (61%) with severe respiratory failure (75%). Of the cohort, 25% had a history of smoking, 21% alcohol dependence and 8% substance use disorder. Median (IQR) ECMO duration was 9 (5-16) days, with 90.7% receiving veno-venous (V-V) ECMO, 7.7% veno-arterial (V-A) ECMO, and 1.6% veno-venous-arterial (V-V-A) ECMO. Median (IQR) daily doses per kg of actual body weight on admission of fentanyl, midazolam and propofol were 58.6 (36.1, 83.0) micrograms, 1.6 (0.6, 2.8) milligrams and 35 (26, 48) milligrams respectively. In our multivariable linear regression models we observed lower fentanyl dose was associated with higher APACHE II score (-1.26; 95% CI: -0.39, -2.12) and VA-ECMO (-23.70; 95% CI: -9.52, -37.88). Higher midazolam dose was associated with COVID-19 infection (0.86; 95% CI 0.49, 1.24); lower propofol dose with older age (-0.32; 95% CI: -0.16, -0.47), higher APACHE II score (-0.59; 95% CI -0.23, -0.95) and VA-ECMO (-11.01; 95% CI: -4.72, -17.29). Tertiary hospital ICU length of stay was 19 (11-30) days; 90-day survival was 74%.

Conclusions: Drug doses were associated with age, APACHE II score, COVID-19 infection and ECMO modality, with less analgosedation used in sicker patients. Analgosedation management in ECMO patients is challenging and influenced by numerous factors. The ECMO circuit alters pharmacokinetics (PK) and pharmacodynamics due to sequestration of drugs, increased volume of distribution due to greater circulating volume, and increased clearance of lipophilic drugs.² Organ dysfunction, extremes of body weight, age, and sex can also affect plasma drug concentrations.^1,2,3 Furthermore, patients requiring VA-ECMO require less analgosedation compared to VV-ECMO due to impaired hepatic extraction in cardiac failure leading to lower drug clearance.^4,5 Future prospective studies should explore strategies to stratify analgosedation dosing based on drug PK, patient characteristics and ECMO modality to optimise patient outcomes, optimise drug dosing without increasing adverse events.

References

1. Dzierba AL, Abrams D, Brodie D. Medicating patients during extracorporeal membrane oxygenation: the evidence is building. Crit Care. 2017;21(1):66.

2. Shekar K, Roberts JA, Mcdonald CI, et al. Sequestration of drugs in the circuit may lead to therapeutic failure during extracorporeal membrane oxygenation. Crit Care. 2012;16(5):R194.

3. Boucher BA, Wood GC, Swanson JM. Pharmacokinetic Changes in Critical Illness. Crit Care Clin. 2006;22(2):255-271.

4. Verbeeck, R.K. Pharmacokinetics and dosage adjustment in patients with hepatic dysfunction. Eur J Clin Pharmacol 64, 1147–1161 (2008).

5. Patel M, Altshuler D, Lewis TC, et al. Sedation Requirements in Patients on Venovenous or Venoarterial Extracorporeal Membrane Oxygenation. Ann Pharmacother. 2020;54(2):122-130.

5425

Elucidating determinants of recovery from intensive care acquired weakness in a human modelmodel

Ashley Thomas¹, Paul Kemp², Julie Sanders³, Mark Griffiths⁴

¹ Barts Heart Centre

² Imperial College

³ QMUL

⁴ BartsHealth

Introduction: Understanding the recovery phase of ICU acquired weakness (ICUAW) is crucial because patients with disease related sarcopenia often present with the established condition for which there are no disease-modifying treatments. Herein, we adapted a well characterised human model¹ to study mechanisms of recovery. We have previously shown that approximately half of patients one week after elective aortic valve surgery suffered at least 10% rectus femoris (RF) wasting (range 0 to 40%) using metabolomics to identify associated pathways and potential biomarkers.^2,3 The plasma metabolome by LC-MS suggested that pre-existing mitochondrial dysfunction was associated with the loss of muscle mass and function, which is consistent with observations in ICUAW patients in whom loss of ATP was a critical component of muscle loss and that this preferentially occurred in patients with pre-existing chronic disease.⁴ Molecular mechanisms discovered in this model have been found by our group to play a role in ICUAW and sarcopenia associated with chronic disease and vice versa.

Objectives: To profile the recovery of muscle bulk and strength after aortic surgery and to correlate both with potential modulators of muscle wasting and recovery, and health related quality of life (HRQoL).

Methods: Adult patients undergoing elective aortic valve surgery at Barts Heart Centre without an established neuromuscular disorder were included in the study (IRAS 18/LO/1618). Rectus femoris cross-sectional area (RF_csa) was measured using ultrasound as an index of muscle mass. Muscle strength was measured as knee extension, hand grip, lying:standing forced vital capacity. Measurements were assessed pre-operatively, at post-op day 7, and 6 weeks after surgery. Potential mediators and biomarkers of sarcopenia, identified in previous studies were quantified by metabolomics and ELISA.

Results: Thirty-one patients were recruited: 22 patients attended follow-up. As expected, patients lost (day 7) and recovered strength at follow-up according to all measured parameters. However, despite the uncomplicated surgery, evidenced by an ICU stay of 2.1 (1.3 days, median and IQR), the trend was for muscle loss at day 7 to continue until follow-up (Fig 1). Hence, 48% patients lost >10% RFcsa between pre-op and day 7, and 54% between pre-op and follow-up. The proportion of muscle lost between day 7 and follow-up correlated with HRQoL at follow-up (Pearson r=0.54, p=0.01, n=22). Finally, we confirmed that circulating carnitines (markers of mitochondrial function) were associated with loss of muscle mass (RFcsa). Furthermore, these data showed that multiple circulating carnitines from day 3 post-op plasma samples associated with muscle loss over the course of this experiment.

Conclusion: In a cardiac surgery model of ICUAW, patients’ strength recovered to baseline but loss of muscle bulk continued until follow-up and correlated with HRQoL. Plasma concentrations of carnitines peaking at day 3 post-op predicted subsequent muscle loss compatible with a central role of mitochondrial dysfunction in this process.

References

1. Bloch SA, Lee JY, Wort SJ, Polkey MI, Kemp PR, Griffiths MJ. Sustained elevation of circulating growth and differentiation factor-15 and a dynamic imbalance in mediators of muscle homeostasis are associated with the development of acute muscle wasting following cardiac surgery. Crit Care Med 2013;41(4): 982-9. DOI: 10.1097/CCM.0b013e318274671b.

2. Kemp PR, Paul R, Hinken AC, Neil D, Russell A, Griffiths MJ. Metabolic profiling shows pre-existing mitochondrial dysfunction contributes to muscle loss in a model of ICU-acquired weakness. J Cachexia Sarcopenia Muscle 2020;11(5):1321-1335. DOI: 10.1002/jcsm.12597.

3. Paul R, Lee J, Donaldson AV, et al. miR-422a suppresses SMAD4 protein expression and promotes resistance to muscle loss. J Cachexia Sarcopenia Muscle 2018;9(1):119-128. DOI: 10.1002/jcsm.12236.

4. Puthucheary ZA, Astin R, McPhail MJW, et al. Metabolic phenotype of skeletal muscle in early critical illness. Thorax 2018;73(10):926-935. DOI: 10.1136/thoraxjnl-2017-211073.

5451

Analgosedation in extracorporeal membrane oxygenation

Christopher Remmington¹, Cathrine McKenzie², Luigi Camporota¹, Fraser Hanks¹, Mike Barker¹, Barnaby Sanderson¹, Louise Rose³

¹ Guy’s and St Thomas’ NHS Foundation Trust

² University Hospital Southampton

³ King’s College London

Introduction: Intravenous analgosedation is commonly administered to patients receiving extracorporeal membrane oxygenation (ECMO).¹ However, there is limited data on factors associated with drug dosing.

Objectives: Our objective was to explore factors associated with analgosedation administered during ECMO.

Methods: We conducted a single-centre retrospective (January 2016 to July 2021) cohort study including patients aged 16 years and older with severe cardio-respiratory failure, receiving continuous intravenous analgosedation during ECMO. We documented demographics, analgosedation doses for intravenous and enteral opioids and sedatives (benzodiazepine and propofol), ECMO parameters, and 90-days survival. Opioids were converted into fentanyl-equivalent dose; benzodiazepines into midazolam-equivalent dose. To calculate the average drug dose/kg/day we divided the total fentanyl-equivalents, midazolam-equivalents and propofol doses by the number of ECMO-days and adjusted using actual body weight on admission to the ECMO unit. We documented the doses on ECMO initiation of intravenous fentanyl, midazolam and propofol as well as, minimum and maximum hourly doses. We assessed associations of drug dose (dependent variable) with demographic and clinical factors selected a priori based on expert opinion and existing evidence using multi-variable linear regression models.

Results: We included 546 ECMO patients with median (IQR) age of 46 (35, 53) years; weight of 83 (71, 100) kg. Most patients were male (61%) with severe respiratory failure (75%). Of the cohort, 25% had a history of smoking, 21% alcohol dependence and 8% substance use disorder. Median (IQR) ECMO duration was 9 (5-16) days, with 90.7% receiving veno-venous (V-V) ECMO, 7.7% veno-arterial (V-A) ECMO, and 1.6% veno-venous-arterial (V-V-A) ECMO. Median (IQR) daily doses per kg of actual body weight on admission of fentanyl, midazolam and propofol were 58.6 (36.1, 83.0) micrograms, 1.6 (0.6, 2.8) milligrams and 35 (26, 48) milligrams respectively. In our multivariable linear regression models we observed lower fentanyl dose was associated with higher APACHE II score (-1.26; 95% CI: -0.39, -2.12) and VA-ECMO (-23.70; 95% CI: -9.52, -37.88). Higher midazolam dose was associated with COVID-19 infection (0.86; 95% CI 0.49, 1.24); lower propofol dose with older age (-0.32; 95% CI: -0.16, -0.47), higher APACHE II score (-0.59; 95% CI -0.23, -0.95) and VA-ECMO (-11.01; 95% CI: -4.72, -17.29). Tertiary hospital ICU length of stay was 19 (11-30) days; 90-day survival was 74%.

Conclusions: Drug doses were associated with age, APACHE II score, COVID-19 infection and ECMO modality, with less analgosedation used in sicker patients. Analgosedation management in ECMO patients is challenging and influenced by numerous factors. The ECMO circuit alters pharmacokinetics (PK) and pharmacodynamics due to sequestration of drugs, increased volume of distribution due to greater circulating volume, and increased clearance of lipophilic drugs.² Organ dysfunction, extremes of body weight, age, and sex can also affect plasma drug concentrations.^1,2,3 Furthermore, patients requiring VA-ECMO require less analgosedation compared to VV-ECMO due to impaired hepatic extraction in cardiac failure leading to lower drug clearance.^4,5 Future prospective studies should explore strategies to stratify analgosedation dosing based on drug PK, patient characteristics and ECMO modality to optimise patient outcomes, optimise drug dosing without increasing adverse events.

References

1. Dzierba AL, Abrams D, Brodie D. Medicating patients during extracorporeal membrane oxygenation: the evidence is building. Crit Care. 2017;21(1):66.

2. Shekar K, Roberts JA, Mcdonald CI, et al. Sequestration of drugs in the circuit may lead to therapeutic failure during extracorporeal membrane oxygenation. Crit Care. 2012;16(5):R194.

3. Boucher BA, Wood GC, Swanson JM. Pharmacokinetic Changes in Critical Illness. Crit Care Clin. 2006;22(2):255-271.

4. Verbeeck, R.K. Pharmacokinetics and dosage adjustment in patients with hepatic dysfunction. Eur J Clin Pharmacol 64, 1147–1161 (2008).

5. Patel M, Altshuler D, Lewis TC, et al. Sedation Requirements in Patients on Venovenous or Venoarterial Extracorporeal Membrane Oxygenation. Ann Pharmacother. 2020;54(2):122-130.

5485

Echoes of Life : Heart under Pressure

Maria Mitri

UCLH

Introduction: On Christmas Eve while many were wrapping gifts and preparing a feast a young teenager of 17 years old needed the gift of saving. For the last 2 months he was extremely lethargic, dizzy, short of breath and for the last 7 days he had a cough and fever. Seen as an outpatient, he was prescribed amoxicillin for a presumed chest infection or a possible streptococcus throat infection with no improvement in his symptoms. He denies recent travel, drugs or alcohol intake and beside this deterioration he used to play tennis and was studying for his A levels. To the surprise of the emergency medicine team his lactate came back as 8 despite fluid boluses.

Main body: Patient was reviewed in A&E and despite fluid boluses as he was thought to be hypovolemic because of poor oral intake his lactate remained significantly elevated. To note that his blood pressure was normal and there were no clinical signs of hypoperfusion. On blood gas: pH is normal with a deranged base excess along with hyperkalaemia and hypochloremia. Clinically he did not appear that unwell as one would expect with such a raised lactate . The FBC showed neutrophils and ceftriaxone was started for a presumed sepsis. LFT panel was also deranged hence hepatitis screen along with paracetamol levels were sent. The impression was that this teenager has an acute hepatitis likely secondary to an infectious source associated with a pre-renal failure. Patient was admitted to adolescent wards and despite fluid maintenance overnight along with broad spectrum antibiotics to cover staphylococcus sepsis and NAC patient remained tachycardic at 115 with a raised lactate of 8 and deranged LFT with a raised creatinine. An urgent CT Scan done overnight showed: a large mediastinal mass with pleural and small pericardial effusion. The mass is most likely malignant and could be a lymphoma but will need biopsy for a definitive diagnosis, The next day, the patient became unwell with worsening shortness of breath, hypoxeamia, somnolence and anuria . His urine dip and labs showed evidence of spontaneous tumour lysis with worsening kidney failure.

He was urgently transferred to intensive care for monitoring and an urgent cardiac ultrasound was done. The pericardial effusion that was visualised on CT was not the sole finding on the ultrasound as there were more unexpected surprises.

Conclusion: This is the case of a young man who complained initially of fatigue, mild difficulty breathing and got worse over the course of few weeks. A chest CT confirmed the presence of a mass plus a small pericardial effusion. Patient deteriorated further and it was exoected based on the clinical signs and imaging findings to have a tamponade. The ultrasound evoqued another diagnosis. Infrequently patients can present with similar clinical features to tamponade, some resemblance on the cardiac ultrasound while having a completely different entity.

Brief Description of ultrasound video: Large mediastinal mass with cystic componed compressing left main bronchus and significant lung collapse . Large mediastinal and pericardial effusion with fibrin and dense material causing constrictive pericarditis

References

1. Oh JK, Hatle LK, Seward JB, Danielson GK, Schaff HV, Reeder GS, et al. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol. 1994;23(1):154-62.

2. Welch TD, Ling LH, Espinosa RE, Anavekar NS, Wiste HJ, Lahr BD, Schaff HV, Oh JK. Echocardiographic diagnosis of constrictive pericarditis: mayo clinic criteria. Circ Cardiovasc Imaging. 2014 May; 7(3):526-34.

5497

Evaluation of a multi-system PoCUS training programme for ICU nurses and ACCPs

Eleanor Corcoran¹, Phil Hopkins¹, Louise Rose²

¹ King’s College Hospital

² King’s College London

Introduction: Point-of-Care Ultrasound (PoCUS) is used increasingly by doctors in intensive care with proven benefits to patient clinical outcomes, including timelier therapy, and reduced risk of prolonged mechanical ventilation and length of stay. However, as little as 6% of doctors that undertake PoCUS training reach accreditation. This results in wasted resources including supervisor and trainee time. To expand the pool of PoCUS trained clinicians and optimise training efficiency, we designed a training programme using a simple multi-system (cardiac subcostal 4-chamber, IVC, lung bases, bladder, major central veins) PoCUS (INSIGHT) scan.

Aim: To determine if the INSIGHT Training Programme achieves competency when delivered to ICU nurses and Advanced Critical Care Practitioners (ACCPs). The definition of programme success was >60% of study participants achieving competency in the INSIGHT Scan.

Method: We designed a training programme guided by The ESICM International Expert Statement on Training Standards for Critical Care Ultrasonography and the UltraNurse training programme conducted in the Netherlands. Trainees were asked to complete a baseline knowledge questionnaire and provided with e-learning prior to a 1-day dace-to-face training day. This included didactic lectures, case studies, and hands-on practice with live models. Ongoing training consisted of 5 directly supervised scans. Trainees then performed two indirectly supervised scans to every one directly supervised scan until competence was achieved. Indirectly supervised scans and corresponding reports were reviewed by an INSIGHT supervisor either remotely using Microsoft Teams or face-to-face after scan completion. Scans were assessed using a standardised form and scored according to pre-defined competency domains. Domains included: (1) image acquisition - ranging from a score of 1 (all 6 images required assistance), to a score of 5 (all 6 images were obtained without any assistance); (2) image quality (score 1-5); (3) interpretation and reporting (score 1-4); and (4) overall proficiency (score 1-5). A score of 15 or higher was considered competent. Competency was achieved once the trainee scored 15 or more in 5 consecutive scans. To establish barriers to achieving competence, we conducted semi-structured interviews with trainees on programme completion.

Results: We recruited 12 ICU nurses and 2 ACCPs to the programme. Six (43%) completed the programme within the 1-year time frame (5 nurses, 1 ACCP). A total of 80 scans were performed on 50 patients with the number performed per trainee ranging from 0 to 14 (median 7.5, 2-10.5). The number of scans performed to achieve competence ranged from 8-14 (median 11, 10-13.3). The first scan to be scored at 15 or more occurred between scan 4 and 7 (median 5.5, 4-6.3).

