scholarly journals 92 Clinical Frailty Scoring Is Crucial For the COVID-19 Era and Beyond

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
L White ◽  
A Tyler ◽  
A Samji
Keyword(s):  
Critical Care ◽  
Mobile Application ◽  
Inpatient Mortality ◽  
Improvement Project ◽  
Nice Guideline ◽  
Number Of Patients ◽  
Nice Guidance ◽  
Observational Cohort ◽  
Audit Standard ◽  
Treatment Escalation

Abstract Introduction The COVID-19 pandemic placed a new focus on provision of clinical resources. With high mortality and limited capacity; appropriate decisions to escalate to critical care were vital for just resource allocation but also to prevent harm where interventions would not change outcomes. NICE guidance highlighted Clinical frailty scoring (CFS) as central to the decision-making process. 1, Despite initial criticism, recent evidence has confirmed increasing CFS as an independent risk factor to inpatient mortality in COVID-19.2 We conducted a quality improvement project with the aim of improving CFS documentation at the Royal Free Hospital. Methods We reviewed the notes of 71 inpatients over the age of 65 years from 6 wards on 08/05/20–12/05/20 for both a CFS score documentation and clear treatment escalation plan at time points of initial clerking, post-take and following ward admission with an audit standard of 100%. We developed teaching sessions, promoted the CFS mobile application, developed a post-take sticker and an elderly medicine ward admission proforma. We re-audited 66 inpatient notes from the same 6 wards from 25/06/20–07/07/20. Results Documentation.of CFS improved from 7% to 17% for clerking and post-take and from 13% to 24% on the ward admission. The number of patients with treatment escalation plans was 50%. Conclusion CFS is crucial for the COVID-19 era and beyond. We have demonstrated that increased awareness improves use of CFS, though it is not yet being widely used in escalation decisions. 1. Covid-19 Rapid guideline: Critical Care in adults. NICE guideline [NG159]: https://www.nice.org.uk/guidance/ng159 Accessed July 2020 2. Hewitt J et al (2020): The effect of frailty on survival in patients with COVID -19 (COPE): a multicentre, European, observational cohort study; The Lancet: https://doi.org/10.1016/ S2468–2667(20)30146–8.

scholarly journals 600 ESCALATION DECISIONS DURING THE COVID-19 PANDEMIC AMONGST OLDER ADULTS

2021 ◽  
Vol 50 (Supplement_2) ◽  
pp. ii8-ii13
Author(s):  
L Bishop ◽  
D Tiwari
Keyword(s):  
Older Adults ◽  
Critical Care ◽  
Retrospective Review ◽  
Decision Aid ◽  
Age Group ◽  
Younger Age ◽  
Nice Guidance ◽  
Treatment Escalation ◽  
Second Wave ◽  
Care Decision

Abstract Introduction NICE guidance recommends that during the COVID-19 pandemic all adults are assessed for frailty, suitability for resuscitation and escalation to critical care on admission to hospital. Risks, benefits and likely outcomes should be discussed with patients/relatives. Aim To investigate impact of intervention on treatment escalation plan (TEP) use during the first wave (W1) and second wave (W2) of pandemic. Intervention W1: An ethically approved TEP and a Critical Care Decision Aid (CCDA) was added to the admission booklet. W2: The TEP update included a ‘confirm discussed with patient/relatives’ section. Method W1: We conducted retrospective review of 62 case-notes of patients admitted through COVID-19 pathway and grouped into >80 and ≤ 80 years old. Resuscitation, TEP, CCDA and communication with patient/relatives were collected. W2: 60 further case-notes of patients with COVID-19 admitted in January 2021 were analysed. Results W1: 100% patients had resuscitation decisions and 95% had TEPs in both groups. Significantly higher proportions of Frailty scores were calculated in >80s (58% vs 35% p = 0.04). On average resuscitation and TEPs were made within 13.8 hours of admission (range 1–72 hours). 53.2% of resuscitation decisions and 30% TEPs were discussed with patients of whom higher proportions were discussed in younger age group, majority were discussed at the time of deterioration. W2: 98.3% patients had resuscitation decisions made and 96.7% had TEPs across both groups. On average resuscitation decisions were made within 14.9 hours of admission. In the >80s, 86.7% of resuscitation decisions were discussed and 63.3% of the TEPs were discussed with patient/relatives. In the <80s, 82.8% of resuscitation decisions were discussed and 71.4% of TEPs were discussed with the patient/relatives. Conclusion We significantly improved Treatment Escalation planning during W1 and W2 of pandemic by introducing the TEP in W1 and adding prompt to improve communication with patients/relatives in W2 (p = 0.02).