The most common barriers to achieving competency included being too busy during work hours to perform scans, not having allocated time to perform scans, stressors external to work limiting mental capacity to commit to the training, and the availability of a scan supervisor and appropriate patients.

Conclusion: In the first iteration of a training programme of a simple multi-system PoCUS scan, we achieved modest success in competency. The most reported barrier impacting programme completion was insufficient time to complete the required training scans.

References

Chen Z, Hong Y, Dai J, Xing L. Incorporation of point-of-care ultrasound into morning round is associated with improvement in clinical outcomes in critically ill patients with sepsis. J Clin Anesth. 2018;48:62-6.

Pontet J, Yic C, Díaz-Gómez JL, Rodriguez P, Sviridenko I, Méndez D, et al. Impact of an ultrasound-driven diagnostic protocol at early intensive-care stay: a randomized-controlled trial. The Ultrasound Journal. 2019;11(1):24.

Rajamani A, Miu M, Huang S, Elbourne-Binns H, Pracher F, Gunawan S, et al. Impact of Critical Care Point-of-Care Ultrasound Short-Courses on Trainee Competence. Crit Care Med. 2019;47(9):e782-e4.

ESICM. International expert statement on training standards for critical care ultrasonography. Intensive Care Med. 2011;37(7):1077-83.

Tulleken AM, Gelissen H, Lust E, Smits T, van Galen T, Girbes ARJ, et al. UltraNurse: teaching point-of-care ultrasound to intensive care nurses. Intensive Care Med. 2019;45(5):727-9.

5422

Focused ultrasound skills at ITU: teaching experience

Tatyana Bolonenkova¹, Richard Beese²

¹ Lewisham and Greenwich Trust, Queen Elizabeth Hospital, London

² Lewisham and Greenwich Trust

Introduction: Our project was to teach doctors how to perform and interpret point-of-care ultrasound in intensive care settings, and to learn about ultrasound for vascular access, chest ultrasound, echo, renal failure, liver failure and jaundice, and DVT diagnosis.

Main body: The teaching has been running weekly at Critical Care and in the Radiology Department on a simulation manikin with provided images of different pathologies. After each session, a questionnaire was offered to assess doctors’ feedback.

During the ultrasound hands-on sessions, a diverse group of the doctors were involved. The doctors’ feedback has shown a high interest in learning about ultrasound. The majority had either no or little experience in performing the ultrasound prior to those sessions.

The teaching has improved the understanding about the different types of ultrasounds probes, scanning positions and obtaining good images. Anonymised ultrasound images have been uploaded on the cloud storage, and shared with the supervising consultant radiologist to review and discuss.

While running the programme there were some pros and cons about ultrasound on Intensive care noted. The pros were: It saves time, because you do not need to wait for the radiology department. It can be performed as many times as needed. It is relatively easy to learn and acquire competencies. The ultrasound findings can direct the treatment.

However, learning ultrasound requires supervision and mentoring by an ultrasound competent professional. It needs regular practice and determination. You have to be aware of limitations and ask for an official scan earlier.

Conclusion: Learning ultrasound skills are the achievable up-to-date competencies for ITU doctors, which can become a routine tool for assessing critically ill patients.

Brief description of ultrasound video: Our presentation will demonstrate a real process of teaching focused ultrasound at Critical care unit in Queen Elizabeth hospital, London. We have collected feedback from doctors after the sessions, which we’ll demonstrate. Our doctors are getting more familiar with ultrasound machines not only for vascular access, but for scanning abdomen, lungs, DVT and heart.

Practicing focused ultrasound on daily bases allows us to scan our patients at any point of their admission to Critical Care in order to enhance our diagnosis (for example, establish a type of shock), plan the management (like, assessment of fluid resuscitation status) and assess for interventions (I.e., thoracocentesis).

We have a gallery of cases, and we shall demonstrate some of them to inspire the interest to focused ultrasound as a fantastic easily available, quick and highly diagnostic tool at Critical Care settings.

References

Keith Guevarra and Yonatan Greenstein, Ultrasonography in the Critical Care Unit, Current cardiology reports [Curr Cardiol Rep] 2020 Sep 10; Vol. 22 (11), pp. 145. Date of Electronic Publication: 2020 Sep 10.

Chiara Robba, Adrian Wong, Daniele Poole, Ashraf Al Tayar, Robert T. Arntfield, Michelle S. Chew, Francesco Corradi, Ghislaine Douflé, Alberto Goffi, Massimo Lamperti, Paul Mayo, Antonio Messina, Silvia Mongodi, Mangala Narasimhan, Corina Puppo, Aarti Sarwal, Michel Slama, Fabio S. Taccone, Philippe Vignon, Antoine Vieillard-Baron & The European Society of Intensive Care Medicine task force for critical care ultrasonography*, Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine, Intensive Care Medicine volume 47, pages1347–1367 (2021).

Stephen Wilson, Bsc MBChB MRCP FRCA, Andrew Mackay, MBChB, FRCA, EDIC, FFICM, Ultrasound in critical care, Continuing Education in Anaesthesia Critical Care & Pain, Volume 12, Issue 4, August 2012, Pages 190–194, https://doi.org/10.1093/bjaceaccp/mks019, Published: 02 May 2012.

5628

Lung Ultrasound for Diagnosis of Primary Graft Dysfunction in Lung Transplantation Recipients

Ellen O’Brien, Antonio Rubino, Stefanie Curry, Jasvir Parmar

Royal Papworth Hospital

Introduction: This is a prospective observational research study into diagnosing Primary Graft Dysfunction (PGD) in recipients of lung transplantation using lung ultrasound (LUS) within the early post-operative period in Critical Care. The primary aim of this study is to compare LUS with the reference standard diagnostic imaging modality for PGD – chest radiography (CXR).

Main Body: Lung transplantation (LTx) is the gold-standard treatment for end-stage respiratory disease, although patient outcomes remain inferior to recipients of other solid organ transplants; the leading cause of mortality in the early post-operative period (<72 hours) is PGD. Early diagnosis of this severe lung injury largely improves prognosis and is therefore a key area of interest for research.¹ LUS is an emerging modality in the bedside assessment of acute pulmonary conditions in Critical Care, it is non-invasive and readily available and has a high diagnostic accuracy for post-operative complications including pneumothorax or pleural effusion.² We are investigating the use of LUS as an additional diagnostic tool to assess aeration of the lungs in the LTx recipient. The benefit of ultrasonographic lung aeration scores has been proven in other lung pathologies that are analogous to PGD including acute respiratory distress syndrome (ARDS)³ although the diagnostic accuracy of LUS for PGD is yet to be investigated. This study, conducted by the multi-disciplinary team in Critical Care will assess this by performing daily LUS scans at defined time points as per the International Society for Heart and Lung Transplantation (ISHLT) PGD grading classification⁴ and correlate the aeration score with the presence of radiographic pulmonary infiltrates on CXR, as a reference standard for PGD diagnosis alongside the recorded PaO₂/FiO₂ ratio at the time of each imaging modality.

Conclusion: If proven an effective assessment tool for PGD in the LTx patient cohort, with statistical correlation to CXR presentation in the context of worsening hypoxaemia, this supports LUS for early identification and grading of PGD and enhance the ability to monitor pathology progression. The impact of earlier diagnosis would be a more rapid implementation of therapeutic intervention by Transplantation and Critical Care medical teams for the recipient; LUS could also be used as a non-invasive tool to monitor the effects of therapeutic management strategies for PGD on lung aeration.

Brief description of ultrasound video: The ultrasound video will demonstrate the LUS scanning protocol on a healthy volunteer and the process of aeration scoring. The video will also include example LUS scans and the corresponding CXR to depict the changes in aeration on both imaging modalities.

References

1. Tore Altun, G., Arslantas, M. and Cinel, I., 2020. Primary Graft Dysfunction after Lung Transplantation. Turkish Journal of Anaesthesiology and Reanimation, 43(6), pp.418-423.

2. Rømhild Davidsen, J., Lawaetz Schultz, H., Henriksen, D., et al., 2017. Lung ultrasound for the diagnosis of post-operative complications after lung transplantation. Transplantation,.

3. Mongodi, S., Bonaiti, S., Stella, A., et al., 2019. Lung Ultrasound for Daily Monitoring and Management of ARDS Patients. Clinical Pulmonary Medicine, 26(3), pp.92-97.

4. Christie, J., Carby, M., Bag, R., et al., 2005. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction Part II: Definition. A Consensus Statement of the International Society for Heart and Lung Transplantation. The Journal of Heart and Lung Transplantation, 24(10), pp.1454-1459.

5472

Ultrasound guided vascular access teaching – a vegan friendly and cost of living proof approach and teaching programme

Alexander Henshall, Sam Nightingale

Royal Berkshire Hospital

Introduction: We present a teaching project undertaken at Royal Berkshire Hospital for Foundation Year 1 (FY1) doctors. Using a home-made and vegan friendly ultrasound phantom, we demonstrate a cost-effective model for developing future ultrasound practitioners.

Main body: Ultrasound training for new practitioners can begin with limited resources. Ultrasound theory – basic physics, indications for use, machine etiquette – these goals can all be achieved with a knowledgeable teacher and a willing student. Handling of the probe, basic knobology and maintaining sterility – important lessons that require only an ultrasound machine.

The next stage of learning is gaining practical experience, and is where as a teacher, challenges arise. The dexterity involved in handling a probe and cannula simultaneously takes time and practice to learn, and it is reasonable to assume that most practitioners’ success will not be instantaneous. We therefore want to avoid patient harm, and unnecessary cannula attempts by practicing simulation on models prior to clinical use.

In departments not fortunate enough to already have practice models, purchasing a purpose built 4 vessel ultrasound phantoms will, as of February 2023, cost around £714. This of course raises multiple challenges, around budgeting and also time spent to for procurement. In capturing and acting on the enthusiasm of future ultrasound users, this is often not going to be a practical approach.

To cater for the above-mentioned phases of training, we have designed and successfully implemented a training programme for FY1 doctors. We first delivered lectures to the year group, followed by a bespoke e-learning module. We then moved to practical sessions, using a homemade phantom with following method materials from a large online supplier:

• Extra-firm tofu - £1.85

• 8 firm paper straws - £0.08

• Blackcurrant squash - £0.89

• 1L plastic food container - £0.50

• Total cost = £3.20

It is important that extra-firm tofu is used to effectively mimic echogenicity of subcutaneous tissues and be able to visualise the needle. Around 1cm below the surface a straw can be inserted parallel to the surface and the length of the way through the tofu. The lumen of this straw will be occluded with tofu. We then railroad a further straw immediately following and replacing this straw. We trimmed the end of the straws, and placed this model into the plastic container. This was then filled blackcurrant juice to just cover either end of the straw.

From my own experience this very closely resembled using a blue phantom, and feedback surveys from candidates echoed this sentiment. 100% of attendees feeling more confident with ultrasound guided access, and each felt ready for supervised clinical practice.

Conclusion: Creating an affordable method for ultrasound phantom creation removes the financial barrier to teaching and education. We hope that by sharing this experience, it will as in our case broaden the scope of who can teach, and therefore who can learn ultrasound guided access.

Video description: A 5-minute video showing model creation from raw ingredients through to supervising a trainee cannulate the model with no time skips.

5141

Perioperative and Critical Care of Transgender and Gender Diverse Individuals

David Harding

Bradford Teaching Hospitals NHS Foundation Trust

This session introduces the main considerations for caring for transgender and gender diverse adults in the perioperative period and in critical care. It will aim to cover the reasons for discussing this topic, how the language we use when caring for these patients is so important, associated medical and psychological conditions and the critical care implications of gender affirming treatments.

References

1. Spirizzi G, Eufrasio R, Lima MCP et al. Proportion of people identified as transgender and non-binary in Brazil. Sci Rep 2021; 11: 2240.

2. House of Commons Women and Equalities Committee. Transgender Equality. First report of session 2015-2016. Available from https://publications.parliament.uk/pa/cm201516/cmselect/cmwomeq/390/390.pdf (accessed 20/01/2023).

3. World Professional Association for Transgender Health. Standards of Care Version 8. Available from https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644 (accessed 20/01/2023).

4. De Brier N, Van Schuylenbergh J, Van Remoortel H et al. Prevalence and associated risk factors of HIV infections in a representative transgender and non-binary population in Flanders and Brussels (Belgium); Protocol for community-based, cross sectional study using time-locations sampling. PloS One 2022; 17 (4): e0266078.

5. New York State Department of Health AIDS Institute. Perioperative Care in Adults with HIV. Available from https://www.hivguidelines.org/hiv-care/perioperative-management/ (accessed 20/01/2023).

5179

Chemotherapy Agents and their Complications

Robert Ross

The Royal Marsden Hospital

A significant number of patients with solid tumours have neoadjuvant chemotherapy before surgical resection and patients with liquid tumours often require chemotherapy as part of their disease management. Both cohorts of patients may be seen in ICU either post-operatively or for organ support due to medical complications of their disease or treatment. Whilst neutropenic sepsis is a common reason for admission to ICU, it is important to understand the other organ complications of chemotherapy to optimise investigation and management of these patients.

This presentation will cover each chemotherapy class and their cardiovascular, respiratory, hepatic, and renal complications in turn to build knowledge in what to expect in this patient cohort.

References

Amjad MT, Chidharla A, Kasi A. Cancer chemotherapy. InStatPearls [Internet] 2021 Sep 7. StatPearls Publishing.

Groenewold MD, Olthof CG, Bosch DJ. Anaesthesia after neoadjuvant chemotherapy, immunotherapy or radiotherapy. Bja education. 2022 Jan 1;22(1):12-9.

Limper AH. Chemotherapy-induced lung disease. Clinics in chest medicine. 2004 Mar 1;25(1):53-64.

Chiruvella V, Annamaraju P, Guddati AK. Management of nephrotoxicity of chemotherapy and targeted agents: 2020. American Journal of Cancer Research. 2020;10(12):4151.

Grigorian A, O’Brien CB. Hepatotoxicity secondary to chemotherapy. Journal of clinical and translational hepatology. 2014 Jun;2(2):95.

5473

Tidal volume, PEEP, Plateau pressure and Driving pressure

Sarala Daram

Sandwell and West Birmingham

A session on Tidal volume, PEEP and Driving pressure in ARDS mechanical ventilation

Ventilator induced lung injury

5614

The Assessment of Upper Airway Patency when Considering Tracheostomy Decannulation

James Lynch

Manchester University NHS Foundation Trust

The potential for decannulation in a tracheostomy patient is complex and we do not always get it right. It requires assessment of a number of variables, each with varying degrees of subjectivity.

Upper airway patency is one such subjective assessment. Whilst it can be directly visualised, bedside assessments of airway patency which can be dynamic, are often performed by nursing staff using traditional clinical examination. Nuanced and attentive assessment over prolonged periods of time means they are well placed to give an important voice to the MDT when considering decannulation.

References

Enrichi C, Battel I, Zanetti C, Koch I, Ventura L, Palmer K, Meneghello F, Piccione F, Rossi S, Lazzeri M, Sommariva M. Clinical criteria for tracheostomy decannulation in subjects with acquired brain injury. Respiratory Care. 2017 Oct 1;62(10):1255-63.

McGrath BA, Wallace S, Lynch J, Bonvento B, Coe B, Owen A, Firn M, Brenner MJ, Edwards E, Finch TL, Cameron T. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. British journal of anaesthesia. 2020 Jul 1;125(1):e119-29.

Pandian V, Miller CR, Schiavi AJ, Yarmus L, Contractor A, Haut ER, Feller-Kopman DJ, Mirski MA, Morad AH, Carey JP, Hillel AT. Utilization of a standardized tracheostomy capping and decannulation protocol to improve patient safety. The Laryngoscope. 2014 Aug;124(8):1794-800.

Singh RK, Saran S, Baronia AK. The practice of tracheostomy decannulation—a systematic review. Journal of intensive care. 2017 Dec;5(1):1-2.

Wallace, S., & McGrath, B. A. (2021). Laryngeal complications after tracheal intubation and tracheostomy. BJA education, 21(7), 250.

5429

The impact of nosocomial infections on the evolution of severe patients from the ICU

Iraida Camerzan

Municipal Clinical Hospital Saint Trinity,Chisinau

Introduction: Nosocomial infections are a major cause of morbidity, mortality and prolonged stay in the ICU, therefore their prevention is essential.

Objectives: To determine the incidence of nosocomial infections acquired in the ICU, their risk factors, pathogens, the length of ICU stay and their impact on the mortality rate.

Material and methods: A prospective, observational study (June – November 2022, ICU “Sf.Treime” Hospital) The study group included 253 patients with a length of ICU stay > 48h. Data regarding disease severity, the main cause of ICU admission, risk factors, presence of infection, causative agent, duration of ICU treatment, and mortality rate were collected.

Results: Rate of nosocomial infections was 12.38%, pneumonia being the most frequent infection 59.37%; 34% of patients were on IMV and 25% were non IMV; urinary tract infections were 28.12% and bloodstream infection associated to a central venous catheter was 12.5%. Detected pathogens were P.aeruginosa 32%, A.baumannii 15.2%, K.pneumoniae 13.7%, E.coli 12.8%, CandidaSpp.11%, Enterococcus spp.7.8%. The hospital-acquired infection led to a significant increase in the ICU length of stay but not lethality.

Conclusion: Nosocomial infections increase the morbidity of hospitalized patients and impact the length of ICU stay. The risk factors were diabetes, COPD, and an ICU stay of ≥5.4 days.

References

1. Rafael Zaragoza, Pablo Vidal-Cortés, Gerardo Aguilar, Marcio Borges, Emili Diaz, Ricard Ferrer, Emilio Maseda, Mercedes Nieto, Francisco Xavier Nuvials, Paula Ramirez, Alejandro Rodriguez, Cruz Soriano, Javier Veganzones and Ignacio Martín-Loeches Update of the treatment of nosocomial pneumonia in the ICU Zaragoza et Critical Care (2020) 24:383 https://doi.org/10.1186/s13054-020-03091-2

2. Sugata Dasgupta, Soumi Das, Neeraj S. Chawan1, Avijit Hazra2 Nosocomial infections in the intensive care unit: Incidence, risk factors, outcome and associated pathogens in a public tertiary teaching hospital of Eastern India ijccm.org DOI: 10.4103/0972-5229.14863.

3. Tommaso Bardi & Vicente Pintado Maria Gomez-Rojo & Rosa Escudero-Sanchez & Amal Azzam Lopez Nosocomial infections associated to COVID-19 in the intensive care unit: clinical characteristics and outcome .DE part of Springer Nature 2021 https://doi.org/10.1007/s10096-020-04142-w

5442

CAR-T cell therapy and its complications

Oscar Short

The Royal Marsden Hospital

Session Summary: Chimeric antigen receptor T (CAR-T) cell therapy is cellular immunotherapy which has shown good results in treating refractory haematological malignancies. There is also promising evidence for its future use in treating solid organ tumours and autoimmune conditions. Toxicities to CAR-T cell therapy are common and a significant proportion of patients will develop life-threatening toxicities requiring management in the intensive care unit (ICU) setting. The outcome of these patients on ICU is relatively good with timely intervention. The use of cellular immunotherapy is likely to expand and therefore the number of patients needing ICU management for related toxicities will inevitably grow. This talk will look at what CAR-T cell therapy is and will cover the common associated life-threatening toxicities. It will focus on their pathogenesis, diagnostic grading systems and management.

References

Shimabukuro-Vornhagen, A et al., Critical Care Management of Chimeric Antigen Receptor T-cell Therapy Recipients. CA Cancer J Clin. 2022;72:78-93.

Brundho, N; Kochenderfer, J. Toxicities of chimeric antigen receptor T cells: recognition and management. Blood. 2016;127(26):3321–3330.

Neelapu, S et al., Chimeric antigen receptor T-cell therapy – assessment and management of toxicities. Nat Rev Clin Oncol. 2018; 15(1):47-62.

Lee, D et al., ASTCT Consensus Grading for Cytokine Release Syndrome and Neurological Toxicity Associated with Immune Effector Cells. Biol Blood Marrow Transplant. 2019;25:625-638.

5523

Does the level of mobility at ICU discharge impact post-ICU outcomes? A retrospective analysis

Rebekah Haylett¹, Jonathan Grant¹, Mark Williams², Owen Gustafson³

¹ Oxford Allied Health Professions Research and Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK

² Centre for Movement, Occupational and Rehabilitation Sciences (MOReS), Oxford Institute of Nursing, Midwifery and Allied Health Research (OxINMAHR), Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK

³ Oxford Allied Health Professions Research and Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Centre for Movement, Occupational and Rehabilitation Sciences (MOReS), Oxford Institute of Nursing, Midwifery and Allied Health Research (OxINMAHR), Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK

Introduction: Rehabilitation and mobility interventions in the intensive care unit (ICU) are established as a key component of recovery after critical illness. However, significant challenges remain in determining the optimum type and timing of interventions due to the heterogenous nature of the ICU population and highly variable design of interventional studies.¹ Delays to commencement of intervention is suggested to contribute to the inconsistency of results, leading to an increased focus on prioritising rehabilitation extremely early after ICU admission.² A recent study implementing a mobility protocol aimed at exercising critically ill patients to fatigue early after ICU admission failed to demonstrate improvements in function and indicated an increase in adverse events.³ However, studies designed to address rehabilitation culture, reduce barriers to mobilisation and enhance clinician decision making have demonstrated reduced ICU and hospital length of stay and improved physical function at ICU discharge.^4,5 Therefore, a focus on interventions to increase level of mobility throughout an ICU admission is considered important to deliver improvement in post-ICU outcomes. However, few studies have explored the relationship between the level of mobility achieved on ICU discharge and post-ICU outcomes.

Objectives: To assess the association of the level of mobility on ICU discharge with discharge destination from hospital and hospital length of stay.

Methods: This retrospective analysis evaluated prospectively collected data for patients admitted to a single UK general ICU in a tertiary teaching hospital, between 1^st February 2018 and 30^th June 2022. Demographic and clinical variables of interest were analysed for association with the outcomes. Variables were entered into binary and linear regression models to assess for independence of association with discharge destination and hospital length of stay, respectively. Level of mobility on ICU discharge was assessed using the Manchester Mobility Score (MMS).

Results: A total of 1861 patients survived to hospital discharge and were included in the analysis. There were 1561 patients discharged to their usual residence (84%). The median (IQR) MMS of patients discharged to their usual residence was 6 (5-7) compared with 4 (3-6) for patients discharged to another setting (p<0.001). Binary logistic regression concluded that MMS (p=0.044), hospital LOS (p<0.001), age (p=0.006), surgical admission (p<0.001) and medical admission (p=0.029) were independently associated with discharge destination. The median (IQR) hospital LOS was 12 (7-24) days. Linear regression concluded that elective admission type (p<0.001), ICU LOS (p<0.001), MMS (p<0.001), and surgical admission (p=0.009) were independently associated with hospital LOS. For every one increase in the MMS there was a 2.5 day reduction in hospital LOS.

Conclusions: Patient mobility level at ICU discharge as measured by the MMS was independently associated with discharge to usual residence and hospital LOS, when adjusted for measures of frailty, comorbidity, and functional status. Interventions to increase level of mobility on ICU discharge should remain a focus of further research, with priority over delivering interventions increasingly early after admission.

*Rebekah Haylett is the Chair of the Physiotherapy Professional Advisory Group.

References

1. Paton M, Chan S, Tipping CJ, Stratton A, Serpa Neto A, Lane R et al. The Effect of Mobilization at 6 Months after Critical Illness — Meta-Analysis. NEJM Evidence 2022;1-12.

2. Denehy L, Lanphere J, Needham DM. Ten reasons why ICU patients should be mobilized early. Intensive Care Med 2017;43(1):86-90.

3. Hodgson CL, Bailey M, Bellamo R, Brickell K, Broadley T, Buhr H et al. Early Active Mobilization during Mechanical Ventilation in the ICU. N Engl J Med 2022;387(19):1747-58.

4. McWilliams D, Jones C, Atkins G, Hodson J, Whitehouse T, Veenith T et al. Earlier and enhanced rehabilitation of mechanically ventilated patients in critical care: A feasibility randomised controlled trial. Journal of critical care 2018;44:407-12.

5. Schaller SJ, Anstey M, Blobner M, Edrich T, Grabitz SD, Gradwohl-Matis I et al. Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. The Lancet (British edition) 2016;388(10052):1377-88.

5261

Launching an Above Cuff Vocalisation service in Intensive Care; usage trends, outcomes and future directions for multidisciplinary team upskill

LAURA Harbert, Jenny Clark, Sally Archer

Guy’s and St Thomas’ NHS Trust

Introduction: Patients in intensive care frequently require cuff up tracheostomy, resulting in lack of voice. Above Cuff Vocalisation (ACV) can be achieved by connecting oxygen to the subglottic port, which enters the trachea above the inflated cuff, providing airflow through the larynx. Suggested benefits of ACV include restored voice, laryngeal re-sensitisation and dysphagia rehabilitation¹. Previously only Blue Line Portex (Smiths Medical, England) were licensed for ACV but more recently Tracoe-Twist tubes (Kapitex, England) have been licensed, increasing potential for widespread use.

Objectives: This work explores trends in usage of a newly launched ACV service by Speech and Language Therapy (SLT) in a large (68 beds) intensive care provision to establish the utility of ACV locally and determine priorities for multidisciplinary team roll out.

Methods: A guideline was developed and agreed via clinical governance processes. Input from tracheostomy tube suppliers, advice from national experts and a literature review informed the new ACV service. SLT’s were trained to risk assess patients and to deliver ACV by completing a competency framework, and a documentation proforma was provided. Every patient on the intensive care SLT caseload was screened against the guideline as part of weekly ward round from January to December 2022. Prospective data collected included tracheostomy type, ventilation status, and length of session. Outcome measures included patient tolerance and the 6-point ICU Functional Communication Score (ICUFCS) ². Frequency of saliva swallows were counted for 10 minutes prior to and during ACV.

Results: Of the 206 patients with a tracheostomy seen by SLT during the study period, 7% (n=15) were identified by SLT for ACV. 94% (n=14) were ventilated, 12 had a Tracoe twist and 3 had a Blue Line Portex. Median session length was 15 minutes (maximum recommended duration as per the guideline). One patient did not tolerate ACV due to discomfort. There were no complications from ACV. 74% (n=11) had improved ICUFCS, most frequently improving by 3 scale points; Increased saliva swallows occurred in 67% (n=10). Of the 4 patients who did not achieve communication improvement, ACV was recommended for ongoing use for 2 to target swallow frequency. Six patients (40%) were in the palliative stage of care, and for 3 of these, ACV use continued for communication benefits, aiming to enable ease of interaction with loved ones or health care professionals at the end of life. Additional sessions were requested by patients and family.

Conclusions: In this study, ACV was appropriate for a minority of the SLT tracheostomy caseload but benefited the majority of those with whom it was trialled, leading to more effective communication. Positive trends were seen in swallow frequency and this motivated therapists to offer further sessions. The utility of ACV with patients receiving end of life care had not been anticipated and is important for informing future practice and training. Further feedback will be sought from the nursing teams and palliative care to inform training and ongoing use.

References

Mills CS, Michou E, King N, Bellamy MC, Siddle HJ, Brennan CA, et al. Evidence for above cuff vocalization in patients with a tracheostomy: A systematic review. The Laryngoscope. 2022 DOI: 10.1002/lary.29591 Laryngoscope. 2022; 132(3) 600-611.

Wallace S, Lynch J, Nicholson L, Wilson M, Purcell R, McGrath BA. Evaluating the effectiveness of communication in ventilator-dependant tracheostomy patients utilising above cuff vocalisation: The ICU functional communication scale. 2015. Available from https://www.globaltrach.org/poster_presentation_on_icu_functional_communication_scale

5598

A review of the Medical Support Worker programme on Intensive Care

Rachel Saunders

Plymouth University Hospital NHS Trust

Introduction: The Medical Support Worker (MSW) role was coined during the Covid-19 pandemic to provide IMGs with clinical experience. In recent years, the role has been likened to that of a physician’s associate, aiding with the diagnosis and management of patients within Intensive Care. MSWs can undertake a range of essential and routine tasks under the supervision of the health care practitioner in charge of the clinical area.

Objectives: The aim of the programme was to seek funding, instate an employment and education pathways and hire 15-20 Refugee and Asylum Seekers to support Intensive Care and Acute Medical Units across the Northwest.

Methods: A business case was written, and funding secured for 20 Refugee and Asylum Seeker MSWs. 10 hospitals were approached and 5 were selected for involvement in the programme. Working closely with RefuAid (a charitable organisation) 68 doctors were screened and 35 were interviewed. 20 MSWs were matched with the Trusts involved, and over the relocation process 3 withdrew. A clinical skills and teaching programme was created, an ePortfolio was organised and Medical Indemnity was secured through the MPS.

Results: The short-term benefits to Critical Care departments are seen through the hybrid role that MSWs can adopt; helping with nursing and medical tasks. Furthermore, the Critical Care environment is ideal for MSWs as most trainee practice is supervised; therefore, the perceived burden posed by MSW supervision is minimal. In the long-term, MSWs who gain GMC registration can feed into national training programmes, regional staff grade positions, associate specialty vacancies, and clinical fellowship roles. Many critical care units across the country are struggling to staff departments, and these recruitment difficulties are often heightened in district general hospitals and geographically isolated regions. Strategic hiring of MSWs with the experience to meet the hospital’s workforce needs once GMC registered, is a cost-effective and efficient way of addressing these difficulties.

Feedback from the hospitals highlighted that the interview process is critical to ensure the trusts understand the abilities of the MSWs. It is vital for the MSW’s supervisors to be involved throughout the interview and hiring process. The ward staff should be familiar with the MSW role; either though lectures, talks or posters. This helps the integration phase and gives a greater understanding of the MSWs role, abilities, and limitations. This will help the MSWs feel accepted and understood; which was highlighted as a common negative feedback.

Conclusions: The MSW role can be a cost-effective method of supporting the Intensive Care workforce. To gain the most from the programme, effort is required from both parties and understanding this from the outset is important.

5620

Ascertaining the Unmet Need for Occupational Therapy in a Developing Critical Care Service: Preliminary Data from a Service Evaluation Project

Sarah Dzumbira

GSTT

Introduction: Occupational Therapists are dual trained to provide therapeutic assessment and intervention for both physical and mental health conditions. Therefore, critically ill patients can benefit from occupational therapy assessment and intervention. Occupational therapy specific input into therapy plans of the critically ill has been shown to decrease mortality, psychological symptoms and length of stay/bed days. Algeo1

Objectives: To inform the development of a new occupational therapy service, we sought to ascertain the unmet need for occupational therapy across an 75 bed critical care service at a London tertiary academic centre with an ECMO unit.

Methods: We commenced the service evaluation in July 2022, collecting data for an initial three-month period with review. As of February 2023, data collection is ongoing and has been collected for 8 months. Prior to commencement of the service evaluation, the occupational therapy service received a median monthly referral of 15, with a 0.9 whole time equivalent funding for the service.

We reviewed the electronic medical records of all admitted ICU patients. We used an occupational therapy prioritisation matrix to ascertain unmet need. This matrix was newly developed and based on prioritisation tools of other hospitals within our academic science network and relevant guidelines; GPICS2, NICE3, The Royal College of Physician’s guidelines for Stroke4 &Prolonged Disorders of Consciousness5. Unmet need was further categorised into assessment and rehabilitation (AR), disability management (DM) or discharge planning (DP) and further delineated as priority one, two or three, with one denoting the highest priority. To better understand the complexity of the ICU caseload, we used an outcome measure – The Rehab Complexity Scale (RCS) to record the unmet need referrals, clinical complexity, over the 8 month period.

Results: Between July 2022 – February 2023 the occupational therapy service received a median of 17.5 actual received referrals (IQR14-20). We identified an additional unmet need of 41 (IQR 31-49) median monthly referrals. Collectively the median for actual referrals and unmet needs was 53 (IQR 47-66) per month.

During July 2022 – February 2023, there were a total of 282 identified unmet need referrals for the assessment and rehab category. AR1 = 159, AR2 = 103, and AR3 = 20. The Rehab Complexity Scale (RCS) outcome measure for unmet need referrals, was a median = 21, where 25 denotes the highest possible complexity.

Table 1.

Table 2.

Conclusion: Comprehensive occupational therapy input is beneficial to critically ill patients who receive treatment. Yet, there is a demonstrable inequity between referrals actually received vs. unmet need – patients who do not receive occupational therapy. Further data collection is ongoing to ascertain trends and patterns in the unmet need for additional occupational therapy, and will form a case for enhancement of occupational therapy services in critical care.

References

1. Algeo N, Aitken LM. The evolving role of occupational therapists in adult critical care in England. Irish Journal of Occupational Therapy. 2019 Sep 20; ahead-of-print(ahead-of-print).

2. Version 2.1 GUIDELINES FOR THE PROVISION OF INTENSIVE CARE SERVICES [Int2. ernet]. 2022. Available from: https://ficm.ac.uk/sites/ficm/files/documents/2022-07/GPICS%20V2.1%20%282%29.pdf

3. NICE. Overview | Rehabilitation after critical illness in adults | Guidance | NICE [Internet]. Nice.org.uk. NICE; 2009. Available from: https://www.nice.org.uk/guidance/cg83

4. Royal College of Physicians. Stroke guidelines [Internet]. RCP London. 2016. Available from: https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines

5. Guidelines & Policy [Internet]. RCP London. [cited 2023 Feb 26]. Available from: https://www.rcplondon.ac.uk/guidelines-policy/prolonged-disorders-consciousness-following-sudden-onset-brain-injury-national-clinical-guidelines.

5621

A multidisciplinary approach towards improving standards on enhanced care

Tae Lee, Anahita Sharma, Samir Sulaiman, Lucy Devlin, Vivian Pringle, Norman Main

Royal Liverpool University Hospital NHS

Introduction: The provision and availability of high dependency care is a valued but limited resource in the United Kingdom¹. Additionally, there is an increasing medical patient cohort who benefit from higher levels of monitoring and management, but do not require intensive care². The Intensive Care Society (ICS) and Society of Acute Medicine (SAM) have recently published standards for development and implementation of Enhanced Care Units³. In the same month, our Acute Medical Unit opened a four-bedded High Care Area (HCA), moving into the new Royal Liverpool University Hospital.

Our first month’s audit (30^th October to 30^th November 2022), highlighted particular national standards to improve upon. None of the HCA patients received twice daily formal senior reviews, and 17.4% of patients had documented treatment escalation plans during admission. The nursing team did not have a specific safety checklist dedicated to the HCA, nor a nominated nursing HCA lead.

Objectives: To improve and fulfil ICS and SAM Enhanced Care standards, particularly:

• Twice daily senior reviews

• Documented treatment escalation plans

• Admission from decision within four hours.

Methods: The department designed rota adjustments to increase consultant and registrar availability for twice daily formal reviews, including introduction of a formal HCA proforma on the online patient notes. We engaged in multidisciplinary communication with the emergency medicine department and medical registrars, regarding our local HCA admission criteria, standard operating procedures and documentation of decision to admit within the four-hour target.