708 Enteral Nutrition Initiation During Periods of Vasopressor Requirements and Elevated Lactate Levels

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S185-S186
Author(s):  
Beth A Shields ◽  
Kaitlin A Pruskowski ◽  
Alicia M Williams ◽  
Leopoldo C Cancio
Keyword(s):  
Critical Care ◽  
Enteral Nutrition ◽  
Regulatory Compliance ◽  
Burn Patients ◽  
Improvement Project ◽  
Ischemic Bowel ◽  
Number Of Patients ◽  
Significant Difference ◽  
Norepinephrine Dose ◽  
Lactate Levels

Abstract Introduction Nutrition is a core component of care for the critically ill burn patient. The Society for Critical Care Medicine recommends initiating enteral nutrition (EN) within 4–6 hours of injury for burn patients, while simultaneously recommending waiting until hemodynamic stability is achieved for critical care patients. The goal of this analysis was to evaluate tolerance of EN during periods of different pressor requirements and lactate levels. Methods We performed a retrospective evaluation on all burn patients admitted to our intensive care unit in 2018 who received EN. This performance improvement project was approved by our regulatory compliance division. Lactate levels and vasopressor use just prior to EN initiation, the highest EN rates and gastric residual volumes during the 24 hours after initiation, and ischemic bowel and aspiration after EN initiation were recorded. Significance was accepted at p< 0.05. Results EN was initiated at 30 ± 20 hours after admission in 58 patients with the following characteristics: 47 ± 19 years old, 29 ± 24% TBSA burn, 13 mechanical ventilator days (IQR: 5–30), 15% mortality. The highest EN rate reached was 100 ± 49 mL/hr during the first 24 hours after initiation. Lactate levels were 1.9 mmol/L at the time of EN initiation (IQR: 1.6–2.4 mmol/L), with a maximum of 4.9 mmol/L. Lactate levels did not have a significant correlation with gastric residual volumes (p=0.532). Most (59%) patients did not have vasopressor requirements, but 21% required vasopressin only, 2% required norepinephrine only, and 19% required a combination of vasopressin and norepinephrine. Those who received norepinephrine received 3.3 ± 1.7 mcg/min, with a maximum of 7 mcg/min. There was a significant difference in gastric residual volumes between patients who had no vasopressor requirements compared to those who required vasopressors [13 mL (IQR: 0–200 mL) vs. 240 mL (IQR: 21–430 mL), p=0.014)]; however, the number of patients with gastric residual volumes over 500 mL was not significantly different (3% vs. 17%, p=0.149). When examining patients receiving vasopressin alone, there was a significant but weak correlation between vasopressin dose and gastric residual volumes (p=0.047, R2=0.339); however, when examining only patients receiving norepinephrine, there was no correlation between norepinephrine dose and gastric residual volumes (p=0.905, R2=0.002). There was 1 episode of aspiration and 1 episode of ischemic bowel, both of which occurred 3 days after EN initiation. EN was initiated without vasopressors running and lactate levels were normal in both cases. Conclusions The majority of patients tolerated EN initiation with vasopressor dosing of norepinephrine up to 7 mcg/min and lactate up to 4.9 mmol/L. Applicability of Research to Practice We found no indication for holding EN for lactate levels under 5 mmol/L and norepinephrine under 8 mcg/min.

scholarly journals Physical Therapist–Established Intensive Care Unit Early Mobilization Program: Quality Improvement Project for Critical Care at the University of California San Francisco Medical Center