We engaged with our nursing colleagues and ward managers for the implementation of the national twice daily safety checklist and a dedicated nursing HCA lead.

We then re-audited HCA admissions from 12^th of January to 9^th February 2023. Patient notes and data were collected using the hospital online ADT Dashboard and PENS systems.

Results: Median admission age was 60 years in the first audit (69 patients) and 64 years in the second audit (45 patients). Admissions commonly arrived from the emergency medicine resuscitation department (58.0% in the first audit, 64.4% second audit). The two most common presentations were community acquired pneumonia (18.8% first audit, 22.2% second audit) and diabetic ketoacidosis (14.5% and 11.1%). Intensive care admissions from HCA were 1.45% in the first audit, 4.44% from the second audit.

The second audit showed increased documented decisions to admit (from 91.5% to 97.8%) by the appropriate acute medical and take teams, increased twice daily formal HCA senior reviews (from 0% to 77.8%), and increased documented treatment escalation plans (from 17.4% to 53.3%). There was a reduction in median time from decision to admit to HCA admission (from 2 hours 27 minutes to 1 hour 50 minutes).

During the second audit, HCA appointed a nursing lead and daily implementation of the ICS and SAM safety checklist during nursing handovers.

Conclusions: Establishment of enhanced care is an initiative tailored to increasing patient care needs, that lie between the boundaries of the wards and intensive care. Our second audit demonstrated targeted improvements towards the new national standards, through collaborative, multidisciplinary effort.

References

1. Wong DJN, Popham S, Wilson AM et al. Postoperative critical care and high-acuity care provision in the United Kingdom, Australia, and New Zealand. BJA 2019; 122(4): 460-469.

2. Faculty of Intensive Care Medicine. Enhanced care: guidance on service development in the hospital setting. Executive summary and key principles. https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/enhanced_care_guidance_executive_summary_key_principles_-_may_2020.pdf (2020, accessed 25 February 2023).

3. Intensive Care Society. Enhanced care units: guidance on development and implementation within acute medicine. https://ics.ac.uk/resource/enhanced-care-guidance-am.html (2022, accessed 25 February 2023).

5597

Whispers from the Community: Differences in Primary Care Utilisation Before Critical Illness

Benjamin Post, Roman Klapaukh, Stephen Brett, Aldo Faisal

Imperial College London

Introduction: Critical illness is associated with significant mortality and morbidity including a risk of long-term disability and functional decline.^1,2 The early identification of patients at risk of critical illness may allow early preventative measures to be instigated to avoid admission and allow individuals to understand the implications of a possible future critical illness. Here we demonstrate that, across the country of Wales, interactions with primary care are significantly different for patients that suffer a critical illness compared to the general population.

Methods: We performed a retrospective observational study using the Secure Anonymised Information Linkage (SAIL) Databank^3-5 which contains billions of linked primary and secondary care, person-based health records and covers over 80% of the population of the country of Wales. We identified all adult patients aged 18-100 in the database for the years 2016-2018 and extracted all dates where at least one data point (e.g., general practice attendance, lab test, prescription, administrative action) was recorded in their primary care electronic healthcare record (EHR). We refer to these dates collectively as General Practice Events (GPEs). Our outcome of interest was emergency ICU admission in the year 2018. For all patients with an emergency ICU admission, we extracted all GPEs up to 24 months prior to their admission. For patients that did not undergo an ICU admission, a random date in 2018 was selected and all GPEs up to 24 months prior were extracted. As such, regardless of outcome, each patient was assigned an outcome date and 24 months’ worth of preceding GPEs were extracted. We calculated the total number of GPEs identified for each patient and the median time difference between all sequential GPEs. We report the median and [interquartile range (IQR)], by outcome group, for each of these values. This study was approved by the SAIL independent Information Governance Review Panel (IGRP) (ref 1323).

Results: 1,400,014 individuals met study inclusion criteria. A total of 3268 patients had an emergency ICU admission in the year 2018 (i.e., ICU admission rate of 0.23%). Patients admitted to ICU were slightly older (62 years [23] vs 60 years [27], had more GPEs in the 2 years prior to ICU admission (128 [165] vs 48 events [52]) and a shorter median time interval between GPEs (5 days [3] vs 9.5 [11]). These differences are more pronounced in younger age groups as the number of GPEs (Figure 1) and median time difference between GPEs (Figure 2) tend to converge for those aged over 85.

Figure 1.

Total GP Events Prior to Outcome Date.

Figure 2.

Median Interevent Time Between GP Events By Age Group Prior to Outcome Date.

*(In both images, patients aged >95 not displayed to minimise risk of identification).

Conclusion: We have shown that, in the country of Wales, the patterns of primary care interaction are different for 2 years prior to an emergency critical care admission. Patients interacted more frequently with primary care services if they subsequently underwent an emergency ICU admission, compared to the rest of the population. These findings suggest that the trajectory of critical illness may evolve over years, opening the possibility of very early identification of patients at risk of future deterioration from electronic healthcare records.

Declarations and Funding

BP was supported by the UKRI CDT in AI for Healthcare http://ai4health.io (Grant No. EP/S023283/1). AAF holds a UKRI Turing AI Fellowship (Grant No. EP/V025449/1). This research was also funded by the NIHR Imperial Biomedical Research Centre (BRC), and by Research Capability Funding.

References

1. McPeake J, et al. Long term outcomes following critical care hospital admission: A prospective cohort study of UK biobank participants. Lancet Reg Health - Eur. 2021 Jul 1;6:100121.

2. Morgan A. Long-term outcomes from critical care. Surg Oxf Oxfs. 2021 Jan;39(1):53–7.

3. Ford DV, et al. The SAIL Databank: building a national architecture for e-health research and evaluation. BMC Health Serv Res. 2009 Sep 4;9(1):157.

4. Lyons RA, et al. The SAIL databank: linking multiple health and social care datasets. BMC Med Inform Decis Mak. 2009 Jan 16;9(1):3.

5. Jones KH, et al. A case study of the Secure Anonymous Information Linkage (SAIL) Gateway: a privacy-protecting remote access system for health-related research and evaluation. J Biomed Inform. 2014 Aug; 50:196–204.

4947

Targeting astrocytes to reduce critical illness-associated brain vulnerability

Zoeb Jiwaji¹, Siddharthan Chandran², Giles Hardingham³

¹ University of Edinburgh

² Centre for Clinical Brain Sciences, Edinburgh Medical School, University of Edinburgh

³ UK Dementia Research Institute, Edinburgh Medical School, University of Edinburgh

Introduction: Brain dysfunction during and following critical illness is common, with 50-80% of patients experiencing delirium and 26% of ICU survivors developing long-term cognitive deficits equivalent to mild Alzheimer’s disease (AD)¹. Despite this high burden, the underlying cellular mechanisms remain unknown which hinders the development of effective therapies.

The brain consists of multiple cell types. Whilst prior research has focused on neurons, non-neuronal cells remain understudied. My research programme investigates the role of astrocytes (the most abundant non-neuronal cell type) in critical illness-associated brain dysfunction. Astrocytes, which play important roles for brain homeostasis and detoxification², undergo morphological and functional reactive changes to systemic inflammation. However, the consequences of risk factors associated with ICU brain dysfunction on reactive astrocytes remained unknown.

Objectives: To determine how risk factors associated with ICU brain dysfunction (pre-existing neurodegenerative pathology and sedative anaesthesia) alter inflammation-associated reactive astrocyte responses. Can altered astrocytes be targeted for neuroprotective benefit?

Methods and Results: During my Wellcome Trust clinical PhD training fellowship, I explored how pre-existing neurodegenerative disease (the major risk factor for delirium) altered astrocytes. I used transgenic mouse models expressing Alzheimer’s disease-associated amyloid and tau mutations (APP/PS1 and MAPT-P301S) and determined pathology-associated changes to astrocyte transcription. I overcame the key challenge of distinguishing astrocyte gene expression changes vs those in other cells with TRAP-sequencing² (Figure 1) using transgenic mice expressing astrocyte-specific GFP-tagged ribosomes. Isolation of astrocyte ribosomes and sequencing of attached mRNA enabled determination of astrocyte-specific gene expression.

Figure 1.

Schematic of TRAP-sequencing: A method to study astrocyte-specific transcription.

I found that astrocytes demonstrated surprisingly heterogeneous responses to Alzheimer’s disease pathology, upregulating predicted inflammation-associated neurotoxic as well as previously unknown neuroprotective signatures (Figure 2A). I identified that the latter involved upregulation of an antioxidant gene set driven by a master cytoprotective transcription factor (Nrf2) and determined that enhancing this protective astrocyte response (by upregulating astrocyte Nrf2 expression) reduced neuronal death and delayed functional loss to Alzheimer’s pathology (Figure 2B) (published Nature Communications, 2022⁴).

Figure 2A.

Astrocytes upregulate both neurotoxic and neuroprotective signatures to Alzheimer’s pathology.

*p< 0.05 (Fisher’s exact test).

Figure 2B.

Boosting neuroprotective astrocyte responses delays disease-associated loss in models of Alzheimer’s pathology.

*p< 0.05 (2-way ANOVA).

Next, during my Chief Scientist Office-funded clinical lectureship, I investigated how sedative anaesthesia altered disease-associated pathways in astrocytes. Sedative drugs by function suppress neuronal firing. In prior work, I found that neuronal firing regulates astrocyte transcriptional pathways important for brain metabolism (published Nature Communications, 2019⁵). By exposing mice to 6 hours of sedative anaesthesia, and using TRAP-sequencing to identify astrocyte transcriptional changes, I found that sedative anaesthesia dysregulates brain homeostatic and neuroprotective pathways previously identified to be regulated by neuronal firing.

To follow this, in Academy of Medical Sciences starter grant and Wellcome ISSF-supported work, I am now investigating the consequences of targeted restoration of neuronal firing during sedation using non-invasive transcranial electrical stimulation, with preliminary results finding successful restoration of deleterious sedative-associated changes (Figure 3).

Figure 3.

Activity-dependent neuroprotective gene expression is suppressed by sedative anaesthesia and restored by neuronal stimulation.

*p< 0.05 (1 way ANOVA).

Summary: My work provides new insights into how reactive astrocytes demonstrate both deleterious and neuroprotective characteristics. Whilst neurodegenerative pathology and sedative anaesthesia drive inflammation-associated neurotoxic changes in astrocytes, I found that these cells also have the capacity to mount neuroprotective responses. Hence, astrocytes represent an attractive therapeutic target and my ongoing work now seeks to understand whether manipulating astrocytes (via drugs or brain stimulation) can mitigate against critical illness-associated cognitive complications.

References

1. P. Pandharipande, T. D. Girard, J. C. Jackson, et al. Long-term cognitive impairment after critical illness. N. Engl. J. Med. 369, 1306–1316 (2013).

2. Z. Jiwaji, G. E. Hardingham. Good, bad, and neglectful: Astrocyte changes in neurodegenerative disease. Free Radic. Biol. Med. 182, 93–99 (2022).

3. M. Heiman, A. Schaefer, S. Gong, et al. A translational profiling approach for the molecular characterization of CNS cell types. Cell. 135, 738–748 (2008).

4. Z. Jiwaji, S. S. Tiwari, R. X. Avilés-Reyes, et al. Reactive astrocytes acquire neuroprotective as well as deleterious signatures in response to Tau and Aß pathology. Nat. Commun. 13, 135 (2022).

5. P. Hasel, O. Dando*, Z. Jiwaji*, et al. Neurons and neuronal activity control gene expression in astrocytes to regulate their development and metabolism. Nat. Commun. 8, 15132 (2017) (*equal contribution).

5329

Delirium Classification in Intensive Care using Non-Invasive Eye Tracking

Ahmed Al-Hindawi

University College London Hospital

Introduction: The development of delirium in patients in intensive care is common. It carries significant mortality, morbidity, and leads to cognitive function akin to mild Alzheimer’s disease.^1,2 However, its pragmatic diagnosis relies upon manual scoring systems (e.g., CAM-ICU) which are labour-intensive and can miss episodes of delirium owing to the intermittent nature of manual testing.³ My PhD focused on visual attention which has been hypothesised to be a good test for delirium. However, the hypothesis has been held back by the lack of a robust technical solution for eye-tracking patients suffering from delirium in a safe, accurate, and precise manner.

Objectives:

Phase 1

Develop a non-invasive eye-tracking solution suitable for use in patients with delirium in intensive care

Phase 2

Deploy the eye-tracking platform as part of a pilot clinical trial across two intensive care units

Perform studies from the data acquired to explore visual attention in delirium

Methods: I designed, developed, and validated an eye tracking device for the diagnosis of delirium. The device meets empirical requirements of safety, accuracy, precision, and performance using state-of-the-art neural networks for the identification of facial landmarks, extraction of eye-patches, blinking, gaze direction, and object fixation.

I then performed a pilot study across two intensive care units where I correlated the device findings with manually diagnosed delirium.⁷ Gathered data was then analysed using neural networks that function across time. Furthermore, to explain the findings of the neural networks, I developed a novel framework to understand visual attention based on how the human brain works.

Results: The device, composed of two cameras arranged around the patient’s bed space, is safe, accurate, precise, automatic, and continuous. My designs have been published in specialised engineering journals.^4-6 I then deployed the device across two general intensive care units recording 42 patients, 210 eye-tracked sessions, totalling 135,610 fixations.

I used machine learning to train a model to diagnose delirium from eye-movements gathered from the study. That resulted in a model which picked up 76% of patients with delirium. I increased the performance of the model by adding a depth camera to include the object of the patient’s gaze. This proved that episodes of delirium are different in their visual attention compared to non-delirious episodes.

The framework that I developed helped explain the model’s findings in a biologically plausible manner and found a statistically significant difference in the way patients with and without delirium look at their surroundings. The findings are in keeping with the established notions of the pathology of delirium.

Conclusion: The developed novel artificial-intelligence based eye tracking platform is suitable for use in intensive care. The gathered data facilitated the development of two models that demonstrate that visual attention is markedly different in episodes of delirium. The framework that I developed helps explain the findings in context. The developed models and framework facilitate the automatic and continuous diagnosis of delirium in intensive care.

Funding

BMA Research Fund

CW+ Charity

Westminster School Fund

References

1. Ely, E. Wesley, et al. “Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit.” Jama 291.14 (2004): 1753-1762.

2. Gunther, Max L., et al. “The association between brain volumes, delirium duration and cognitive outcomes in intensive care unit survivors: a prospective exploratory cohort magnetic resonance imaging study.” Critical care medicine 40.7 (2012): 2022.

3. Ely, E. Wesley, et al. “Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU).” Jama 286.21 (2001): 2703-2710.

4. Al-Hindawi A, Vizcaychipi MP, Demiris Y. Continuous Non-Invasive Eye Tracking In Intensive Care. In 2021 43rd Annual International Conference of the IEEE Engineering in Medicine & Biology Society (EMBC) 2021 Nov 1. IEEE.

5. Al-Hindawi A, Vizcaychipi MP, Demiris Y. What is the Patient Looking At? Robust Gaze-Scene Intersection Under Free-Viewing Conditions. In ICASSP 2022-2022 IEEE International Conference on Acoustics, Speech and Signal Processing (ICASSP) 2022 May 23. IEEE

6. Al-Hindawi A, Vizcaychipi M, Demiris Y. Faster, Better Blink Detection through Curriculum Learning by Augmentation. In 2022 Symposium on Eye Tracking Research and Applications 2022 Jun 8 (pp. 1-7).

7. https://clinicaltrials.gov/ct2/show/NCT04589169

5401

Hypermetabolism and myopathy in the recovery phase of experimental sepsis are not caused by browning of white adipose tissue

Robert Tidswell¹, Ali Alqallaf², Joseph Harris¹, Johnathan Falconer¹, Angela Palo², Ketan Patel², Michael Duchen¹, Mervyn Singer¹

¹ University College London

² University of Reading

Introduction: Sepsis is defined as the dysregulated host response to infection resulting in organ dysfunction and, in some cases, death. Temperature impacts outcomes from sepsis – patients with fever are more likely to survive. However, in the recovery phase, thermogenesis may be detrimental. Survivors frequently develop cachexia and myopathy which impairs recovery and increases long term mortality. In conditions akin to sepsis, including burn injury and cancer-associated cachexia, this has been attributed to catabolism driven by hypermetabolism due to a process called ‘browning’. Browning describes the switch of energy-storing white adipose tissue to a thermogenic energy-burning brown adipose tissue-like phenotype. The canonical marker of browning is uncoupling protein 1, aka ‘thermogenin’. Browning is further characterised by increased mitochondrial density, multiloculation of lipid droplets and expression of other thermogenic mechanisms, including futile substrate cycles. Identification and prevention of browning in patients with sepsis may improve outcomes.

Objectives: Identify browning of white adipose tissue in an animal model of sepsis and identify therapeutic targets of sepsis-induced myopathy and cachexia.

Methods: Experimental sepsis was induced in rats using intraperitoneal zymosan which causes a prolonged inflammatory insult. Whole organism metabolism was measured by indirect calorimetry. Immunofluorescence and body and muscle mass were used to identify cachexia and myopathy. Expression of thermogenic browning mechanisms were studied in epididymal (eWAT) and retroperitoneal adipose tissue and (rpWAT) using thermal imaging, high resolution respirometry, RNA-sequencing and Western blot. Mitochondrial function and adipose tissue architecture was interrogated by multiphoton imaging in live adipose tissue explants.

Results: Rats with zymosan peritonitis developed a sepsis-like illness with a mortality of 17% at 14 days. Compared to sham animals, sepsis survivors developed hypermetabolism, cachexia and myopathy with reduced muscle mass and myofibre thickness. Oxygen consumption of eWAT and rpWAT per milligram of tissue was elevated at days 3, 7 and 14 of sepsis recovery, however, when controlled for lipid droplet size or mitochondrial or cell number, the increase was abolished. Compared to sham, RNA sequencing of rpWAT showed inflammation and down regulation of genes related to oxidative phosphorylation and thermogenesis at 14 days after septic insult. Uncoupling protein 1 protein was not expressed. Notably, SERCA2 mRNA and SERCA2 protein were increased, suggesting increased futile calcium cycling. Multiphoton microscopy showed neither increased mitochondrial density nor lipid multiloculation consistent with browning. The NAD(P)H pool was, however, more oxidised in tissue from animals recovering from sepsis, suggesting increased metabolism.

Conclusion: Hypermetabolism, cachexia and myopathy in the recovery phase of experimental sepsis are not caused by classical browning. Calcium cycling mechanisms in adipose tissue may be implicated. The findings are counter to many established studies and merit further investigation.

References

1. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA [Internet]. 2016;315(8): 801–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26903338

2. Petruzzelli M, Schweiger M, Schreiber R, Campos-Olivas R, Tsoli M, Allen J, et al. A switch from white to brown fat increases energy expenditure in cancer-associated cachexia. Cell Metab [Internet]. 2014; 20(3):433–47. Available from: http://dx.doi.org/10.1016/j.cmet.2014.06.011

3. Sidossis LS, Porter C, Saraf MK, Børsheim E, Radhakrishnan RS, Chao T, et al. Browning of Subcutaneous White Adipose Tissue in Humans after Severe Adrenergic Stress. Cell Metab [Internet]. 2015;22(2):219–27. Available from: http://dx.doi.org/10.1016/j.cmet.2015.06.022

4. Ayalon I, Shen H, Williamson L, Stringer K, Zingarelli B, Kaplan JM. Sepsis Induces Adipose Tissue Browning in Nonobese Mice But Not in Obese Mice. SHOCK [Internet]. 2018 Nov [cited 2019 Aug 13]; 50(5):557–64. Available from: http://insights.ovid.com/crossref?an=00024382-201811000-00010

5521

A data-driven approach to classifying readmissions after critical care

Nicholas Plummer¹, Nazir Lone²

¹ East Midlands School of Anaesthesia

² University of Edinburgh

Introduction: Critical care survivors suffer physical, cognitive, and mental complications placing them at risk of excess health needs over other patients discharged from hospital, including emergency hospital readmissions.¹ However interventions which delay early readmissions in sepsis survivors have little impact on, or even increase, the rate of late readmissions.²

Attempting to identify and prevent “avoidable” readmissions therefore relies on understanding the varying and competing drivers for readmission over time. As such if we wish to reduce the impact of unscheduled readmissions we must consider whether early readmissions reflect different underlying processes to later ones and so require different forms of intervention, especially in the context of a highly heterogeneous patient population.³

Objectives: Operationalise a model to classify unscheduled hospital readmissions after critical care into clinically relevant groups, and assess for differences in outcomes during one year of follow up between patients experiencing different forms of readmission. Subsequently, use machine learning (ML) approaches to identify modifiable risk factors for these different classes.

Methods: National, regional, and local data regarding critical care survivors in NHS Lothian over an eight-year period was linked at the patient level, and an iterative data-driven classification system⁴ was applied to hospital readmissions after discharge home from an admission including at least one critical care stay. Interpretable ML was used to identify features that predict different classes of readmission.

Results: 47% of critical care survivors experienced an unplanned hospital readmission within one year, and 2% died without hospital readmission.

Four distinct classes of readmission were reliably identified. Random forest models for any unscheduled readmission (ROC AUC 0.815) and class of readmission (ROC AUC 0.869) were able to reliably identify individuals with anticipated but unpredictable readmissions, but misclassified those experiencing potentially preventable and unrelated readmissions. Class of readmission was associated with age, pre-existing health needs, proportion of the admission spent in critical care, and specific diagnoses.

Conclusions: Overall performance is similar to previously published predictive models for readmission,⁵ and misclassification of potentially preventable and unrelated readmissions may account for their underperformance in recognizing readmissions driven by other forces.

This is to an extent intuitive. Potentially preventable readmissions such as direct complications of care would be mitigated prior to discharge, hence should occur at random across all admissions. Similarly, readmissions entirely unrelated to the index admission (such as trauma and de novo illness) should by definition be unpredictable. That these are at all predictable suggests that they may not be as unrelated to the episode of critical illness as thought, explaining why models struggled to distinguish between related and unrelated readmissions and providing additional potential targets for intervention in avoiding unscheduled readmission.

By identifying specific risk factors for classes of readmission and appreciating their relationship with long-term outcomes, this study provides a more intuitive appreciation of the individual, physiological, disease-specific, and socioeconomic drivers for readmission – and hence continued morbidity – after critical illness. This can improve outcomes in survivors of critical illness by providing a more focussed and resource effective critical care follow up service which targets patient-specific avoidable risk factors.

References

1. McPeake J, et al. Hospital re-admission after critical care survival: a systematic review and meta-analysis. Anaesthesia 2022; 77: 475–85.

2. Shankar-Hari M, et al. Rate and risk factors for rehospitalisation in sepsis survivors: systematic review and meta-analysis. Intensive Care Medicine 2020; 46: 619–36.

3. Lone NI, et al. Predicting risk of unplanned hospital readmission in survivors of critical illness: a population-level cohort study. Thorax 2019; 74: 1046–54.

4. Blunt I, et al. Classifying emergency 30-day readmissions in England using routine hospital data 2004-2010: what is the scope for reduction? Emergency medicine journal: EMJ 2015; 32: 44–50.

5. Shankar-Hari M, et al. Development, Validation, and Clinical Utility Assessment of a Prognostic Score for 1-Year Unplanned Rehospitalization or Death of Adult Sepsis Survivors. JAMA network open 2020; 3: e2013580.

5622

Neurally adjusted ventilatory assist for patients at risk of extended ventilation: A randomised feasibility trial with local and national surveys

Daniel Hadfield¹, Louise Rose², Nicholas Hart³, Fiona Reid², Victoria Cornelius⁴, Sian Saha⁵, Harriet Noble⁶, Danny McAuley⁷, John Smith¹, Phil Hopkins¹, Gerrard Rafferty²

¹ King’s College Hospital NHS Foundation Trust

² Kings College London

³ Guys and St Thomas NHS Foundation Trust

⁴ Imperial College London

⁵ King’s College Hospital

⁶ King’s College Hospital

⁷ Queen’s University Belfast

Introduction: Neurally adjusted ventilatory assist (NAVA) uses electromyographic signals from the diaphragm detected via a specialized naso-gastric feeding catheter, as a measure of neural respiratory drive and means of controlling the delivery of inspiratory support by a mechanical ventilator.¹ The clinical effectiveness of NAVA has yet to be demonstrated.

Objectives: Our aim was to investigate (1) feasibility of a randomized controlled trial (RCT) of NAVA for weaning critically ill adults at risk of extended mechanical ventilation (MV) duration; (2) clinician beliefs and barriers to using NAVA from an institution with significant NAVA experience; and (3) NAVA capacity across the UK including clinician attitude and support of a proposed effectiveness trial.

Methods:

• 1) Open-label, parallel group, allocation concealed, single centre feasibility RCT of NAVA compared to Pressure Support Ventilation (PSV) with primary outcomes of ventilator mode adherence and protocol compliance. Secondary exploratory outcomes ventilator-free days (VFDs), sedation, and mortality (NCT01826890; London Westminster REC. 13/LO/0012).

• 2) Electronic and paper-based cross-sectional survey (39 questions) administered to ICU clinicians within a single institution.

• 3) Web based national survey (12 questions) of ICU clinicians distributed via UK ICU professional societies and social media with minimal risk ethics approval from King’s College London Research Ethics Committee (MRA-20/21-24479)

Results:

Feasibility RCT ²

We recruited 78 participants over 45 months (2013-18). Of the 72 participants commencing weaning, median (95% CI) adherence to allocated mode was 83.1% (64.0–97.1%) (NAVA); 100% (100–100%) (PSV). Protocol compliance was 66.7% (50.3–80.0%) (NAVA); 100% (89.0–100.0%) (PSV). Exploratory outcomes found more VFDs to day-28 (median difference 3.0 days, 95% CI 0.0–11.0; p = 0.04) and fewer in-hospital deaths (relative risk 0.5, 95% CI 0.2–0.9; p = 0.032) favouring NAVA. Time to breathing without ventilator assistance and to alive ICU discharge were shorter in NAVA (Figure 1). No significant differences were observed in MV duration; ICU or hospital stay; or ICU, day-28, and day-90 mortality.

Figure 1.

Kaplan-Meier estimates of probability of unassisted breathing (a) and live dischare from ICU (b) from randomization to D28.

Survey 1 ³

Of 466 distributed questionnaires, 301 (64.6%) were returned from 236 nurses (78.4%), 53 doctors (17.6%) and 12 physiotherapists (4.0%). Most agreed NAVA was safe (136/177, 76.8%) and effective (99/176, 56.3%). Most perceived improved synchrony, improved comfort and diaphragm monitoring as key advantages (Figure 2). Technical issues, perceived difficulty and low experience were the most cited disadvantages (Figure 2). Most perceived NAVA as more challenging than PSV (105/174, 60.3%).

Figure 2.

Perceived advantages,disadvantages, barriers to use and reason for cross-over from NAVA to PSV.

Survey 2

From June-Sept 2021, we received responses from 163 ICU clinicians from 86 NHS hospitals. Out of 130 responses, 81 (62.3%) would use NAVA if available; 41 (31.5%) were unsure. 111 (85.4%) agreed current evidence is uncertain; 119 (91.5%) wanted more evidence. Regarding recruitment to a proposed trial, 86 (66.2%) would definitely/probably recruit, 38 (29.2%) would possibly recruit or were unsure; 6 (4.6%) would not recruit. NAVA capable ventilators were available in 28/70 (40%) of responding hospitals. Of these, 35/62 (56.5%) clinicians indicated experience with NAVA.

Conclusions: This research demonstrates trial protocol feasibility and support for an effectiveness trial, albeit with the need to address stated barriers. We recently applied for NIHR Health Technology Assessment funding for a UK effectiveness trial, which was shortlisted for the 2022 Intensive Care Society’s Research Prioritisation exercise.

References

1. Sinderby C, Navalesi P, Beck J, Skrobik Y, Comtois N, Friberg S, et al. Neural control of mechanical ventilation in respiratory failure. Nat Med. 1999;5(12): 1433-6.

2. Hadfield DJ, Rose L, Reid F, Cornelius V, Hart N, Finney C, et al. Neurally adjusted ventilatory assist versus pressure support ventilation: a randomized controlled feasibility trial performed in patients at risk of prolonged mechanical ventilation. Crit Care. 2020;24(1):220.

3. Hadfield D, Rose L, Reid F, Cornelius V, Hart N, Finney C, et al. Factors affecting the use of neurally adjusted ventilatory assist in the adult critical care unit: a clinician survey. BMJ Open Respiratory Research. 2020;7(1):e000783.

5194

The cost of being more environmentally friendly. Introducing a new metric, the POCK – “Price of a CO2 Kilo”

Richard Kirkdale

Royal Derby Hospital

Introduction: I, like many of us, would like to make environmentally sound choices. As a dual trainee with anaesthetics I am used to using low flow vapours, TIVA and avoiding using, the polar bear killing, desflurane or nitrous. However, I get a little lost when comparing apples with oranges. Sevoflurane is better for the environment than desflurane, with a much lower global warming potential over 100 years (GWP₁₀₀) and less is released during an average anaesthetic. Things get a bit “mushy” in my mind with TIVA. How much does it “cost” the environment to make Propofol, or 50ml syringes? In critical care this gets even more blurry. Perhaps a 250ml bag of fluid and 5 ampules of Noradrenaline is less environmentally damaging than single ampules in multiple 50ml syringes, but what if some of it is thrown away? My dishwasher and washing machine at home have energy efficiency labelling, which helps inform my decision when buying them, but what about a Drager Evita vs a Maquet Servo-I? Could it, or should it, ever be appropriate to balance clinical risk against environmental impact? For instance, balancing the infection risk of using infusion sets for 48 hours instead of the standard 24 hours vs the environmental impact of halving the plastic thrown away as a result? We have all spent our careers learning to gauge the clinical balance of these questions, but we have little resource to enable us to assess the environmental impact of these choices.

Main Body: As a UK practitioner, cost is rarely a consideration I have to think about on a day-to-day basis; however, we work in an increasingly resource scarce environment. Often at home the price paid for a lower environmental burden, such as an electric or hybrid car, can be measured in thousands of pounds. This is why I propose a metric to help ease in the making of these decisions, the “Price of a CO₂ Kilo” (POCK).

The GWP₁₀₀ of a ton of CO₂ is a reasonably well accepted benchmark for environmental impact. The energy required and CO₂ generated in the production of most raw materials (e.g. metals, paper and plastics) are available, as is the impact of manufacturing processing (i.e. wire drawing for needles, injection moulding of syringes) and estimates of transport cost. With these data we can make a reasonable assessment of the GWP₁₀₀ of many of the treatments we use in critical care. Add in some numbers about the cost of different options and you have the number I think we would all like to know – how much will being more environmentally friendly cost my department?

Conclusion: I’m sure all of us would like to be more environmentally friendly if we could. With the help of the POCK I believe that making the difficult decision of whether a more eco option is a good choice will be easier. Most importantly, how much are we all willing to pay to look after the environment?

5367

Prioritise doing good, deprioritise the environment?

Rasmus Knudsen

Mid Yorkshire Hospitals Trust

Introduction: To mitigate our environmental impact we should first deprioritise our environmental concern and focus on good outcomes rather than good intentions.

Environmental changes are an inevitable challenge for humanity, but we must fundamentally change our current perspective and approach. Only a realistic, economically considered approach will efficiently allow us all to adapt to a changing environment. We should stop seeking “popular” interventions that have poor scientific and economic foundations and focus on how we can actually improve more lives and our environmental impact. We can do this by embracing three things Intensivists are good at: reflection, critical appraisal of evidence, and pragmatic action.

Main Body: We must reflect on our motivation before we can make effective changes. Why are we concerned about our environmental impact and what is the root cause of the concern? Fundamentally our concern is not a desire to reduce greenhouse gases or global temperatures, in isolation these makes no sense. It is something more integral to the work of an Intensivists: a desire to help people, particularly those in extremis. While concern for biodiversity may be considered with a similar approach, only by confronting our genuine root concerns for human suffering can we effectively save and improve lives in the context of a changing climate.

Environmental changes will disproportionally impact the poor and adaptation will be both necessary and expensive. Lower income countries have less capacity to adapt, therefore ensuring improvements in poverty and global health are paramount. Popular policies such as aggressive emission reductions are inefficient and will increase poverty.¹

The United Nations regularly asks millions of people worldwide to prioritise global issues. Tackling climate change is repeatedly prioritised near the bottom. When a group of Nobel laureate economists analysed the available research, climate change was prioritised near the bottom. These results are replicated when separate forums of university students and UN ambassadors are asked to appraise the evidence. The results are clear; we should focus on evidence based, cost effective measures to improve lives worldwide. In doing so, resilience to environmental changes would be increased.

Consider a single illustrative example based on global priorities and an investment of £24,095 (75% of ICS subscribers donating 5% of their subscription cost).² This could offset 4077t carbon dioxide yielding a benefit of £6,564.^3,4 Alternatively if invested in higher ranking global priorities, thousands of mosquito nets could be provided to yield £867,420 of economic and social benefit.⁵

Conclusion: Reprioritising, but not ignoring, our environmental concern would allow a pragmatic approach to improving lives, reducing poverty and increasing global environmental resilience. This could be achieved by individuals, or through organisations such as the Intensive Care Society (ICS), refocussing their sustainability agenda to follow an evidence based global priority approach. The ICS should actively encourage this approach to members while Intensivists as individuals should not shy away from using their skills in reflection, critical appraisal and communication to promote evidence based global priorities and interventions that not only sound good, but do good.

References

1. Campagnolo L, Davide M. Can the Paris deal boost SDGs achievement? An assessment of climate mitigation co-benefits or side-effects on poverty and inequality. World Development. 2019 Oct 1;122:96-109.

2. Intensive Care Society. Trustees Annual Report 2021 [Internet]. 2021 [cited 2023 Feb 12]. Available from: https://ics.ac.uk/about-us/how-we-re-governed/trustees-annual-reports.html

3. Carbon offset [Internet]. My Carbon Plan. [cited 2023 Feb 12]. Available from: https://www.mycarbonplan.org/offset

4. Tol RS. The marginal damage costs of carbon dioxide emissions: an assessment of the uncertainties. Energy policy. 2005 Nov 1;33(16):2064-74.

5. Malaria No More. Malaria: Bad for business [Internet]. Malaria No More. [cited 2023 Feb 12]. Available from: https://malarianomore.org.uk/file/2286/download?token=DuJHxTdR

5459

Keep calm and just stay in the hospital

Emily Yeung

NHS Greater Glasgow and Clyde

Introduction: Critical care medicine as a speciality has toyed with the idea of having round-the-clock consultant resident cover for the last decade. However, the 2018 Faculty of Intensive Care Medicine (FICM) survey evaluating the workforce profile in intensive care units (ICU) across the United Kingdom (UK) showed that this has yet to become the norm, with only 1% of respondents providing contractual resident cover out of hours for their unit.¹ It has been previously estimated that non-resident on call consultants receive up to 6 phone calls per night after 9pm.² With increasing recognition that the physical presence of specialist input leads to improved patient outcomes and training opportunities,³ it would seem fair to predict that the likelihood of consultants returning to the hospital out-of-hours will only become an increasing occurrence.