2013 ◽  
Vol 93 (7) ◽  
pp. 975-985 ◽  
Author(s):  
Heidi J. Engel ◽  
Shintaro Tatebe ◽  
Philip B. Alonzo ◽  
Rebecca L. Mustille ◽  
Monica J. Rivera
Keyword(s):  
Quality Improvement ◽  
Physical Therapy ◽  
San Francisco ◽  
Physical Therapist ◽  
Medical Center ◽  
Early Mobilization ◽  
Quality Improvement Project ◽  
Improvement Project ◽  
Icu Admission ◽  
Number Of Patients

Background Long-term weakness and disability are common after an intensive care unit (ICU) stay. Usual care in the ICU prevents most patients from receiving preventative early mobilization. Objective The study objective was to describe a quality improvement project established by a physical therapist at the University of California San Francisco Medical Center from 2009 to 2011. The goal of the program was to reduce patients' ICU length of stay by increasing the number of patients in the ICU receiving physical therapy and decreasing the time from ICU admission to physical therapy initiation. Design This study was a 9-month retrospective analysis of a quality improvement project. Methods An interprofessional ICU Early Mobilization Group established and promoted guidelines for mobilizing patients in the ICU. A physical therapist was dedicated to a 16-bed medical-surgical ICU to provide physical therapy to selected patients within 48 hours of ICU admission. Patients receiving early physical therapy intervention in the ICU in 2010 were compared with patients receiving physical therapy under usual care practice in the same ICU in 2009. Results From 2009 to 2010, the number of patients receiving physical therapy in the ICU increased from 179 to 294. The median times (interquartile ranges) from ICU admission to physical therapy evaluation were 3 days (9 days) in 2009 and 1 day (2 days) in 2010. The ICU length of stay decreased by 2 days, on average, and the percentage of ambulatory patients discharged to home increased from 55% to 77%. Limitations This study relied upon the retrospective analysis of data from 6 collectors, and the intervention lacked physical therapy coverage for 7 days per week. Conclusions The improvements in outcomes demonstrated the value and feasibility of a physical therapist–led early mobilization program.

151 Optimising Bone Health on Sheffield Frailty Unit Through Quality Improvement

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
C M Orton ◽  
N E Sinson ◽  
R Blythe ◽  
J Hogan ◽  
N A Vethanayagam ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Fracture Risk ◽  
Fragility Fracture ◽  
Bone Health ◽  
Assessment Tool ◽  
Health Assessment ◽  
Fragility Fractures ◽  
Improvement Project ◽  
Number Of Patients ◽  
Fracture Risk Assessment Tool

Abstract Introduction NICE and the National Osteoporosis Guidance Group (NOGG) advise on evaluation of fracture risk and osteoporosis treatment1,2, with evidence suggesting that screening and treatment reduces the risk of fragility fractures 3,4,5. However, it is often overlooked in the management of older patients within secondary care. Audit data from Sheffield Frailty Unit (SFU) in 2018 showed that national guidance was not routinely followed. Fracture Risk Assessment Tool (FRAX®) scores were not calculated and bone health was poorly managed. Therefore, we undertook a quality improvement project aiming to optimise bone health in patients presenting to SFU. Method & Intervention In January 2019 we collaborated with Sheffield Metabolic Bone Centre (MBC) to develop a pathway aiming to improve bone health assessment and management in patients presenting to SFU with a fall or fragility fracture. This included a user-friendly flow chart with accompanying guidelines, alongside education for staff. Performance was re-evaluated in May 2019, following which a tick box prompt was added to post take ward round documentation. A re-audit was performed in March 2020. Results In March 2018 0% of patients presenting with a fall had a FRAX® score calculated and only 40% of those with a new fragility fracture were managed according to guidelines. In May 2019, this had improved to 18% and 100% respectively. In March 2020 86% of patients had a FRAX® score calculated appropriately and 100% of fragility fractures were managed according to guidelines. In both re-audits 100% of FRAX® scores were acted on appropriately. Conclusions There has been a significant increase in the number of patients who have their bone health appropriately assessed and managed after presenting to SFU. However, achieving optimum care is under constant review with the aim to deliver more treatment on SFU, thereby reducing the need for repeat visits to the MBC.