Main body: What are the implications of clinicians having to return to their place of work out-of-hours? In the NHS, transport and travel are responsible for approximately 10% of its total carbon dioxide emission.⁴ It is not infrequent to encounter rotational trainees commuting in excess of 30 minutes to their place of work, with an average one-way distance of 18 miles.⁵ In contrast, consultants are expected to reside within a distance of either 10 miles by road, or up to 30 minutes of travelling time each way. Although this represents a shorter distance and time spent on travelling, the additional trips a non-resident on call (NROC) consultant has to make to return to the hospital probably make up for the difference.

Taking a hypothetical example, assuming the worst case scenario: the NROC consultant makes their way back to the hospital every night of the week to provide emergency patient care, by making a 20-mile round trip. This equates to an additional 140 miles travelled per week, or 560 miles per month per unit. Multiply 560 miles by the total number of 283 intensive care units³ results in an excess of 158,480 miles travelled per month; or 1,901,760 miles per year by NROC consultants in England, Northern Ireland and Wales. That is, roughly, 467 metric tonnes of potentially avoidable carbon dioxide emission.

Conclusion: By taking the leap to make resident consultant cover the norm, we can offset a significant proportion of our carbon footprint. Indeed, this is one of the environmental advantages of the rapidly growing field of telemedicine. Clearly, remote consultations are less applicable to critical care medicine but reduced travel time could be alternatively achieved by on-site consultant presence. This is in addition to clinical benefits such as better resource utilisation in triage and management of unwell patients outside the unit, and providing educational opportunities for trainees. Certainly, there will need to be a whole system change and organisational engagement to ensure the hospital has the infrastructure to implement a resident consultant rota. But in return, the environmental reward will be far greater than any initiatives focusing on equipment or chemical waste.

References

1. Grailey KE, Bryden DC, Brett SJ. The Faculty of Intensive Care Medicine Workforce Survey–What impacts on our working lives?. Journal of the Intensive Care Society. 2019;20(2):111-7.

2. Thomas EO. A national survey of ICU consultant working practices at weekends. Anaesthesia. 2004; 59(10):960-6.

3. Faculty of Intensive Care Medicine. Workforce Data Bank for Adult Critical Care. [Internet]. 2021 [cited 2023 Feb 20]. Available from: https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/workforce_data_bank_2021_-_for_release.pdf

4. Tennison I, Roschnik S, Ashby B, et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. The Lancet Planetary Health. 2021 1;5(2):e84-92.

5. McClelland L, Holland J, Lomas JP, Redfern N, Plunkett E. A national survey of the effects of fatigue on trainees in anaesthesia in the UK. Anaesthesia. 2017;72(9):1069-77.

5510

Enteral nutrition in Critical Care – there must be another ‘whey’

Cat Anderson

Sheffield Teaching Hospitals

Introduction: Food production is responsible for one quarter of global greenhouse emissions, so one of the biggest modifiable elements to a persons carbon footprint is their diet. Changing from a diet heavy in animal protein to a plant based one could reduce an individual’s diet related carbon footprint by over 50%. The impact of different foods is shown below:

The traditional protein source in nasogastric (NG) feed is whey. Whey was a dairy industry by-product, traditionally seen as an ‘environmentally friendly’ option but is now a popular product in its own right. The protein content of milk is small, so you need large volumes of milk to produce the whey. The carbon footprint of milk is a CO2 equivalent (CO2eq) of 5.4kg/100g protein. There are also a variety of other animal products used in NG feeds and supplements such as beef collagen and fish oils.

Pea protein is a good alternative, it contains all the essential amino acids and can be grown in the UK, with a CO₂eq of 0.36kg/100g protein. Pea plants have symbiotic bacteria in their roots that fix nitrogen, reducing the need for nitrogen fertilizer. Reducing nitrogen represents significant additional environmental benefit as we are beyond the high risk line for nitrogen in the biogeochemical flows planetary boundary (shown in graphic).

Proposal: In the UK we treat around 200,000 patients in Critical Care each year, of these around 50% receive NG feed at some point in their stay. The average length of admission is five days (according to NHS digital data). European guidelines suggest 1.3-1.5g/kg/day of protein, so I have used a figure of 100g of protein per day for my calculation.

I propose the use of pea protein, along with replacement of other animal derived products in NG feed and supplements. Through the lens of the triple bottom line (financial, social and environmental) a plant based NG feed has potential to benefit all sectors, be inclusive with regard to dietary and allergy needs and currently does not exist on the market.

Switching to pea protein from whey could save 4350 tonnes of CO2eq nationally per year, the equivalent of driving a petrol car around the world 224 times. This calculation is based only on the protein content, there is likely to be additional carbon savings from making all enteral nutrition entirely plant based.

A more controversial option would be insect protein. Insects have a complete amino acid profile, a smaller CO₂eq of just 0.11kg/100g protein, and very low land and water usage. It may be a harder concept to sell though due to possible aversion to ingesting insects, and would not cover all dietary needs.

Conclusion: Nasogastric feed and supplements are very commonly used and switching to plant based NG feeds could significantly reduce the environmental impact of Critical Care. Furthermore, consideration of a low carbon diet throughout Critical Care and the hospital eliminating beef, dairy and lamb in favour of chicken, eggs and plant based options would result in large reductions in carbon footprint.

5600

Climate conscious medicine starts with the basics

Nina Hjelde

Manchester Foundation Trust

Introduction: The tinkle of the tea trolley as it rattles through the corridor is a unifying moment for all staff. Battle weary from COVID the morale remains nourished by the trolley’s predictable rattle. This tell-tale noise arises from a haphazard collection of cups with not a single piece of plastic in site. Nor are there individual packets of tea but instead one enormous teapot containing a monster teabag. The ethos here is minimal waste.

Main Body: Pollution breeds ill health which in turn generates higher healthcare waste. The NHS already generates 4% of the UK’s carbon footprint yet recognition of climate change is poor and methods to tackle it feel overwhelming. This is especially the case in intensive care where we rely so heavily on multiple plastic tubes, lines and personal hygiene equipment that must adhere to strict infection control measures.

What we present is a simple and sustainable method to start reducing waste. Sustaining good practice is half the battle when tackling climate change and a department with good morale and ongoing motivation to make this concept work is likely to nurture further environmentally sustainable practice. A staff survey showed 100% satisfaction and no-one missed plastic utensils. There is an environmental cost of water and electricity to fuel the washing machine; and not all departments have this luxury.

Conclusion: Dodging plastic cups is nearly impossible in most hospital departments but success in this small matter makes future sustainable change more tangible. The trolley can then be a platform for advertising further climate conscious challenges and goals. Tomorrow’s consultants cannot hope to influence meaningful culture change surrounded by the hypocrisy of needless plastic waste (and luke-warm tea).

5174

Changing practice by changing culture – the implementation of a protocolised daily paired sedation hold and breathing trial

Alex Small, Emily Good, James Morgan

BTHFT

Introduction: Daily sedation holds have consistently been proven to have widespread benefits to patients who are intubated and sedated on an Intensive Care Unit (ICU)^1-4. These benefits include shorter time requiring mechanical ventilation and reduced mortality¹. They appear greatest when paired with a mandated period of spontaneous breathing¹.

Despite these data, the implementation of this practice is not widespread. Furthermore, it has likely worsened over the recent past due to high staff turnover and the unique requirements of patients on ICU with COVID-19. To accomplish such a change in practice, a change in culture is required.

Main Body: Our aims were as follows:

1. To achieve paired sedation holds and spontaneous breathing trials on appropriate patients in >70% of days intubated.

2. To understand local barriers to implementing such change and provide a framework for future translational projects.

Baseline data on current sedation hold practices were collected which revealed a 35% rate of sedation holds per days intubated on appropriate patients. A nurse-led protocol was then designed with input from senior medical, nursing and physiotherapy teams. This was agreed upon at the ICU MDT meeting and implemented. A strategy was embedded within the protocol to mitigate against the risk of an increase in accidental extubations. In addition, a comprehensive relative contraindications list was published to minimise risk to unsuitable patients.

Information dissemination was key, with staff education taking numerous forms including bedside tea-trolley teaching, posters and the ICU newsletter. Emphasis was placed on data supporting the benefits of the intervention, including the comparatively low mortality NNT of 7¹, alongside it’s low cost of implementation. Furthermore, there was an ongoing multidisciplinary feedback and protocol adjustment process applied to ensure optimisation.

Reaudit revealed an improvement from 35% to 74% sedation holds per days intubated. There was 1 accidental extubation, an incidence of 2%. This patient did not require emergent re-intubation. A survey of nursing staff revealed 100% felt the protocol empowered nursing staff to lead sedation holds and 88% felt it led to better patient care.

Conclusions: The key to this culture change in the ICU was education, empowerment and subsequent staff buy-in. We managed to train >90% of nursing staff on this protocol over a 4 week period. Once a critical mass of staff appreciated the effect of such a simple implementation and were empowered to be part of the process, the culture changed.

As a rotational trainee implementing such a protocol, with inevitable increased nursing workload, had its challenges. The key here was to involve all major stakeholders within the MDT at every step of the process. This allowed the protocol to be developed with all voices heard.

A protocolised daily sedation hold with paired spontaneous breathing trial is an excellent example of a simple, free intervention which can save lives and reduce the burden on a stretched service. Understanding the multidisciplinary barriers to implementing of such a protocol is key in signposting future developments in the drive towards excellence.

References

1. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008 Jan 12;371(9607): 126-34. doi: 10.1016/S0140-6736(08)60105-1. PMID: 18191684.

2. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010 Feb 6;375(9713):475-80. doi: 10.1016/S0140-6736(09) 62072-9. Epub 2010 Jan 29. PMID: 20116842.

3. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000 May 18;342(20):1471-7. doi: 10.1056/NEJM200005183422002. PMID: 10816184.

4. Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J et al. SLEAP Investigators; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012 Nov 21;308(19):1985-92. doi: 10.1001/jama.2012.13872. Erratum in: JAMA. 2013 Jan 16;309(3):237. PMID: 23180503.

5374

Trach to basics: organisational tracheostomy improvement

Rebecca Hetherington, Brenna Fossey, Georgina Picot

EKHUFT

Introduction: Patients with altered airways are reliant on competent, skilled staff to provide safe and effective care. Sufficient staff training, access to the right equipment and the infrastructure of the care environment is linked to a reduction in patient harm, morbidity (1).

At East Kent Hospitals University Foundation Trust (EKHUFT), anecdotal and objective evidence collected over several years suggested that tracheostomy care was not meeting the standards set out by the Intensive Care Society (ICS), the National Tracheostomy Safety Project (NTSP) or the Global Tracheostomy Collaborative (GTC).

In 2020, a group of like-minded and passionate clinicians at EKHUFT formed East Kent Tracheostomy Review and Collaboration in Hospital (EK-TRACH); making changes to the strategic and safety issues pertinent to the organisation.

Main Body: We separated the quality improvement into three key metrics as outlined below. These were evaluated separately to assess compliance and effectiveness.

Standardisation of Care

• Ensuring bedhead signs were present at the bedside for all altered airway patients

• Standardisation of emergency equipment and introduction of the Kapitex Trachi-Case

• Introduction of patient pathways with cohort wards for patients with altered airways

• Trust-wide Altered Airways Policy written and ratified

Staff Training

• Staff training was redesigned with a blended learning approach and introduction of emergency simulation training. We took a novel approach to training within the Intensive Care Unit (ICU) aiming to train all staff in a month.

• The National Tracheostomy Safety Project (NTSP) competencies were introduced Trust-wide.

Tracheostomy Multi-Disciplinary Working

• Introduction of weekly ward round for all patients with altered airways with a view to establishing individualised weaning plans, implementation of earlier laryngeal rehabilitation, educating bedside staff and providing wellbeing support to patients

• Improved documentation and subsequent consistency and continuity of care

• We audited ‘pre-MDT’ and ‘post-MDT’ outcomes looking specifically at length of ICU stay, advanced respiratory days and tracheostomy days.

Results: We mapped our progress against the key interventions for improving tracheostomy care as described by McGrath, et al. (20):

	Pre-dates improvement work	Implemented	In Progress	Short-term priority	Long-term priority
Organisational efficiency
O1 Implement a hospital steering group		✔
O2 Ensure mandatory training for staff caring for tracheostomised patients				✔
O3 Institute a hospital-wide tracheostomy policy		✔
O4 Designated tracheostomy cohort wards		✔
O5 Dedicated tracheostomy coordinator					✔
O6 Tracheostomy link nurses in relevant wards			✔
Patient-centred quality of care interventions
Q1 Include patient champions				✔
Q2 Implement multidisciplinary tracheostomy team that sees patients		✔
Q3 Integrate speech and language therapists (SLTs) in ICU care	✔
Q4 Involve SLTs on head and neck wards	✔
Q5 Involve SLTs on general wards	✔
Q6 Train SLTs to be fibreoptic endoscopic evaluation of swallowing (FEES) proficient	✔
Q7 Capture patient-level data				✔
Safety interventions
S1 Establish competency standards for staff caring for patients with tracheostomies		✔
S2 Formalise MDT reviews of adverse incidents with learning			✔
S3 Standardise bedside and ward area tracheostomy equipment		✔
S4 Routinely place tracheostomy bedhead signs		✔
S5 Use standardised tracheostomy care bundles				✔

Staff Training: Qualitative feedback from ICU staff indicated an improvement in confidence with 53% of staff not confident in basic tracheostomy care and 36% of staff not confident in dealing with tracheostomy emergencies. After training, 100% of staff reported feeling confident in dealing with basic and emergency care of tracheostomies.

Tracheostomy Multi-Disciplinary Working

We audited all the tracheostomy patient case files from ICU in the years 2019 (pre introduction of MDT) and 2022 (post implementation).

We excluded the following patients:

• Died (tracheostomy days would have appeared shortened)

• Maxillo-facial patients (separately analysed)

• COVID positive patients (not enough known)

• Pre-existing altered airway

We saw a significant reduction in tracheostomy and advanced respiratory days.

Year	2019	2022
Patients	54	52
Age	56.7	61.71
Apache Score	15.57	15.62
Mean Tracheostomy Days	16.51	14.39
Mean Advanced Respiratory days	20.12	18.06

Conclusion: Our quality improvement project has aligned EKHUFT tracheostomy care with national recommendations. Our results suggest significant improvement to ventilatory and tracheostomy days, and staff confidence in providing care. By employing a proactive and can-do approach, we have collaboratively led effective change that has improved the patient pathway, supported the development and wellbeing of the workforce and shown a cost improvement despite an increasingly pressured NHS.

5447

One chance to get it right - a framework for the multidisciplinary team to improve individualised withdrawal of life-sustaining treatment for ICU patients

George Craven¹, Helen Meehan¹, Edward Presswood², Rowan Hardy¹, Clare Hommers¹, Fiona Kelly¹, Sophia Henderson¹

¹ Royal United Hospitals, Bath

² Dorothy House Hospice, Winsley, Bradford-on-Avon

Introduction: The Faculty of Intensive Care Medicine recommends that care at the end of life should allow natural death with minimal interference from medical technology.¹ The achievement of this goal can be complicated by the myriad of life-sustaining treatments which need to be considerately withdrawn to allow a dignified, peaceful death. Through collaboration between the critical care multidisciplinary team (MDT), palliative care clinicians, and review of national and international recommendations,^2,3 we present here a framework to guide best practice in withdrawing life-sustaining treatment in critical care.

Main Body: The guidance has been written collaboratively with stakeholders across the MDT. It is hoped that this empowers all members of staff to use it, whilst recognising the value of their involvement in the process of withdrawal of life-sustaining treatment (WLST). Anecdotal evidence suggests that when the goal of treatment changes from life-sustaining to palliative, patients on intensive care receive lower staffing ratios, and less involvement from the wider MDT. Therefore, a key theme of the guideline is that excellent end-of-life care requires similar levels of attention to detail as is routine in the treatment of the most critically unwell, ‘Level 3’, patient.

The framework promotes a holistic approach to managing end-of-life care, and delineates the different stages involved in WLST. At the outset it recommends assessing the individual patient’s dependence on life-sustaining treatments, thereby promoting a patient-centred plan for subsequent withdrawal. It recognises areas of uncertainty occurring at the end-of-life which are important to consider, as well as opportunities to involve the expertise of other specialists and offer additional support to family and loved ones.

Palliative care is not about doing less; it is about doing more of what matters most when the prognosis is short. Therefore, to promote this amongst the complexity of critical care treatment, the guidance concludes with a checklist to ensure that the most important actions are considered and communicated throughout the team.

Experienced practitioners will provide many aspects of end-of-life care intuitively, built upon years of practice. A strength of the guidance and quick-reference checklist is its value as a training and educational resource. It offers a comprehensive structure for all healthcare professionals to develop their skills and confidence in managing withdrawal of life-sustaining treatment.

Whilst there is consensus across many areas outlined in the guideline, there are some aspects which remain debated. In particular, pharmacological management of end-of-life care can become complicated on ICU, where patients may be receiving anaesthetic medicines which are not established in the palliative care setting.

Assessing the value of the guideline requires use in clinical practice. Qualitative, rather than quantitative, assessment is a more applicable measure of whether the framework helps. We intend to interview clinicians using the guideline to accrue valuable qualitative feedback to further develop the framework.

Conclusion: The withdrawal of life-sustaining treatment guidance is a novel, holistic, and multi-disciplinary document which aims to promote the highest standards of care at the end of life. For each patient, there is only ever once chance to get this right.

References

1. Faculty of Intensive Care Medicine (FICM). Care at the End of life: A guide to best practice, discussion and decision-making in and around critical care 2019. https://www.ficm.ac.uk/standardssafetyguidelinescriticalfutures/care-at-the-end-of-life (Accessed 23/2/23).

2. Downar J et al. Guidelines for the withdrawal of life-sustaining measures. Intensive Care Medicine 106; 42(6): 1003-1017.

3. Sprung CL et al. Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) study. American Journal of Respiratory and Critical Care Medicine 2014; 190(8): 855-866.

5548

Introducing Quality Improvement Educational Program: Meeting the Learning and Development needs of a Multi-Professional Workforce using Experiential Learning

Laura Lydon, Gemma Claire Lee, Peter Lynas

Blackpool Teaching Hospitals

Introduction: During the COVID pandemic, teaching for nurses in critical care halted, much like rest of the world. I like many, was new to critical care but even amongst senior staff there was a consensus that teaching, and development was at an all-time low. The elements anecdotally identified by our team as being important and hence incorporated int the development of the training, were inclusivity, accessibility, and experiential learning (Yardley, 2012). This led to the development of Blackpool Victoria Hospital ECHO.

Main Body: Project ECHO (P.Arora, 2010) (Enhancing Community Health Outcomes) uses a tele-mentoring network to share best practice, enable case-based learning to manage complexity, develop virtual communities of practice and build capacity in logistically challenged services. In the development of our sessions, a survey was sent out to allow the team to select the best time to run the sessions and identify the topics they would like to cover. The initial cycle was 6 sessions. The success of the first cycle has led to 2 further cycles and ongoing development.

Each 90-minute session comprises of a 30-minute talk and 2, attendee delivered topic relevant case-based discussions. To date we have run 16 sessions over the course of the last 10 months, with an average of 15 staff in attendance. Delivering over 5760 hours of learning to 240 staff.

Feedback after each cycle suggested that shared experience learning, with a didactic element delivered by an ICU consultant, develops confidence and knowledge and build trust between the team – 80% of participants felt more confident in asking questions at ward round and 100% had gained new knowledge from each session. (Zhou, 2016)

Cycle development included additional topics, Inclusion of more peripheral team members (Critical care outreach, Acute response team, Allied Health Practitioners (AHP)). We have excluded school holidays form the program and included onsite availability (seminar room hosts the zoom event).

To increase and maintain engagement we have curriculum mapped all of the sessions to the STEPS program ensuring time owing can be claimed, adapted topics at short notice to meet the demands of the network such as a paediatrics session at the height of the Strep A outbreak and encouraged dual presentation of one case to learn from different perspectives (e.g. Nurse & Physiotherapist).

Conclusion: Since the ECHO’s have started there has been a positive culture change on our unit, there is now a greater emphasis on multidisciplinary teaching on our unit. With introduction of integrated simulation teaching, development of an Advanced Care Practitioner (ACP) program (inclusive of other departments) and inclusion of nurses and AHP’s in developing BVH wider profile with opportunities such as presenting at SOA.

One senior staff member commented: “ECHO has been very good with a positive impact on those who have shared/discussed and given confidence to this group of staff.”

References

P.Arora. (2010). Expending access to HCV treatment- Extension of Community Healthcare Outcomes (ECHO) Project : Disruptive innovation in speciality Care . Hepatology, 1124-1133.

Yardley, S. (2012). Experiential Learning: AMEE Guide No 63. Medical Teacher, e101-e115.

Zhou, S. (2016). The impact of project ECHO on participant and patinet outcomes: A systematic review . Academic Medicine, 1439-1462.

5550

The Data Clinic: A multidisciplinary model for improving the efficacy of the data requesting process within a critical care department

Ruaraidh Campbell, Conor Foley, Hrisheekesh Vaidya, Sarah Vaughan, Dan Stein, Humayra Chowdhury, David Egan, Tracey Crissell, Timothy Bonnici

University College London Hospital

Introduction: The adoption of electronic healthcare record systems (EHRS) holds the potential to democratise the use of patient data.

Despite this, clinical staff continue to manually extract data for projects such as audits and quality improvement (QI) – a process that is laborious, time consuming and limits the feasibility of certain projects. This inefficiency stems from difficulties in automating EHRS data extraction, a lack of familiarity with EHRS storage systems and inexperience with data analysis.

We sought to address these issues in the Critical Care department of University College London Hospitals (UCLH) through the creation of the “Data Clinic”, a novel multi-disciplinary service that aims to help frontline clinical staff gain access to and interpret EHRS data for projects. It is available to all members of the multidisciplinary team, regardless of previous data experience or seniority.

Main Body: The Data Clinic is run as a quality improvement initiative with an ongoing iteration of its operation. Figure 1 shows a summary of the current process.

Figure 1.

Flowchart of the Data Clinic process for providing data to requestors.

The Clinic pairs a doctor with data science experience with a Data Analyst to process the data requests. This combines the data analytic abilities of the Analyst with clinical knowledge provided by the doctor.

Initially, the staff requesting data meet with the Data Clinic team to clarify the aims of their project, the data required and the output needed. If further methodology support is needed, a partner Methodology Clinic helps requestors refine their project aims and methodology.

Following this meeting, the data are extracted by the Data Clinic team. The code used to perform the extraction is stored on a GitHub repository so it can be adapted to increase the ease of future projects or QI cycles. If changes are required by the requestor, a revised extraction is performed and the process repeated until the output provided is satisfactory. A key benefit of this process is the flexibility offered; Data Clinic outputs have included spreadsheets, presentation slides, R notebooks, and SQL scripts depending on the requestor’s specific requirements.

For every project, qualitative and quantitative feedback is collected through feedback forms and structured After-Action Review meetings. These measure satisfaction with the data provided and guide changes to the Data Clinic process itself. For example, after identifying difficulties in interpreting the data, the Clinic now offers help with statistical analysis if required.

So far, 12 projects have been completed. The requests have come from a variety of multidisciplinary team members: consultants, junior doctors, nursing staff and physiotherapists. They have included audits, QI, validation studies, project feasibility studies and service evaluations. The time taken to complete the data requests has a median of 34 days (range 1-137 days), while the required number of meetings ranged from 1 to 4.

Conclusion: We describe the Data Clinic, a multidisciplinary model to improve the access to and use of electronic healthcare data by clinical staff in a critical care department.

5584

Factors influencing medicines practice change in critical care: a quantitative and qualitative evaluation

Ya-Hui Liang, Lucy Evans, John Warburton

University Hospitals Bristol and Weston Foundation Trust

Introduction: Potassium management is crucial in critically ill patients as abnormalities are associated with life-threating arrhythmias and increased mortality.¹ From a recent review of intravenous potassium administration across three critical care units in our Trust, we found three different methods of administration, using three different formulations. As staff frequently work across different units, changing to one standardised approach is fundamental. However, organisations experience failure rate up to 70% when trying to deliver change.² Thus, it is pivotal to identify motivators towards change as part of the Change Model.³ As nurses are the integral part of intravenous potassium administration we must understand their perspectives.

Main Body:

Methods:

A survey was created by the Critical Care Pharmacy Team, using Microsoft® Forms, to ascertain motivators for changing practice and piloted on pharmacist and nurse colleagues. The refined survey was distributed to nursing staff in three critical care areas within the Trust via email and posters.

The willingness to change practice at baseline, and in response to each motivator, was assessed on an 11-point Likert scale (0 “not at all willing”- 10 “extremely willing”). The motivators presented to respondents to change their current practice were:

1. Increased cost-effectiveness

2. Increased total time that the serum potassium is in range

3. Reduction in number of intravenous preparations you need to check in a shift

4. Reduction in number of arterial blood gases you need to do in a shift

5. No evidence that any one method is better than another

6. The method being championed by a senior nursing colleague

The final question invited respondents to identify any motivators not previously mentioned and the qualitative responses were analysed according to grounded theory. The survey was open for two weeks with a follow-up reminder four days prior to the deadline. Statistical analyses were performed using Microsoft® Excel.

Results: A total of 72 responses were received out of approximately 250 nurses (28.8%). Two duplicate responses were removed prior to analysis.

The table below illustrates the mean scores and the mean change with respect to baseline.

Of all the factors, “increased total time that the serum potassium is in range” shows the greatest impact on nurse willingness with 63% increase in their scoring compared to baseline.

Themes identified from the qualitative responses were that respondents cared greatly about the benefits and safety for their patients and that there was common desire of all three units to share the same practice.

Conclusion: The results confirm that five out of six motivators surveyed are likely to encourage changes, with “increased total time that the serum potassium is in range” (efficacy) being the most compelling factor. These findings will be used to shape the organisational strategy for managing change around potassium administration and the approach, if successful, could be replicated to inform many areas of future practice change. Implementing change must be effective, sustainable and inclusive of stakeholder perspectives, this approach contributes significantly to that agenda.

References

1. Lott C, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021 Apr; 161: 152–219.

2. Balogun J, et al. Landing transformational change: closing the gap between theory and practice. Research report, University of Bath School of Management, UK, September 2015.

3. NHS England. The Change Model Guide, https://www.england.nhs.uk/publication/the-change-model-guide/ (2018, accessed 24 February 2023).

5601

A retrospective review of the implementation of the Advanced Airway Module for Advanced Critical Care Practitioners at Warrington and Halton Teaching Hospitals

Andrea Berry

Warrington and Halton Hospitals NHSFT

Introduction: The Critical Care Unit at Warrington appointed three Advanced Critical Care Practitioners (ACCP’s) in August 2020. Post-qualification training was targeted to support local patient and department needs. With publication of the National Education and Competence Framework for Advanced Critical Care Practitioners¹ ACCPs are now forming part of the intensive care workforce and in most situations working on the trainee medical rota². As a result of the “Guidelines for the provisions of intensive care services” all staff that contribute to the resident rota must have basic airway skills and all critical care units must have immediate 24/7 on-site access to a doctor or ACCP with advanced airway skills.²

Training in advanced airway management utilising the Royal College of Anaesthetists’ Initial Assessment of Competence was scheduled, however shortly before commencement the Faculty of Intensive Care Medicine introduced the optional skills framework (OSF)³ for advanced airway management, which has now been fully implemented in Warrington. Theatre based training of ACCPs commenced in February 2020 followed by ICU based training which has now been completed by two practitioners. Ongoing regular theatre sessions and skill drills ensure skills retention and ongoing competency assessment.

Main Body: Traditionally at Warrington Hospital, advanced airway management has been undertaken by anaesthetists, anaesthetic trainees assisted by senior Operating Department Practitioners (ODP’s). The introduction of “nurses” to a realm of airway practitioners was met with some scepticism and concern on an institutional level. Issues contributing to this view included the unfamiliarity of the ACCP role within the trust, concerns over competency acquisition and maintenance, concerns regarding professional accountability, and a degree of “professional envy” amongst some ODP colleagues, owing to the lack of advanced practice roles open to ODPs.

An extensive PR campaign promoting the ACCP role with the theatre staff and anaesthetic department, along with integration of the ACCP’s into the theatre team as a “familiar face” ensured they were warmly welcomed for the theatre component of their airway module. The comprehensive FICM competency-based module with clear governance structures reassured all parties that skills would be appropriately maintained following completion of training. Finally, the ongoing presence of ACCP’s in Intensive Care, theatre and the emergency department has integrated the ACCP’s fully with the anaesthetic and ODP team. Despite the initial scepticism the entire team has rallied to support the training and development of our ACCP’s and, following the success of training for this group, the trust has recently recruited anaesthetic associate trainees to commence their training in March 2023. Feedback received from both ACCP’s and Trainers report excellent satisfaction with the training programme and skill delivery.

Conclusion: We report the successful deployment of the FICM Advanced Airway OSF in a district general hospital. This module has been proven to be invaluable in the ongoing progression of ACCP’s, ongoing improvement in patient management and an enhanced skilled workforce. Ongoing work will review the clinical outcomes achieved with ACCP advanced airway management, and the continued roll out of further OSF modules.

References

1. Department of Health. National Education and Competence Framework for Advanced Critical Care Practitioners. March 2008.

2. The Faculty of Intensive Care Medicine & Intensive Care Society. Guidelines For the Provision of Intensive Care Services. Version 2.1. July 2022

3. Faculty of Intensive Care Medicine. Advanced Airway Management for Advanced Critical Care Practitioners. ACCP Optional Skills Framework. January 2022.

5495

Focused ultrasound at Critical Care helped to diagnose necrotising pneumonia and liver abscesses caused by Streptococcus intermedius

Tatyana Bolonenkova¹, Richard Beese², Francesca Ferretti²

¹ Lewisham and Greenwich Trust, Queen Elizabeth Hospital, London

² Lewisham and Greenwich Trust

Introduction: Streptococcus intermedius is associated with deep seated infections and abscess formation. Diagnosis might be challenging in critically ill patients. We here present a case of disseminated Streptococcus intermedius infection diagnosed at bedside with focused ultrasound.

Main body: A 52 female, presented to our Critical care with type 1 respiratory failure secondary to community acquired pneumonia. She had a background of unprovoked pulmonary embolism, obesity (BMI 48), lymphoedema, previous DVT, anxiety. On admission she complained of shortness of breath, left sided chest pain, and a productive cough. She completed a course of antibiotics, but her symptoms had not improved.

On admission CT Pulmonary artery showed no evidence of acute or chronic pulmonary embolism, but left lower lobe pneumonia, moderate to large volume parapneumonic left pleural effusion and small ascites were found. Blood cultures grew Streptococcus intermedius and targeted antibiotics were started.

On HDU she required high flow nasal oxygen with FiO2 of 60%, but remained hemodynamically stable. We performed a bedside focused ultrasound and found left base moderate parapneumonic effusion, “moth eaten” severe consolidation, fibrin streaks, poorly mobile lung, which were suggestive of severe likely necrotising pneumonia or empyema. A chest drain was inserted, and about a litre of pleural fluid obtained, however, no microorganisms were found. Given the lack of clinical response, we requested a CT scan of the abdomen to look for other infective foci. However, the patient did not tolerate this due to ongoing high oxygen requirements and severe anxiety.

Therefore, we did a portable liver ultrasound, which showed multiple collections in the left lobe of the liver, the biggest one approximately 14 cm. The liver and perihepatic drains were inserted by an Interventional Radiologist and about 2.2L of pus drained. Perihepatic pus sample (16 S PCR rRNA gene sequencing result) detected Bacteroides. The liver, perihepatic and chest drains have been removed. The patient will need to complete a 6 weeks course of antibiotics.

Conclusion: Streptococcus intermedius bacteraemia of unknown source should prompt the physician to search for deep-seated infection. Bedside focused ultrasound at ITU helped us identify the presence of an empyema, multiple liver abscesses and intra abdominal collections, allowing us to perform chest and hepatic drainage and to identify a second pathogen (Bacteroides) which guided antibiotic treatment.

Lack of source control is a well known risk for treatment failure, therefore focused ultrasound was a valuable tool to ensure the good outcome of this case.

References

1. Iwata, Hiroyoshi, Hadano, Yoshiro, Septic thrombophlebitis of the superior mesenteric vein with bacteraemia caused by Bacteroides fragilis and Streptococcus intermedius as a complication of diverticulitis. BMJ Case Reports; Jan2013, p1-3, 3p, 2013.

2. Parthvi, Rukma, Amin, Mohsena, Mehra, Sunil, Antimicrobial Therapy for Pyogenic Liver Abscess Secondary to Streptococcus Intermedius Bacteraemia. American Journal of Therapeutics; Nov/Dec2017, Vol. 24 Issue 6, pe770-e771, 2p. 2017

3. Maliyil, Jepsin; Caire, William; Nair, Rajasree; Bridges, Debbie, Splenic abscess and multiple brain abscesses caused by Streptococcus intermedius in a young healthy man. Baylor University Medical Center Proceedings (BAYLOR UNIV MED CENT PROC), Jul 2011; 24(3): 195-199.

4. Hannah M. Wexler, Bacteroides: the Good, the Bad, and the Nitty-Gritty, Clinical Microbiology Reviews 2007 Oct; 20(4): 593–621.

5388

Lung ultrasound ‘agitation bubble ‘contrast” technique: A technique to diagnose pneumothorax in the presence of pleural effusion

Rochelle Smith, Matyas Andorka

Surrey & Sussex NHS Trust

Introduction: The use of point-of-care ultrasound ‘agitation bubble ‘contrast” (ABC) has previously been described for diagnostic assistance in identifying free-peritoneal gas in the presence of ascites.

We report a case using the same concept to support the diagnosis of hydropneumothorax, this has not previously been discussed in the literature.

Case: A young man in his 20s was admitted to critical care with a urinary tract infection for vasopressor support, on the background of a progressive neuromuscular condition. Subsequently, he had an in-hospital cardiac arrest, cardiopulmonary resuscitation (CPR) was commenced and return of spontaneous circulation (ROSC) was achieved. The patient remained profoundly hypoxic post-ROSC. Therefore, a lung ultrasound was initiated to investigate differential causes for the profound hypoxia and associated hypotension.

The conventional use of lung ultrasound to rule in pneumothorax requires the identification of a lung point. A lung point is defined as the junction between a ‘sliding’ aerated lung, seen when the parietal pleura slides over the visceral pleura, and no sliding, which suggests the presence of a pneumothorax. Ultrasound excluded the presence of a right-sided pneumothorax but provided inconclusive results on the left side.