Evaluation of the safety of inter-hospital transfers of critically ill patients led by advanced critical care practitioners

2021 ◽  
Vol 30 (8) ◽  
pp. 470-476
Author(s):  
Gavin Denton ◽  
Lindsay Green ◽  
Marion Palmer ◽  
Anita Jones ◽  
Sarah Quinton ◽  
...  
Keyword(s):  
Critical Care ◽  
Quality Improvement ◽  
Critically Ill ◽  
Process Of Care ◽  
Related Complication ◽  
Improvement Project ◽  
Hospital Transfer ◽  
The Uk ◽  
Critically Ill Adults ◽  
Ill Adults

Introduction: Ten thousand inter-hospital transfers of critically ill adults take place annually in the UK. Studies highlight deficiencies in experience and training of staff, equipment, stabilisation before departure, and logistical difficulties. This article is a quality improvement review of an advanced critical care practitioner (ACCP)-led inter-hospital transfer service. Methods: The tool Standards for Quality Improvement Reporting Excellence was used as the format for the review, combined with clinical audit of advanced critical care practitioner-led transfers over a period of more than 3 years. Results: The transfer service has operated for 8 years; ACCPs conducted 934 critical care transfers of mechanically ventilated patients, including 286 inter-hospital transfers, between January 2017 and September 2020. The acuity of transfer patients was high, 82.2% required support of more than one organ, 49% required more than 50% oxygen. Uneventful transfer occurred in 81.4% of cases; the most common patient-related complication being hypotension, logistical issues were responsible for half of the complications. Conclusion: This quality improvement project provides an example of safe and effective advanced practice in an area that is traditionally a medically led domain. ACCPs can provide an alternative process of care for critically ill adults who require external transfer, and a benchmark for audit and quality improvement.

scholarly journals Regional Anaesthesia, The Seed of Opportunity In COVID-19 Crisis: The Balance Has Shifted

2020 ◽  
Vol 6 (3) ◽  
Keyword(s):  
Critical Care ◽  
General Anaesthesia ◽  
Regional Anaesthesia ◽  
Albert Einstein ◽  
Multimodal Analgesia ◽  
Nerve Blocks ◽  
Great Opportunity ◽  
Aerosol Generation ◽  
Number Of Patients ◽  
Alternative Drugs

Albert Einstein once said, “in the midst of every crisis, lies great opportunity.” There’s no question that we’re in the midst of a global crisis. There’s no doubt that a crisis creates problems, lots of them, but it also creates opportunities. Something that every anaesthetist does day in day out safely, intubation of trachea, is now become a risk factor for spread of the disease. So where is the opportunity in this crisis? In the west, regional anaesthesia is often used as an adjunct rather than as sole anaesthetic technique, as part of multimodal analgesia in patients who are being operated under general anaesthesia. Unfortunately, general anaesthesia requires airway manipulation that is associated with aerosol generation and risks transmission of corona virus. This is a risk that can be averted with use of regional anaesthesia techniques for procedures that can be done with patient awake rather than asleep. At the beginning of the pandemic with surge of patients requiring endotracheal intubation and ventilation, increased intensive care admissions affected anaesthesia services in many ways. The increased number of patients needing critical care increased the demand for drugs used in both anaesthesia and critical care and this demand led to shortage of anaesthesia drugs and led the Association of Anaesthetists (AOA) and the Royal College of Anaesthetists (RCoA), working closely with the Chief Pharmaceutical Officer at NHS England to produce a guidance which summarised potential mitigations to be used in the management of such demand. Direct alternative drugs and techniques were offered (1). The options identified in the guidelines were not exhaustive but give a way of thinking about this situation we all have landed up in. We were unsure of how long this demand would continue and how we would manage the situation. This is where the opportunity to use regional anaesthesia for procedures that could be done purely under neuraxial or peripheral nerve blocks became

scholarly journals Assessing Nurses’ Knowledge of Noise in the Intensive Care Unit: An Educational Intervention Project

2021 ◽  
Author(s):  
Jennifer Fortes
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Intensive Care ◽  
Quality Improvement ◽  
Educational Intervention ◽  
Quality Improvement Project ◽  
Minimal Risk ◽  
Improvement Project ◽  
Staff Members ◽  
Nurses Knowledge

Noise in the intensive care unit (ICU) has been studied for over thirty years, but it continues to be a significant problem and a top complaint among patients. Staff members are now reporting detrimental health effects from excessive noise. One of the significant factors of inadequate noise control in the ICU is that nurses have insufficient awareness regarding the hospital noise issue and its negative impact on health status. The level of knowledge of clinical staff on the topic of noise is not known. A quality improvement project to explore noise in the ICU could facilitate better understanding of the phenomenon and formulation of new ways to continue to reduce noise at a community hospital in Massachusetts. The purpose of this quality improvement project was to evaluate nurses’ knowledge of the potentially harmful effects of noise on patients as well as on nurses, to identify opportunities for improvement of the environment, and to conduct an educational intervention aimed at reducing noise in the intensive care unit. The methodology for this project included a pre-test, followed by an educational session, and completion of a post-test. The participants included registered nurse staff members in the Intensive Care Unit (ICU) and the Critical Care Unit (CCU). Exclusion criteria included staff members who are not registered nurses. The project posed minimal risk. No identifying or biographical data was collected, and results included analysis of aggregate data. Descriptive statistics were used to assist with analysis. Results were disseminated to the staff of the ICU and CCU, posted on a bulletin board in the critical care area, presented as a poster presentation at the Spring RIC MSN Symposium, and available as a manuscript on the RIC Digital Commons.

scholarly journals Melatonin prescribing practices and the provision of sleep hygiene/parent-led sleep behavioural Interventions in S-CAMHS, Aneurin Bevan University Health Board (ABUHB)- Service evaluation as part of quality improvement project

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S351-S352
Author(s):  
Kathryn Speedy ◽  
Lokesh Nukalapati ◽  
Kathryn Speedy ◽  
Megan Davies-Kabir
Keyword(s):  
Mood Disorder ◽  
Management Practices ◽  
Sleep Hygiene ◽  
Evidence Base ◽  
Health Board ◽  
Prescribing Practices ◽  
Sleep Habits ◽  
Improvement Project ◽  
Behavioural Interventions ◽  
Number Of Patients

AimsTo identify the number of patients currently on melatoninTo determine the average duration of use of melatonin in patients under the care of S-CAMHS in ABUHBTo investigate whether behaviour interventions were tried and reinforced from time to timeTo identify any areas of improvementMethodData were collected at St. Cadoc's hospital, in January, 2021. S-CAMHS database was used. Out of total 346 patient currently being managed with pharmacological therapies, 115 (33.2%) are currently on melatonin. 57/115 were randomly selected as a sample for this this project. Patient notes and EPEX software were also used to collect information regarding the sleep management practices.ResultDuring analysis, it was noticed that within the sample, only 46 patients were actively on melatonin. Melatonin is prescribed for sleep related issues in ASD (8/46), ADHD (15/46), ASD and ADHD (10/46), ADHD and mood disorder (0/46), ASD and mood disorder (6/46), ADHD and behaviour difficulties (2/46), ASD with behaviour difficulties (1/46), mood disorder (4/46).39/46 patients are currently on melatonin for more than a year (85%). These patients also include 10 patients who have been using melatonin for 5 years or more.35 patients (76%) reported improved sleep or some benefit from melatonin.Evidence for implementation of parent-led sleep behavioural interventions:Prior to commencing melatonin- Clear evidence available for 35 patients only (76%). These interventions were however not deemed helpful by most of the service users.While prescribing melatonin- Clear evidence available for 39(85%) patients. Evidence base for melatonin was also discussed during this visit.During last follow-up visit- Evidence available for 31 patients only (67%).ConclusionMajority of patients under S-CAMHS ABUHB remain on melatonin therapy for longer than one year. Most of these patients have reported benefit from this therapy and preferred to remain on it despite being informed about evidence base for melatonin. Also, there is evidence for implementation of sleep behavioural interventions prior to prescribing melatonin, however their benefit remains unclear.Recommendations:The quality of education on sleep hygiene offered should be assessed and improved if neededFormal group sessions/workshops on sleep hygiene/parent-led sleep behavioural interventions at regular intervals might be useful in reducing the chances of long term polypharmacy or unlicensed drugsUse of outcome measures such as Child Sleep Habits Questionnaire at intervals can be helpful in identifying any improvement from educational/pharmacological interventionsS-CAMHS database (for patients actively on medications) needs a review and update

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