It was noted that on visualisation of the right side, there was the presence of lung sliding and interstitial changes (B-lines). But on the left side, it was difficult to confidently conclude the presence of lung sliding, and a lung point was not found. The left side was also suspicious for pneumothorax because an A-line profile was observed when the expected pattern was interstitial changes in keeping with the right-sided ultrasound findings. This information was gathered within the complex and time-sensitive situation surrounding the investigation of peri-arrest hypoxia. We had to move on from this view to visualise the lung bases.

On such visualisation, the right side showed significant interstitial changes, no consolidation and no significant pleural effusion. The left side showed the presence of a large pleural effusion and lung collapse.

The hydrothorax was visualised on the ipsilateral side of the queried pneumothorax, it was theorised that an attempt to create an ‘agitated bubble ‘contrast” within the pleural cavity may assist to confirm the presence of fluid and air within the same anatomical space. This is done by applying repeated pressure to the lateral chest wall to cause agitation. If air and fluid are within the same space it will identify the presence of a ‘bubble artefact’. This was demonstrated in this case and confirmed the presence of a hydropneumothorax.

Thereafter, the patient had an immediate finger thoracostomy, followed by the placement of an intercostal chest drain and improvement in the patient’s ventilation status.

Conclusion: In this case, we were able to use this technique in a novel way to diagnose, treat and improve a patient’s condition in an otherwise challenging circumstance. The use of this technique, in this case, has highlighted the potential for using this technique to detect pneumothorax in the presence of hydrothorax in the future.

References

1. J et al (2020). The ‘agitation bubble ‘contrast’ technique: A technique for using intra-peritoneal free air as contrast for the diagnosis of organ perforation. Sage Journals. Vol 28, issue 1, p47-50. Accessible at: https://journals.sagepub.com/doi/epub/10.1177/1742271X19859384

2. D (2015). BLUE-Protocol and FALLS- Protocol. Two applications of lung ultrasound in the critically ill. Chest journal. Vol 147, issue 6. Accessible at: https://journal.chestnet.org/article/S0012-3692(15)37223-8/pdf

5357

Lung ultrasound guided Bronchoalveolar Lavage in Intensive Care

Nicola Raeside, Matayas Andorka

East Surrey Hospital

Introduction: Bedside lung ultrasound scan (LUS) is a clinically useful tool in the critical care setting and has been used to aid lung pathology diagnosis and assessment of alveolar aeration. Therefore, it can be used to demonstrate progress following a therapeutic intervention such as bronchioalveolar lavage or a lung recruitment manoeuvre.^1,2 In this case we used real time LUS to guide and direct a BAL, a technique that has not been discussed in literature before.

Case: A 39-year-old male patient was intubated due to an upper gastrointestinal bleed in conjunction with liver decompensation. Following a period of spontaneous ventilation during a sedation hold, he decrecruited and had an increase in oxygen requirement and ventilation pressures. LUS showed consolidated lung base with minimal air-bronchogram on the left. We were unable to re-recruit him using ventilation manoeuvres.

Bronchoscopy was performed with subsegmental suctioning following lavage with normal saline. LUS was performed simultaneously and showed some air-bronchogram appearing with minimal re-aeration as secretions were cleared. Despite bronchi appearing cleared on the BAL, LUS was still showing some consolidated areas with no air-bronchogram. This prompted further lavage and suctioning with good effect: more widespread air-bronchogram appeared. At the end of the procedure a recruitment manoeuvre was performed, also under ultrasound scanning, which showed near complete re-aeration of the collapsed lobe overall resulting in significantly improved gas exchange.

Conclusion: In this case, we were able to identify areas on LUS which required further suctioning during the BAL that would otherwise have been left. This improved our ability to clear the secretions allowing patent bronchial tree and then successful recruitment of the collapsed alveoli. We hope to use simultaneous LUS with further investigations in the future.

References

1. Nguyen M, Benkhadra S, Douguet C, Bouhemad B. Real-Time visualization of left lung consolidation relief using lung ultrasound. Am J Respir Crit Care Med [Internet]. 2016 Jun 1;193(11):e59–60. Available from: www.atsjournals.org

2. Tusman G, Acosta CM, Costantini M. Ultrasonography for the assessment of lung recruitment maneuvers. Crit Ultrasound J [Internet]. 2016 Dec 1;8(1). Available from: /pmc/articles/PMC4975737/

5580

Mitral valve prolapse presenting as a missed myocardial infarction

Ketan Champaneri, Ashley Miller

Shrewsbury and Telford Hospitals

Introduction: An elderly but very active gentleman presented overnight with progressive shortness of breath and leg swelling, two weeks after experiencing chest pain while lifting heavy objects in the garden. The presumed diagnosis was a missed myocardial infarction leading to heart failure exacerbated by a new diagnosis of atrial fibrillation. Despite diuresis and rate control, he became progressively more hypoxic and was taken to ICU for non-invasive ventilation. An initial POCUS scan of heart and lungs by an ultrasound fellow undertaking FUSIC accreditation showed a hyperdynamic heart, pulmonary oedema, and bilateral pleural effusions. The echocardiogram was reviewed and repeated by an advanced level operator which dramatically altered the patient’s diagnosis and management.

Main body: A gentleman in his early 80s presented to the Emergency Department in type one respiratory failure with a high work of breathing. Examination and investigations demonstrated raised inflammatory markers, new atrial fibrillation with a rate of 140, large bilateral plural effusions, and pitting oedema to the groin.

Troponin was normal, and the BNP was 4500. ECG showed no ischaemic changes and CXR was consistent with fluid overload and/or pneumonia. Initial management consisted of supplemental oxygen, diuretics, heart rate control, and antibiotics. Despite this his oxygenation deteriorated and he was admitted to the ICU for CPAP, and metaraminol for his hypotension.

An initial FUSIC heart scan did not show any signs of ventricular failure. In fact, the heart was hyperdynamic which was more consistent with sepsis. A lung ultrasound did however demonstrate large bilateral plural effusions and the significant pitting oedema of the lower limbs found on clinical examination still suggested a cardiac cause and so help was asked of an advanced level operator. A review of the images and a repeat scan revealed a severe prolapse of the posterior mitral valve leaflet with free, eccentric mitral regurgitation. The leaflet prolapse was not visible on the 1st set of images and was only discovered by more comprehensive scanning. The patient was reviewed by a cardiologist within 30 minutes and transfer to a tertiary centre for emergency mitral valve repair was arranged.

Conclusion: Standard history, examination, and investigations of this patient led to a presumed diagnosis of ischaemic ventricular failure. While a basic heart ultrasound did not reveal the pathology, it did demonstrate signs not consistent with the suspected diagnosis prompting a request for a more comprehensive ultrasound assessment. This revealed the underlying pathology, significantly altering the patient’s management. This was all done by intensive care clinicians at the bedside, significantly shortening the time to diagnosis and correct management. This case is a good example of why Intensive Care clinicians should be trained in point of care ultrasound at both basic and advanced levels.

5361

Rapid identification of ventricular rupture causing tamponade post anterior Myocardial Infarction

Harry Bamber¹, Annmarie Brunswicker²

¹ Glan Clwyd Hospital

² Liverpool Heart and Chest Hospital

Introduction: Ventricular rupture after myocardial infarction typically presents 3-5 days post a transmural infarct. Diagnosis is made by echocardiography which may reveal hemopericardium and flow across the defect in the wall. The condition carries a significant mortality of >50% (Damluji et al., 2021) and therefore prompt diagnosis and referral to a centre capable of definitive management is crucial. This case described the rapid identification of a ventricular rupture in a patient who survived.

Main body: A gentleman in his 60s presented to the emergency department after a transient loss of consciousness at home. He was hypoxaemic, had altered mental status and had a metabolic acidosis with significant lactataemia and clinical signs of hypoperfusion. His troponin was also elevated. He described some indigestion four days previously. His ECG showed anterior Q waves and ST elevation.

Bedside echocardiography revealed a probable left ventricular apical rupture with haemopericardium of mixed echogenicity, right atrial and ventricular collapse and a fixed dilated IVC >2.5cm. An akinetic apex of the left ventricle was also noted containing a thrombus, close to the site of probable rupture. A CT Aorta showed a renal infarct and a common femoral thrombus but no evidence of aortic dissection. He was transferred to the cardiothoracic centre within 2 hours of presentation with suspected left ventricular rupture post anterior STEMI causing tamponade. An angiogram showed LAD occlusion, 90% occlusion of OM1 and mild diffuse proximal RCA disease. A pericardial drain was placed in the cath lab with 150ml blood aspirated initially and an intra-aortic balloon pump inserted. A repeat transthoracic echocardiogram three days later showed resolution of the haemopericardium.

His clinical course was complicated by an acute kidney injury requiring renal replacement therapy, limb ischaemia requiring embolectomy and fasciotomy and an acute liver injury. He survived with a similar premorbid status.

This case describes cardiogenic/obstructive shock. The Intensive Care Society (ICS) has recently published ‘Shock to Survival’ which seeks to improve the care and outcomes of people with cardiogenic shock in the UK. One aspect identified in the report is prompt access to emergency echocardiography and early referral to specialist centres (Intensive Care Society & British Cardiovascular Society, 2022).

In this case, emergency echocardiography was performed within 30 minutes of presentation and led to rapid identification of significant pathology meaning early referral for definitive treatment. The patient was transferred without further echocardiography highlighting the validity of the images.

Conclusion: In this case bedside echocardiography by a FUSIC accredited operator was able to rapidly and accurately diagnose a ventricular rupture post MI and therefore expedite transfer to an appropriate centre for definitive treatment.

References

Damluji A, van Diepen S, Katz J, Menon V, Tamis-Holland J, Bakitas M, et al. Mechanical complications of acute myocardial infarction: A scientific statement from the American Heart Association. Circulation. 2021;144(2).

Intensive Care Society, British Cardiovascular Society [Internet]. Shock to Survival. Intensive Care Society; 2022 [cited 2023]. Available from: https://ics.ac.uk/resource/shock-to-survival-report.html

4977

The value of echocardiographic haemodynamic assessment on intensive care

Ben Stoney¹, Steve Lobaz², Simon Chau²

¹ Sheffield Teaching Hospitals

² Barnsley District General Hospital

Introduction: A 57 year old female presented to a district general hospital emergency department, with a 3-day history of shortness of breath and increasing drowsiness. She had tested positive for COVID-19 10 days previously and had a past medical history of COPD and heavy smoking. On arrival she was peri-arrest with a reduced consciousness level, hypotension, acidosis and a type 2 respiratory failure. Her ECG showed fast atrial fibrillation with lateral ST depression which resolved with an improved blood pressure. She was intubated and ventilated and taken for a CTPA which did not show a PE, but did show evidence of bilateral basal consolidation, bilateral effusions and a suggestion of pulmonary oedema.

Main Body: She was taken to ITU for further stabilisation where the working diagnosis was COVID-19 with a superadded chest infection and sepsis. On intensive care she was stabilised with noradrenaline and fluid resuscitation. Due to haemodynamic instability a bedside echo was performed. Impression was that the LV cavity appeared hyperdynamic with papillary muscle apposition in systole. Impression of vasoplegia – due to sepsis. The patient was peripherally cool, remained acidotic and was oliguric.

Cardiac output monitoring was started (LiDCO) which showed a cardiac index of 1.7dynes.sec/cm⁵/m², stroke volume of 40ml and SVRI 2900l/min/m², which was not in keeping with the original echo findings. A further echo with a focus on haemodynamic and valvular assessment was performed which demonstrated prolapse of the posterior mitral valve leaflet with severe mitral regurgitation. The papillary muscles were intact. The LV was hyperdynamic with a dilated LA.¹

The troponin was found to be over 10,000. The patient was discussed with cardiology and diagnosed with ischaemic mitral regurgitation following an acute myocardial infarction^2,3. ACS treatment was started and haemodynamic stabilisation took place with dobutamine and noradrenaline. The patient was discussed with cardiothoracics who accepted for transfer to the regional centre where she underwent a coronary artery angiogram, a transoesophageal echo and an intra-aortic balloon pump was inserted.

The angiogram showed a chronic total occlusion of the left anterior descending artery and an acute thrombotic occlusion of the proximal circumflex. The right coronary artery was unobstructed and collateralising the left anterior descending and circumflex artery. (Angiogram and TOE images to be shown).

The patient was stabilised on cardiac intensive care for a few days whilst she was treated for pneumonia, but she deteriorated and the decision was made for urgent surgery. She underwent a mitral valve repair and a double coronary artery bypass graft. Post-op she spent a few weeks recovering in hospital and has now been discharged home and is making a slow but reasonable recovery.

Conclusion: In this case the focussed echo with haemodynamic assessment helped unify the diagnosis, in a case with multiple confounding factors, and allowed prompt referral and treatment of the underlying condition. It also highlights the importance of clinicians undertaking further echo qualifications that take into account haemodynamics and more advanced valvular assessment.

References

1. Acute Mitral Regurgitation. Watanabe, N. BMJ Heart 2019; 105:671-677.

2. Ischaemic Mitral Regurgitation. Varma, P. et al. Ann Card Anaesth.2017 Oct-Dec; 20(4): 432–439.

3. Ischaemic Mitral Regurgitation. Izquierdo-Gómez, M. et al. European Society Cardiology. Vol. 16, N° 12 - 30 May 2018.

5358

Haematopoietic stem cell transplants for the intensivist

Sef Carter

The Royal Marsden NHS Foundation Trust

Session Summary: Haematopoeitic stem cells transplants are an increasingly common method of treating both malignant and non-malignant haematological disorders. Transplant patients account for two percent of admissions to intensive care within the United Kingdom. Despite general improvements in ICU care and advances in the transplant process, patients admitted to ICU have a significantly worse 1-year prognosis compared to matched transplant recipients that do not require admission. This talk will describe the transplantation process, and cover important complications such as: infection, graft-versus-host disease, veno-occlusive disease, posterior reversible encephalopathy syndrome, and the endothelial cell activation syndromes.

References

Gruber P and Wigmore T. Haematological Malignancy. In: Bersten and Handy, editors. Oh’s intensive care manual. Elsevier; 2018. p1189 - 1201

Dignan FL et al. Diagnosis and management of acute graft-versus-host disease. BJH 2012; 158: 30-45.

Kedia S et al. Infectious Complications of Hematopoietic Stem Cell Transplantation. J Stem Cell Res Ther 2013; S3:002

Mohty M et al. Prophylactic, pre-emptive, and curative treatment for sinusoidal obstruction syndrome/veno-occlusive disease in adult patients: a position statement from an international expert group. Bone Marrow Transplantation 2020; 55: 485–495.

Young JA et al. Transplant0associated thrombotic microangiopathy: theoretical considerations and a practical approach to an unrefined diagnosis. Bone Marrow Transplantation 2021; 56: 1805 – 1817.

5381

Eye care in the Intensive Care Unit

Olivia Morley

Chelsea and Westminster NHS Foundation Trust

Session Summary: Eye care in the Intensive Care Unit (ICU) is an important subject which is often overlooked. Patients in the ICU are at increased risk of developing ophthalmological conditions such as ocular surface disease (OSD), which affects up to 60% of ventilated patients. Increased awareness of eye care in the ICU setting with regular examination and simple measures can have an significant impact on the prevention and treatment of potentially serious eye conditions. This talk will cover the basic eye examination and eye care protocols for patients on ICU. The risk factors for OSD will be discussed, along with the diagnosis, management and potential complications of the conditions that make up OSD, including chemosis, exposure keratopathy and microbial conjunctivitis and keratitis.

References

Eye Care in the Intensive Care Unit. The Royal College of Ophthalmologists; The Intensive Care Society; The Faculty of Intensive Care, 2020.

Hearne J et al. Eye Care in the Intensive Care Unit. J Intensive Care Soc 2018; 19(4): 345-350.

Werli-Alvarenga et al. Corneal injuries: incidence and risk factors in the intensive care unit. Rev Lat Am Enfermagem 2011; 19: 1088–1095.

Guidance for Prone Positioning in Adult Critical Care. The Faculty of Intensive Care Medicine; Intensive Care Society 2019.

Sansome SG, Lin PF. Eye care in the intensive care unit during the COVID-19 pandemic. Br J Hosp Med 2020; 81(6): 1-10.

5455

Health Literacy in the ICU

Dominique Byrne

Portsmouth hospital university trust

Session Summary: To take control of their health, patients and their families and carers need to understand the information they receive from healthcare professionals and be able to apply that information. They require optimal health literacy. People with low health literacy may find it challenging to manage their condition and take steps to prevent ill-health, which may lead to an increase in acute hospital admissions. Low health literacy is one of the main barriers preventing healthcare professionals from adequately transmitting information to people in their care. It is crucial that we do not assume that everyone will understand information about their health, so we should adapt our communication and create an environment where people feel empowered to ask questions. This session looks at health literacy, explains the consequences of low health literacy, and identifies strategies and techniques we can use to mitigate low health literacy in the ICU.

References

Byrne D. Understanding and mitigating low health literacy. Nursing Standard 2022; 5:37 (10): 27-34.

Rowlands, G., Protheroe, J., Winkley, J., Richardson, M., Seed, PT. and Rudd, R. A mismatch between population health literacy and the complexity of health information: an observational study. The British Journal of General Practice: The Journal of the Royal College of General Practitioners [online], 2015; 65 (635), e379-e386.

Public Health England. Local action on health inequalities. Improving health literacy to reduce health inequalities. UCL institute of health equity. 2015

Schapira, MM., Swartz, S., Ganschow, PS., Jacobs, EA., Neuner, JM., Walker, CM., Fletcher, KE. Tailoring educational and behavioural interventions to level of health literacy: a systematic review. MDM Policy and Practice [online], 2017; 2, 2017.